Foundations Simulation

Patient Safety

Patient: Anne Smith

Weight: 145lb/65.9kg
DOB: 01/01/1931
Healthcare Provider: Dr. Benoffsky
Manikin: None – Standardized Patient (SP)

Participant Roles:

Overview
The patient is a 72-year-old female, admitted last night with the diagnosis of syncope, and
change in mental
status. She has a history of HTN, CAD, and HF. She lives alone; her daughter found her at
home on the floor,
a little confused and unsure as to what had happened. There was no apparent injury and the
daughter called
911. The patient is awake, alert, oriented to person, but confused to time and place, but reorients
easily. This
scenario consists of three states that are transitioned by the facilitator (Clinical Faculty).

Learning Outcomes at the end of this scenario, the students will:

 Identify two methods for patient identification.

 Adheres to proper hand hygiene and promotes patient hygiene.

 Identifies missing allergy bracelet on patient.

 Identifies incorrect bed position (high with all side rails up - restraint) and corrects it.

 Demonstrates proper body mechanics when moving/ambulating patient.

 Identifies and verbalizes importance of turning and positioning patient.

 Performs health status assessment.

 Correctly assesses vital signs.

 Corrects placement of nasal cannula on patient and ensures correct L/min.

 Measures and documents intake and output of patient, while verbalizing importance.
State 1 Orders:

 Monitor VS q4h

 Call provider if BP > 160/100, HR > 100bpm or < 60bpm, RR > 20bpm or < 12bpm, SpO2 <
95%, T >
100.4ºF

 Neuro check q4h

 Turn and position patient q2h

 Activity: bed rest

 Diet: No added salt (NAS), 2,000cal ADA

State 1 Expected Learner Behaviors/Interventions:

 Students are to introduce themselves, wash hands, and perform patient identification via two
methods.

 Students reposition patient in bed (if done properly SP will comply, if proper mechanics not
utilized SP
will complain/non-compliant).

 Once patient comfortable in bed students are to position bed properly (bed in low position, side
rail up).
All four side rails are up – students are to recognize this as a form of restraint and verbalize
importance
of proper side rail position.

 Perform a physical, neurological and vital sign assessment. Upon assessment students note
patient
awake, alert, and oriented to person. Re-orients patient to time and place.

 Document and sign off on completed orders.

 Communicates therapeutically with the patient and communicates effectively during handoff
(SBAR).
State 1 Initial Assessment-Patient Info:

Vital Signs BP: 150/88 supine, 140/80 sitting, 136/80 standing

HR: 85bpm and regular
RR: 22
T: 98.6ºF
SpO2: 90%

Assessment Patient is found lying in bed in a distorted position (on bed rest as per physician
orders). Patient is awake, alert and oriented person, re-orient to time and place.

 Patient appears anxious/confused.

 Skin is warm, dry, intact, and bruises noted d/t fall.

 HEENT: PERRLA,

 Respiratory: decreased, bibasilar crackles r/t HF,

 CV: NSR, Abdominal: no findings,

 Neruo: awake, alert, oriented to person,

 MS: generalized weakness, Pedal Edema +1, DTRs 2+, and

 Developmental: assess for any learning barriers.

Patient has c/o feeling dizzy and GCS = 14. VSS assessed and patient is
transferred back to bed. Nasal cannula is not on patient.

Patient “I feel so dizzy.”

Response “Where am I?” “I have to go, I’m late for work.”
The patient is slightly anxious and confused, and asks many questions about her
care and where her daughter is.

Diagnostic Review physician orders.

Test

State 2 Orders:

 Monitor VS q4h

 Call provider if BP > 160/100, HR > 100bpm or < 60bpm, RR > 20bpm or < 12bpm, SpO2 <
95%, T >
100.4ºF

 Neuro check q4h

 Administer O2 @ 2L/min via Nasal Cannula

 Monitor intake and output q1h

 Complete daily patient care.

 Turn and position patient q2h

 Diet: No added salt (NAS), 2,000cal ADA

State 2 Expected Learner Behaviors/Interventions:

 Students will introduce themselves and demonstrate proper hand hygiene.

 Students will identify patient via two methods.

 Students will notice missing allergy ID band and correct.

 Patient hygiene completed (oral care, washing hands, face, etc. – VERBALIZE that they would
do a bed
bath).

 Students will review physician orders, noting new orders to measure and document I’s and O’s.

 Correct nasal cannula placement and administer O2 at 2L/min.

 Document and sign off on completed orders.

 Communicates therapeutically with the patient and communicates effectively during handoff
(SBAR).

State 2 Patient Info:

Vital Signs Re-assessment of VS:
BP: 150/88 supine, 140/80 sitting, 136/80 standing
HR: 85bpm and regular
RR: 22
T: 98.6ºF
SpO2: 90%

Assessment Re-assess neuro status in order to re-orient patient to place and time. Measure
and document patient’s intake and output.

Patient Patient will be somewhat more at ease but is still asking for her daughter and
Response expresses desire to leave. Patient still responds not oriented to time and place.

Diagnostic Measure intake and output and document.

Test

State 3 Orders:

 Monitor VS q4h

 Call provider if BP > 160/100, HR > 100bpm or < 60bpm, RR > 20bpm or < 12bpm, SpO2 <
95%, T >
100.4ºF

 Neuro check q4h

 Administer O2 @ 2L/min via Nasal Cannula

 Monitor intake and output q1h

 Turn and position patient q2h

 Activity: advance from bed to chair, chair to walking as tolerated.

 Diet: No added salt (NAS), 2,000cal ADA

State 3 Expected Learner Behaviors/Interventions:

 Students will introduce themselves and demonstrate proper hand hygiene.

 Students will identify patient via two methods.

 Students will review physician orders, noting new orders advance activity from bed to chair.
 Students will demonstrate proper procedure and body mechanics while assisting patient to a
seated
position, standing position, and ambulation to chair.

 Make unoccupied bed.

 Students will review diet orders with patient and assist with tray set up and feeding.

 Document and sign off on completed orders.

 Communicates therapeutically with the patient and communicates effectively during handoff
(SBAR).

Sate 3 Patient Info:

Vital Signs Re-assessment of VS:

BP: 150/88 supine, 140/80 sitting, 136/80 standing
HR: 85bpm and regular
RR: 22
T: 98.6ºF
SpO2: 90%

Assessment Re-assess neuro status in order to re-orient patient to place and time. Assist
patient to seated position and assess for dizziness, light-headedness, etc. Assist
patient to standing position and assess for dizziness, light-headedness, etc. After
transfer to chair students should re-asses patient and follow up on any findings
(example: patient c/o dizziness, students shall re-asses vital signs).
Patient Patient re-orients easily to time and place. Patient feels better sitting up and is
Response ready to eat. If scenario is going well patient is compliant, if not patient will
give push-back (i.e.: refuses meal tray, persistently asks for daughter, etc.)

Diagnostic Review sodium lab value and relate importance to blood pressure. Review
Test importance of low sodium diet.
NAME: Smith, Anne
MR:
DOB: 01/01/1931
MD: Dr. Benoffsky
ADM. DATE:

PMH:
PHYSICIAN ORDERS 1
 HTN

 CAD
DIAGNOSIS: Syncope and change in mental status.
 HF

ALLERGIES: PCN HT. 63inches/160cm

WT. 145lbs/65.9kg
DATE TIME ORDER SIGNATURE


Monitor VS q4h

 Call HCP if BP > 160/100, HR > 100bpm or <

60bpm, RR > 20bpm or < 12bpm, SpO2 < 95%, T
> 100.4ºF

 Neurological Checks q4h

 Turn and position patient q2h

 Activity: bed rest

 Diet: No added salt (NAS), 2000cal ADA

NAME: Smith, Anne
MR:
DOB: 01/01/1931
MD: Dr. Benoffsky
ADM. DATE:

PMH:
PHYSICIAN ORDERS 2
 HTN

 CAD
DIAGNOSIS: Syncope and change in mental status.
 HF

ALLERGIES: PCN HT. 63inches/160cm

WT. 145lbs/65.9kg
DATE TIME ORDER SIGNATURE


Monitor VS q4h

 Call HCP if BP > 160/100, HR > 100bpm or <

60bpm, RR > 20bpm or < 12bpm, SpO2 < 95%, T
> 100.4ºF

 Neurological Checks q4h

 Turn and position patient q2h

 Activity: bed rest

 Diet: No added salt (NAS), 2000cal ADA

 Administer O2 @ 2L/min via Nasal Cannula

 Monitor intake and output q1h

 Complete daily patient care

 NAME: Smith, Anne

MR:

DOB: 01/01/1931

MD: Dr. Benoffsky

ADM. DATE:

PMH:
PHYSICIAN ORDERS 3
 HTN

 CAD
DIAGNOSIS: Syncope and change in mental status.
 HF

ALLERGIES: PCN HT. 63inches/160cm

 WT. 145lbs/65.9kg

DATE TIME ORDER SIGNATURE


Monitor VS q4h

 Call HCP if BP > 160/100, HR > 100bpm or <

60bpm, RR > 20bpm or < 12bpm, SpO2 < 95%, T
> 100.4ºF

 Neurological Checks q4h

 Turn and position patient q2h

 Activity: bed rest

 Diet: No added salt (NAS), 2000cal ADA

 Administer O2 @ 2L/min via Nasal Cannula

 Monitor intake and output q1h

 Complete daily patient care

 Activity: advance from bed to chair, chair to

walking as tolerated

 Complete patient education regarding diet

 NAME: Smith, Anne

MR:
DOB: 01/01/1931

MD: Dr. Benoffsky

ADM. DATE:

CHEMISTRY

DATE DATE DATE RANGE

TIME TIME TIME

ALBUMIN 3.5 – 5 g/dL

ALT 10 – 35 g/dL

ALP 42 – 136 g/dL

AMMONIA 15 – 45 µG/dL

AMYLASE 30 – 170 U/L

AST 0 – 35 U/L

BILIRUBIN 0.1 – 1.3 mg/dL

INDIRECT 0.1 –
1.0 mg/dL
DIRECT 0.1 –
0.3 mg/dL
TOTAL 0.1 –
1.2 mg/dL

BUN 5 – 25 mg/dL

CALCIUM 10:1 – 20:1

CHLORIDE 9 – 11 mg/dL

CHOLESTEROL 95 – 105 mEq/L

HDL <200 mg/dL

LDL >45 mg/dL

CPK <130 mg/dL

CREATININE 5 – 35 IU/L

GLUCOSE 70 – 120 mg/dL

GGT 3 – 23 IU/L

IRON 50 – 150 ug/dL

IRON-BINDING CAPCITY (TIBC) 250 –
450 ug/dL

LACTIC ACID (VENOUS) 0.5 – 1.5 mmol/L

LDH 100 – 190 IU

LIPASE 20 – 180 IU/L

MAGNESIUM 1.5 – 2.5 mEq/L

OSMOLAITY 280 – 300

POTASSIUM 3.5 – 5.3 mEq/L

PROTEIN 6 – 8 g/dL

SODIUM 135 – 145 mEq/L

TRIGLYCERIDES 10 – 150 mg/dL

URINE
CREATININE CLEARANCE 85 –
135 mL/min
NAME: Smith, Anne
CREATININE 0.8 –
2 g/day
MR:
PROTEIN <150 mg/day
DOB: 01/01/1931
URIC ACID MD: Dr. Benoffsky 2.5 – 7.5 mg/dL

ADM. DATE:

Hematology

DATE DATE DATE Range

TIME TIME TIME

CBC
RBC 4 - 6 x 106
/L
MCV 80 –
98 fl
MCH 27 –
31 pg/cell
MCHC 32 –
36 g/dL
RDW 11.5 –
14.5 %
HGB 12 –
18 g/dL
HCT 38 –
54 %

RETICULOCYTES 0.5 – 1.5 % RBC’s

WBC 4,500 – 10,000 x

9
10/L
DIFFERENTIAL %

NEUTROPHILS 50 -70 %

SEGS 50 –
65 %
BANDS 0–
5%
EOSINOPHILS 0–
3%
BASOPHILS 1–
3%
LYMPHOCYTES 25 –
35 %
MONOCYTES 2–
6%

PLATELETS 150,000 – 400,000

9
x 10/L

PT 11 – 15 sec

aPTT 24 – 36 sec
INR 1.0

D-DIMER NEGATIVE
Prop List

 Standardized patient w/ bruising moulage

 Patient ID band

 Allergy Band

 Hospital Gown

 Skid resistant socks

 Bed w/ linens

 Bedside tray

 Hand Sanitizer

 Plastic Pitcher and Cup

 Box of Tissues

 Blood Pressure Cuff

 Thermometer

 Pulse Ox

 Nasal Cannula – O2

 Simulated food tray – low sodium diet

 Simulated urine in bed pan to be measured for I&Os

 Graduate

 Patient Chart w/ physician orders, MAR, labs, intake and output, etc.
Pre-Simulation Assignment

Complete the following questions prior to your simulation date. Use Fundamentals of Nursing
Care Concepts,
Connections & Skills book, along with additional resources to answer questions fully.

1. Describe the six components of the Infection Chain and identify nursing measures that can
break the
infection chain.

2. List and describe three principles of body mechanics.

3. Name and describe three to five factors that contribute to an unsafe patient environment.

4. Identify an assessment tool used to evaluate a patient at risk for falls and describe how you
would
incorporate that tool into a nursing care plan.

5. List three or more ways to identify your patient.

6. List three examples of true restraints. Explain the difference between true restraints and
restraint
alternatives.
Pre-Simulation Assignment – Answer Key
Faculty Only
(Fundamentals of Nursing Care, Chapter 13 and 14)

1. Describe the six components of the Infection Chain and identify nursing measures that can
break the
infection chain.

a. The six components of the Infection Chain include: microorganism, reservoir, portal of exit,
mode of transmission, portal of entry, and susceptible host.
b. Nursing measures that could break the infection chain include but are not limited to:
sterilization
of equipment, proper disposal of contaminated materials, covering mouth/nose when coughing
or
sneezing, hand washing, use of sterile technique for invasive procedures/changing dressings,
and
promoting proper nutrition/prevention of skin breakdown.

2. List and describe three principles of body mechanics.

a. Principles of body mechanics include: work close to object, wide base of support, use legs
rather
than back muscles, pull rather than push, stoop, do not bend, use mechanical assistive
devices,
and/or ask for assistance.

3. Name and describe three to five factors that contribute to an unsafe patient environment.

a. Age and ability to understand: elderly patients, especially those confused due to cognitive
impairments, medications, or unfamiliar surroundings, are particularly at risk for falls.
Limitations that are explained may not be remembered or clearly understood as listed above.
b. Impaired Mobility: Weakness or prolonged bed rest can contribute to poor balance making
patients at risk for injury.
c. Communication: a language barrier can present an obstacle to understanding safety
instructions.
d. Pain and discomfort: Pain can cause a patient to feel more anxious and irritable leading to a
patient to disregard safety precautions in order to gain comfort.
e. Delayed assistance: not answering call lights in a timely manner; patient may not wait for
assistance when it is needed.
f. Equipment: can create obstacles when patient is ambulating.
4. Identify an assessment tool used to evaluate a patient at risk for falls and describe how you
would
incorporate that tool into a nursing care plan.

a. Morse Fall Scale

b. Fall assessment rating scales can be used as a way to assess risk, as well as track
improvement
during care. By assigning a number to a patient’s risk status the nurse will be able to quickly
identify those at high risk and implement strategies to prevent falls.

5. List three or more ways to identify your patient.

a. Patient name, patient birth date, and patient medical record number. One can ask the patient
to
confirm his/her name and date of birth by checking the patient’s identification band.
6. List three examples of true restraints. Explain the difference between true restraints and
restraint
alternatives.

a. Three examples of restraints include vests, jackets, or bands with connected straps that are
tied
to the bed, char, or wheelchair to keep the patient in one place. There are physical restraints as
well as chemical. Restraints should only be used as a last resort.
b. The difference between true restraints and restraint alternatives is that restraint alternatives
are
used to avoid using true restraints. Restrain alternatives are less restrictive than true restraints
and are used as ways to help remind the patient of their limitations or can be used to alert
nursing
staff that the patient is trying to ambulate unassisted.