129CHAPTER 13
Acute Management of Respiratory Distress in the Adult Patient
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY AND AVAILABILITY OF EDUCATIONAL MATERIALS IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
As new faculty we are looking at ways to improve our teaching techniques and optimize the resources available to us. High-fidelity simulators were not available when we graduated from our nursing programs. They are now a valuable resource and presently available to nursing educators. We are currently using high-fidelity patient simulators as medical–surgical/critical care instructors in the state university system. Dr. Linda Warren is a critical care nurse at a local medical teaching hospital and Dr. Monica Sousa is a clinical nurse specialist/cardiac educator in another medical teaching hospital. As educators we are not experts with patient simulation. However, we use simulation in seminar experiences to teach key concepts from lecture and reading assignments in order to encourage critical thinking among students in all phases of the nursing program. Some of our important focuses are evidence-based practice, standards of care, and patient safety. Simulation allows students to practice basic as well as complex skills in a nonthreatening environment. It also provides opportunities for standardized clinical experiences and addresses competencies in order to promote readiness for clinical practice. The acute care setting is a high-risk area with increasingly complex patients with multiple comorbidities. Students need to develop accurate assessment skills as well as the ability to think critically and react in emergency situations. Active listening skills during handoff communication are an important concept in this scenario. Nurses must use a holistic approach when assessing critically ill patients. They are also important members of the interprofessional health care team, who integrate problem-solving skills into their assessments in order to develop an effective plan of care for the patient.
B. EVOLUTION OF YOUR EXPERIENCES IN TEACHING AS YOU BEGAN TO USE SIMULATIONS
The intensive care unit (ICU) lab at Western Connecticut State University (WCSU) is equipped with SimMan® 3G by Laerdal. SimMan® 3G is easy to operate and allows programming of original scenarios or has preprogrammed scenarios available for use. Faculty has the ability to critique and give immediate feedback through debriefing to enhance student learning. SimMan® 3G also has various moulage elements to make scenarios more realistic. The computer technology allows instructors to follow a fixed program or manually change the scenario based on student 130reactions. In the spring of 2016, SimMan® 3G received the Laerdal Learning Application (LLEAP) upgrade to enhance the clinical simulation experience. The faculty received an 8-hour training from Laerdal on the new software.
The simulation lab can accommodate a group of six to eight students. Therefore, instructors can promote leadership, team-building, and critical thinking skills in the simulation process. The ICU lab is also equipped with an over-bed monitor for ease of visibility to the group. SMART Board technology is also located in the ICU lab to enhance student learning. A code cart is available for students to practice code management skills as well as preparation and administration of medications that may be required during an emergency situation.
Recently, a medication-dispensing system was purchased as well as a computer on wheels. We have used both to simulate the complete medication-administration process. Within the medication-dispensing system medications have been programmed and stocked, it is interesting to note that there are medications that have been stocked improperly. For example, look-alike/sound-alike medications are in the same drawer, and two of the same medications in different doses are in the same drawer. This was done to educate students to always look at the medication and perform the five rights of medication-administration during all phases of the medication-administration process.
In early 2016, the nursing department received funding to purchase the Harvey, the cardiopulmonary patient simulator. This simulator is a life-size mannequin that provides students with the opportunity to listen, feel, and see clinical cardiac and pulmonary findings. For example, for congestive heart failure students can listen to an S3 heart sound, feel the displaced point of maximum impulse (PMI), and visualize jugular venous distention (JVD). With the additional funding, the nursing department is building new simulation labs with the latest technology for simulation and debriefing. This will greatly expand our opportunities and use of simulation in all courses. We will be receiving a birthing simulator, newer SimMan human patient simulators (HPS), and actual control rooms. Currently, faculty stay in the same room to facilitate and control the simulation.
Simulation has enhanced our teaching experiences by providing students with hands-on learning. It encourages student engagement in the learning process by allowing the students to respond to various situations while providing a safe learning environment. It has also allowed us, as instructors, to be better able to assess student needs and learning styles that support and enhance learning using current digital technology (Fountain & Alfred, 2009; Leigh, 2008; Rogers, 2007). Simulation has also provided a way for us to link theory with clinical practice.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Overall objectives of the scenario are for students to demonstrate critical thinking skills in the care of the complex patient. Students must be able to identify inconsistencies with hand-off communication, recognize symptoms, and establish treatment options for acute respiratory distress as a result of congestive heart failure or pulmonary edema. This scenario addresses Clinical Nurse Practice III of the bachelor of science in nursing (BSN) undergraduate program; the course objectives are:
1. Synthesize knowledge from the arts, sciences, and humanities with nursing theory as the basis for making nursing practice decisions for individuals experiencing complex illnesses.
2. Critically evaluate situations through the use of the nursing process to assess, diagnose, plan, implement, and evaluate the care provided to individuals experiencing complex illnesses.
3. Apply the nursing process to design, implement, and evaluate therapeutic nursing interventions to provide preventative, curative, supportive, and restorative care for individuals experiencing complex illnesses.
4. Selectively apply appropriate communication techniques, including written documentation, in the process of assessment, counseling, and therapeutic intervention with individuals experiencing complex illnesses.
5. Selectively apply appropriate teaching–learning strategies in the provision of health teaching for individuals experiencing complex illnesses.
6. Use the process of scientific inquiry and research findings to design and critically evaluate nursing interventions with individuals experiencing complex illnesses.
D. INTRODUCTION OF SCENARIO
Setting the Scene
A 72-year-old female patient named Mary Jane Brown was feeling her usual self up until a week ago. She began to feel increasingly more short of breath and unable to complete her normal activities of daily living before she needed to stop and catch her breath. She has been feeling palpations in her chest on and off during the past few days. She has also noticed that her ankles are swollen. Pertinent medical history includes coronary artery disease, diabetes, and hypertension. Current medications are Lopressor 25 mg twice a day, baby aspirin 81 mg daily, and Metformin 1 tab daily. Her daughter is with her today and mentioned that her mother has been going out to a local diner with some friends over the past few weeks and is worried she is getting overworked and not eating properly. The daughter called 911 when she found her mother breathing heavily and not looking good.
Emergency medical service (EMS) provided supplemental oxygen at 2 L by nasal cannula. Vital signs upon arrival to the emergency department (ED) are: heart rate (HR): 110 beats/minute, respiratory rate (RR): 28 breaths/minute, and blood pressure (BP): 138/88 mmHg. On hand-off report from the ED vital signs were: HR: 114 beats/minute, RR: 32 breaths/minute, BP: 146/88 mmHg, pulse oximetry: 92% on O2 via nasal cannula at 2 L. The patient was reportedly very anxious and exhibiting signs of respiratory distress. Lungs on auscultation present with bibasilar crackles; +2 pedal and ankle edema is present; heart sounds are rapid and regular. Chest x-ray shows congestion of bilateral lung fields. Lasix 20-mg intravenous (IV) push was ordered and administered. IV fluids are ordered and infused to keep vein open (KVO). Cardiac monitor showed sinus tachycardia at a rate of 116 beats/minute. Patient weight is 101 kg and height is 62 inches (body mass index [BMI]: 40.7).
Patient is admitted to your unit in respiratory distress with indication of decreased cardiac output and cardiac compromise.
Technology Used
Patient simulator, video-recording device, medical equipment (e.g., patient monitor, oxygen flowmeter, pulse oximeter, BP cuff, and stethoscope), medical records, Foley catheter, x-ray, 12-lead EKG, and arterial blood gases (ABGs)
Objectives
1. Circulation, airway, breathing principle
2. Implement a focused cardiac and respiratory assessment
3. Demonstrate correct administration and evaluation of IV push medications and IV fluids
4. Identify the need to optimize cardiac output
5. Administer IV medication for cardiac stability
6. Identify discrepancies in hand off communication
7. Provide physical and emotional support to a patient in distress
8. Patient and family education
Description of Participants
Three to four junior/senior nursing students are needed to play the role of one primary nurse and three staff nurses on the unit. The scenario is videotaped to encourage peer participation and evaluation. The 132simulation is observed and supervised by the faculty. Other students are encouraged to take an active role in the simulation by reading the scenario, role-playing, or critiquing student performance.
E. RUNNING OF THE SCENARIO
Students will have completed at least two semesters of medical–surgical nursing courses to be adequately prepared. They will have completed lectures related to cardiac and respiratory emergencies. They will also have fundamental skills in assessment, taking vital signs, basic arrhythmia, and EKG interpretation. Before the simulation scenario, ground rules addressing trust and respect as well as expectations of the simulation exercise will be discussed. Students will be oriented to the simulation lab, including equipment, participant roles, specific objectives, method of evaluation, and time allocated for the scenario. One student will be given a copy of the demographics and the ED report to hand off to the other students, who will be managing the simulation scenario. They will have time to ask questions and participate in a postsimulation discussion.
This scenario takes approximately 20 minutes with an additional 15 minutes of debriefing time allowed for discussion and evaluation.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Acute Management of Respiratory Distress in the Adult Patient
Scenario Level
NUR 335: Clinical Nursing Practice III, Junior/Senior Critical Care Course
Focus Area
This chapter focuses on the management of a patient in pulmonary edema. The students must be able to look at the patient and assessment findings holistically.
Scenario Description
Students must be able to critically evaluate the information provided in the ED report presented earlier, identify the signs and symptoms of heart failure/pulmonary edema, and the rationale for the treatments provided. Simulation practice will consist of handoff communication, assessing respiratory and cardiac function, assessing signs and symptoms of pulmonary edema, demonstration of the administration of IV push medication, identifying medication actions and indications, demonstrating medication safety, and providing emotional support for a patient in distress.
Scenario Objectives
Overall, students are evaluated using the guidelines set forth by the American Association of Colleges of Nursing (AACN; 2008), The Essentials of Baccalaureate Education for Professional Nursing Practice. The BSN Essentials used in our evaluations are the following:
Essential II: Basic Organizational and System Leadership for Quality Care and Patient Safety
Essential III: Scholarship for Evidence-Based Practice
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