285CHAPTER 24
Care of an Older Adult With Congestive Heart Failure
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Because geriatrics content is typically offered during the second year of the baccalaureate program, elementary simulations allow faculty to introduce foundational content essential to the care of older adults. Examples of content reinforced through the use of scenarios has included (a) differentiating delirium, dementia, and depression and (b) distinguishing normal from abnormal changes of aging.
At Fairfield University, faculty have also been able to participate in a faculty learning community (Shea, Campbell, & Miners, 2013), which facilitated discussions about the goals and expected outcomes associated with simulations. In addition, there was discussion of the pedagogical theory supporting the use of simulations to enhance the delivery of nursing content.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The Fairfield University School of Nursing’s Robin Kanarek Learning Resource Center is a state-of-the-art facility that presents realistic patient care scenarios. It comprises a simulation room, a control room, and an adjacent classroom enabling classes of up to 35 students to view the ongoing scenario as it progresses. A high-fidelity human patient simulator (HPS) allows students to assess the typical vital signs (VS) and lung sounds of a nursing home resident with an acute exacerbation of congestive heart failure (CHF). In the following scenario, students may use an actual computer interface to access patient lab values and history. If such technology is not available, sample charting materials can be provided.
C. SPECIFIC OBJECTIVES OF SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
This scenario is intended for students enrolled in Geriatric Nursing, a second-year course in a 4-year baccalaureate nursing program. The course focuses on the nursing care of older adults living in long-term care settings. Building on skills developed in a previous course in health assessment, normal physiological changes of aging and related assessment skills are incorporated into this course. Management of common geriatric care problems is emphasized. Because geriatric nursing is the first 286clinical course in the nursing curriculum, students will also be provided with the opportunity to develop an understanding of how the nursing role merges with life goals, philosophy, and meaning and to use those values to develop professional behaviors consistent with these aspects of life. In our curriculum, students have studied pharmacology before geriatric nursing coursework. This scenario allows for the reinforcement of pharmacology content, and reviews the side effects of diuretics.
D. INTRODUCTION OF SCENARIO
Setting the Scene
The simulation will take place in a nursing home. The resident will be in bed in his or her room. A certified nursing assistant (CNA) will provide a report on the resident.
Technology Used
This simulation will make use of a medium- or high-fidelity HPS with the capacity to transmit respiratory sounds, a video-recording device, simulated oxygen, pulse oximeter, blood pressure (BP) cuff, stethoscope, electronic health record, water pitcher, call light, and ID bracelet. The patient should be wearing a diaper.
Objectives
Nursing students will be required to evaluate and manage the complex and dynamic hydration status of the older adult nursing home patient suffering from CHF. This simulation will include evaluating the nursing home resident for signs and symptoms of both dehydration and overhydration. The scenario will test decision-making skills regarding the administration of diuretic medications and the evaluation of key laboratory values and will require communication with other nurses, physicians, and the patient’s family members.
Description of Participants
One or two students; an instructor to act as the voice of the resident, Mrs. Fertal; a “CNA” to deliver the patient report; and a “physician” to whom students may report change of condition
E. RUNNING OF THE SCENARIO
The initial settings for the HPS for parts 1 to 3 are (a) BP: 130/85 mmHg, P: 75 beats/minute, respiratory rate (RR): 17 breaths/minute, temperature: 97.5°F; (b) oxygen saturation (O2 sat) settings should be set to 90%; (c) place notecards on the legs of the HPS indicating that she has +1 pitting edema to her ankles; (d) lung sounds with slight crackles bilaterally; (e) atrial fibrillation; (f) resident is sitting in bed in a high Fowler position; and (g) place a reddened area on the patient’s coccyx indicating a stage 1 pressure ulcer (use a model when available/appropriate).
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Care of an Older Adult With Congestive Heart Failure
Scenario Level
This simulation is used within a geriatric course given during the second-semester sophomore year of a baccalaureate program or first-semester freshman year of an associate degree program.
287Focus Area
This scenario is geared toward sophomore-level geriatric nursing students practicing in long-term care settings.
Scenario Description
One or two students will receive a report from a CNA working nights, and some key data will be missed and/or misinterpreted (e.g., weight gain). An instructor will act as the voice of Mrs. Fertal, and a physician will be available (either by phone in the control room or physically present) for students to report changes of condition.
Nursing students will be required to evaluate and manage the complex and dynamic hydration status of the older adult nursing home patient, including evaluating the patient for signs and symptoms of both dehydration and overhydration in light of the diagnosis of CHF. The scenario will test decision-making skills regarding the administration of diuretic medications and the evaluation of key laboratory values and will require communication with other nurses, physicians, and patient family members.
Scenario Objectives
1. Introduce self.
2. Check ID band.
3. Check VS, including pulse oximeter.
a. Note low pulse oximeter reading.
b. Note that decreased temperature is a common and normal finding in the older adult.
4. Conduct a head-to-toe assessment.
c. Note rales in bilateral bases.
d. Note pedal edema.
e. Note reddened area on coccyx.
f. Note atrial fibrillation.
5. Check the compressor to ensure that it is working and delivering the correct amount of oxygen to the patient.
6. Assess mental status for signs of acute confusion and signs of depression.
7. Student documents relevant findings: color, position, breath sounds, heart sounds, VS, weight, change in activity level, presence of a stage 1 pressure ulcer. While charting, student checks back to compare the current weight with the previous weight. Student checks the chart for relevant lab values.
8. Student notes that abnormal labs indicate hypovolemia: decreased blood urea nitrogen (BUN) and decreased hematocrit.
9. Student contacts the physician and reports relevant findings in a cohesive way. This may be done via phone in the simulation room, which connects him or her to faculty in the control room acting as the nurse practitioner and physician.
The scenario allows students to practice key elements from the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan (National Council of State Boards of Nursing, 2015), including: Physiological integrity: Basic care and comfort (nutrition and oral hydration, rest, and sleep), Pharmacological and parenteral therapies (expected effects/outcomes, pharmacological agents/actions), Reduction of risk potential (laboratory values, system specific assessments, VS), Physiological adaptation (hemodynamics, fluid and electrolyte imbalances, pathophysiology).
288Setting the Scene
Patient: Mrs. Irma Fertal
Age: 89 years
Allergies: Penicillin, codeine
Weight: 177.2 pounds
Physician: Dr. Newman
Major diagnoses: CHF, chronic obstructive pulmonary disease (COPD), diabetes, hypothyroidism, atrial fibrillation, osteoarthritis of the left hip
Medications and orders:
Fluticasone propionate (Advair discus) 250/50
Furosemide (Lasix) 20 mg by mouth daily
Levothyroxine (Synthroid), 50 mcg by mouth daily
Predisone (Deltasone), 10 mg by mouth daily
Wafarin (Coumadin), 5 mg by mouth daily
Neutral protein Hagedorn (NPH) insulin, 25 U each morning and each evening
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