233CHAPTER 21
Pediatric Nursing Care Clinical Simulation Scenarios for Prelicensure Students
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
As experienced in other areas of clinical practice, pediatric clinical sites are becoming sparse in health care systems that are dedicated exclusively to the care of children and their families. Likewise, available and meaningful clinical learning experience in suburban and rural-based settings are limited. In addition, the strong emphasis of safety practices within pediatric-based institutions limits the scope of practice of prelicensure nursing students.
The following four pediatric-based clinical scenarios were created by two pediatric faculty members and a simulation-based expert at Villanova University, College of Nursing, who holds a certification as a Certified Healthcare Simulation Educator (CHSE). At Villanova University, College of Nursing pediatric clinical learning experiences for undergraduate learners are augmented with these four formative simulation scenarios offered during the 7-week pediatric clinical experience, along with a summative clinical scenario conducted after the 7-week clinical practicum. The pediatric clinical practicum is offered in the first semester of the fourth year for traditional undergraduate baccalaureate students. These learners were previously enrolled in a 12-week adult medical–surgical clinical, an adult complex (critical care) clinical experience, and a mental health and women–infant clinical practicum.
This chapter describes these four formative scenarios, which involve the care needs of a young child with asthma; a preschool-age child who is postoperative, recovering from a laparoscopic surgery for a ruptured appendix; an adolescent with sickle cell disease (SCD) who is experiencing vasoocculsive crisis; and a 9-month-old infant who is undergoing a well-child checkup. These formative scenarios are offered between the third and sixth week of the 7-week practicum course. Students in groups of seven to eight participate in the scenarios. The four scenarios are all done within a 6-hour day. Two students actively participate in each scenario and the remaining five to six students are observers. All students are prebriefed, which includes an orientation to the patient care setting, specifically the equipment being used in the scenario. There is a debriefing session following each scenario, which is described later in this chapter. The facilitator observes from a control room and can be the voice of any person the student needs to collaborate with, such as a health care provider, a pharmacist, or a respiratory therapist.
The companion pediatric nursing theory course provides the theory content, including nursing interventions for each of these disease processes as well as content addressing the psychosocial needs of the children and their families. It is intended that the theory content of these disease processes is taught before students participating in these formative scenarios. The preparation materials, which 234include information about the scenarios, are posted on the Blackboard learning management system (LMS) and are available to students at the start of the pediatric nursing theory course. These materials can be downloaded and students can complete the necessary preparation-for-learning activities before the simulation-based learning experiences (SBLEs). Faculty materials related to the scenario and debriefing methods are made available privately to faculty on the LMS.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The simulation lab in which the scenarios are implemented is a state-of-the-art facility that includes one floor of laboratory spaces in which students can experience skills preparation and simulated clinical experiences. This 12,000-square foot Simulation and Learning Resource Center (SLRC) includes six clinical simulation labs with six to 10 beds or examination tables in each room, five standardized patient rooms, and three simulation rooms (one of which is a simulated operating room). There are computers in between beds or individually in smaller rooms to permit access to electronic health records and resource information; audiovisual equipment for visualization and/or recording of simulation scenarios is available in all rooms. Students also have access to eight adult human patient simulators (HPSs), nine pediatric HPS, and one birthing HPS, as well as seven medication-dispensing machines and many other types of task trainers, equipment, and supplies to create a realistic simulated learning environment. Two to three staff and the director of the SLRC are available to assist the faculty and students during these simulation teaching–learning experiences.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The simulation teaching–learning experiences are intended to support the learning objectives for the entire practicum course, which are:
1. Use reliable sources of information to implement evidence-based care of children, adolescents, and families.
2. Apply health assessment findings and clinical reasoning to family-centered care of children and adolescents.
3. Demonstrate selected patient care skills.
4. Integrate the concepts of genetics, culture, ethnicity, spirituality, and development into the care of children, adolescents, and families.
5. Use information management and technology in the care of children, adolescents, and families.
6. Demonstrate effective therapeutic and professional communication in providing care to children, adolescents, and families.
7. Incorporate patient safety, dignity, and quality family-centered care with children and adolescents.
8. Integrate professional values, health care policy, and ethical principles in the care of children, adolescents, and families.
9. Relate the scope of practice and responsibilities to the role of the professional nurse in the care of children, adolescents, and families.
10. Translate the principles of teaching and learning into the care of children, adolescents, and families.
235SCENARIO 1
D. INTRODUCTION OF SCENARIO
Setting the Scene
Scenario 1. Adolescent with SCD admitted for vasoocclusive crisis
Technology Used
• Patient actor and parent actor
• Video clips of previously filmed scenario in stages could be used if the simulation is conducted as part of a classroom teaching–learning experience
• An HPS can be used, but it is more difficult to simulate the degree of pain and respiratory distress with an HPS versus a standardized patient or person
Equipment needed: See Exhibit 21.1.
Resources needed: Access to an online drug formulary or a pediatric drug text such as the Lexicomp Online | Clinical Drug Information (www.wolterskluwercdi.com/lexicomp-online)
Exhibit 21.1 Equipment Needed
Video-recording device, medical equipment (e.g., patient monitor, oxygen hookup, IV pump/pole, pulse oximeter, blood pressure cuff, and stethoscope), medical record (electronic or paper) |
Vital sign display: If no monitor is available, vital signs can be placed on a card for students to view when students assess the patient’s vital signs; also the scenario can include a pulse oximetry machine with a sticker that identifies an initial reading of 86%, and later on in the scenario a second sticker can be placed to signify the pulse oximetry reading increased to 90%—(after treatment). Other alternatives are use of a computer and monitor from another manikin or a PowerPoint display showing vital signs for various scenes. The parent can change the display as needed during the scenario. |
Vital sign settings at the beginning of the scenario: (HR: 112 beats/minute, BP: 104/70 mmHg, RR: 32 breaths/minute, temperature: 39.5°C [103.1°F]; SpO2:86%) |
Patient-controlled analgesia pump or simulated pump hanging on a pole with a device to look as if patient is controlling PCA pump for morphine administration |
Ventriloscope (a simulation stethoscope that uses a wireless transmitter to play sounds stored as MP3 files on a sound card, allowing students to hear abnormal sounds in a simulated patient care setting; Ventriloscope will be “playing” crackles). An alternative is using a Laerdal sounds trainer with a device that simulate crackles. |
IV solution 5% dextrose, 0.45% NSS on IV pump noting the rate of 175 mL/hr; with a secondary port for IV antibiotic administration. |
IV medication infusion pump for administration of morphine |
MSO4 in a multidose vial that reads: “15 mg/1 mL for rescue dose of morphine.” |
Vial of hydromorphone (Dilaudid) 1.5 mg/mL (used as a distracter) |
Three of each syringe sized: 1 mL, 3 mL, 5 mL (students need to select the appropriate-sized syringe) |
Liquid Tylenol dose—650 mg (325 mg/5 mL) |
236Tylenol tabs 325 mg/tab |
Plastic medicine cups |
Oxygen setup with flowmeter and humidification bottle, with O2 mask set at 1–2 L FiO2 via face mask, which is off patient when the nurse enters room. |
Directions for actor |
Patient gown |
Name band for patient—Jack/Jackie Sullivan—that includes patient’s full name with MRN and DOB. |
Incentive spirometer |
Identification bracelet with full name, MRN and DOB |
A swimming pool “noodle” with IV catheter and extension set inserted and a bag hanging beneath it to simulate patient’s arm; set on bed next to patient, so IV can actually be administered (see photograph) |
BP, blood pressure; DOB, date of birth; HR, heart rate; IV, intravenous; MRN, medical record number; NSS, normal saline solution; PCA, patient-controlled anesthesia; RR, respiratory rate.
Objectives
1. Complete patient assessment of an inpatient with sickle cell anemia.
2. Obtain a pertinent history related to the patient’s current health status.
3. Provide priority nursing interventions related to patient’s current situation.
4. Communicate effectively with patient and family member during scenario.
5. Communicate as needed with other medical personnel during scenario.
6. Safely administer medications related to the adolescent’s care needs as described in the scenario.
Description of Participants
Two student nurses assume the role of direct patient care providers. The patient is Jackie, a 13-year-old female in the hospital with a known diagnosis of sickle cell anemia who was admitted for a painful vasoocclusive crisis. A family member is at the patient’s bedside and is appropriately concerned.
E. RUNNING OF THE SCENARIO
A 13-year-old adolescent with a confirmed diagnosis of sickle cell anemia has been admitted to the pediatric inpatient setting and is experiencing a vaso-occlusive crisis. The patient is complaining of pain in legs, belly, and arms and states that her vision is blurry, she is dizzy, and is having difficulty breathing. 237Two direct care providers are at the patient’s bedside to address the patient’s physical, and psychosocial care needs based on maintaining physiological safety, followed by psychosocial care needs.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Nursing Care of the Adolescent With Sickle Cell Anemia
Scenario Level and Focus Area
Senior-level course—Health Care of Children and Adolescents
Scenario Description
This scenario introduces concepts of pain management for a child experiencing acute pain, as well as potential signs and symptoms of respiratory and neurological functioning that can affect her physiological safety. The scenario allows learning opportunities for students to prioritize care needs according to the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) standards of care.
Setting the Scene and Scenario Implementation
The setting is a hospital room in an acute care pediatric-based medical health care system. The patient was admitted at 12 noon and it is now 4:00 p.m. (1600). The report is received from another nurse. Exhibit 21.2 provides chart information for this patient.
Prebriefing: 10 minutes
Expected activity run time: 20 minutes
Debriefing: 30 minutes
Clinical Course of the Simulated Scenario
Students are expected to come prepared, having completed the written preparation questions (see text that follows). Prebriefing includes an orientation to the environment, reviewing expectations, determining roles, and getting a patient report. Following prebriefing, the facilitator, who is usually a faculty member, observes from the control room.
Student Preparation to Be Completed Before the Scenario Participation
Students should know the following information before the simulation:
1. For a patient with SCD, what are the important questions to ask regarding past medical history and why?
2. When completing a pain assessment for a patient with SCD, what assessments are important to perform and why?
3. When completing a neurological assessment for a patient with SCD, what assessments are important to perform and why?
4. What are the important components of a respiratory assessment for a patient with SCD and why?
5. Why do some clients with SCD experience cerebral vascular attacks (CVAs) and/or transient ischemic attacks (TIAs)? If this is in the patient’s history, what are the significant clinical care actions to take?
6. What are the critical nursing interventions for a patient with SCD? Prioritize these interventions.
7. Why is morphine sulfate administered to a patient with SCD?
8. Why is Tylenol administered?
9. What is the importance of intravenous (IV) fluid therapy for a patient with SCD?
Exhibit 21.2 Chart Information
Weight 50 kg |
Urinalysis with urine-specific gravity = 1.030 (Normal [N] = 1.010–1.025) |
Chemistry panel with the following abnormal results: BUN = 21 mg/dL (N = 10–20 mg/dL); sodium = 132 mEq/L (N = 135–145 mEq/L); potassium is on the low side, 3.5 mEq/L (N = 3.5–5 mEq/L) |
CBC with the following abnormal results: WBC = 20,000 mm3 (N = 5,000–10,000 mm3); hgb 6 (N = M: 14–18 g/dL; F: 12–16 g/dL); hct 17 (N = M: 42–53%; F: 37–47%) |
Reticulocyte = 4.5 (N = 0.5–1.5) |
Intake and output sheet |
Physician order sheet (see subsequently) |
BUN, blood urea nitrogen; CBC, complete blood count; F, female; hct, hematocrit; hgb, hemoglobin; M, male; WBC, white blood cell.
Physician Orders
1. Admit to the inpatient hematology unit
2. Patient-controlled analgesia (PCA) pump: morphine sulfate in D5W 1:1 concentration; basal rate of 2 mL/hr; bolus: 1.0 mg; lockout time 15 minutes
3. Morphine sulfate 7.5 mg IV every 4 hours (therapeutic range is 0.1–0.2 mg/kg every 4 hours) for breakthrough pain
4. 650 mg Tylenol (acetaminophen) elixir orally every 4 hours, as needed (prn) for a temperature greater than 38.5°C
5. Intravenous fluid therapy (IVF) D5.45 normal saline solution (NSS) with 20 mEeq of KCl at 175 mL/hr (2 × maintenance)
6. Cardiorespiratory monitor with continuous pulse oximetry
7. Humidified O2 at 1 to 2 L to maintain saturation at or above 90%
8. Chest physiotherapy (PT) and incentive spirometry every 2 to 4 hours
9. Strict intake and output monitoring
10. Initial settings for monitor:
Temperature: 39.5 (C°) 103.2 (F°)
Pulse: 112 beats/minute
Respiratory rate: 32 breaths/minute
Blood pressure: 104/70 mmHg
Pulse oximetry: 88%
Monitor display changes as students interact with the patient:
• If oxygen mask is put back on patient: SpO2 increases to 90%; Respirations decrease to 26 (trend over 30 sec). Lung sounds: coarse crackles in all lungs filed bilaterally
If the student initiates chest PT or incentive spirometry, then pulse oximetry increases to 93%
If Tylenol is given temperature decreases to 101.7°F (38.7°C)
If rescue dose of morphine is given: heart rate reduces to 87; respiratory rate (RR) reduces to 24 (trend over 45 sec)
Participant Roles
Patient/Actor Instructions
You are Jackie, a 13-year-old adolescent in the hospital. Your diagnosis is sickle cell anemia with vasoocclusive crisis and splenic sequestration. Exhibit 21.3 provides a script for patient responses to nurse’s questions.
239In persons with SCD, the red blood cells become crescent or sickle-shaped and become inflexible. The abnormal cells stick inside the capillaries, blocking blood flow to vital organs. Persons with sickle cell anemia can have symptoms such as yellow-appearing eyes and skin, pale skin, delayed growth, bone and joint pain, increased risk for infections, development of leg ulcers, eye damage, anemia, and damage to the organs affected by the obstruction.
Vasoocclusive crisis—a type of sickle cell crisis in which there is severe pain caused by infarctions (areas of the body that are not receiving blood supply) that may be in the bones, joints, lungs, liver, spleen, kidney, eye, or central nervous system). Splenic sequestration crisis occurs when the spleen enlarges and traps the blood cells. Aplastic crisis results when an infection causes the bone marrow to stop producing red blood cells.
An IV solution is being administered to you via peripheral intravenous catheter (PIV); you are in significant body pain, specifically, in your legs, belly, and arms. You have on an oxygen mask to help you breathe better. You are having difficulty breathing, sometimes you make a “grunting sound”. When the nurse assesses your breathing, she will use the When the nurse assesses your breathing, she may use a device (such as a Ventriloscope® or other device) to allow the students to hear abnormal breath sounds. It will show that you have noisy lungs with mucus in them. You have a fever. When you respond, act as if you are uncomfortable. Move your arms and legs continually to stress that you are in pain. Moan when you speak and keep your focus on how much you hurt. You can only focus on yourself and your pain. When asked the following questions, respond with the statements in Exhibit 21.3.
Parent/Actor Instructions
You are the parent of Jackie, a 13-year-old female in the hospital with a diagnosis of sickle cell anemia who is experiencing a vasoocclusive crisis and splenic sequestration (see preceding text for explanation). You are very worried about your child, and hate to see her in so much pain. You hover and appear concerned. The students will need to do an assessment of Jackie before giving her pain medication. They will have some trouble because Jackie has a hard time focusing on them because of the pain. The nurse should give Jackie pain medication (morphine) and Tylenol for fever, but Jackie cannot swallow pills, so medication has to be in liquid form. Prompt the course of the clinical encounter along, if needed, by saying things like:
• Pain: “I’ve never seen her in so much pain. It’s really scaring me.”
• Morphine: “I’ve never given that medication before. What will it do to her?”
• Fever: “She feels so hot.”
Exhibit 21.3 Script for Nurse and Patient
Tell me how your symptoms began or what happened to bring you to the hospital? | State: My symptoms started about 2 days ago. |
Have you ever been hospitalized before? | State: Yes, I have had four prior hospitalizations. |
Have you ever had a stroke? | State: Not that I know of. |
On a scale of 1 to 10, can you describe your pain? | State: It is a 10 out of 10 all over, but especially in my legs, belly, and arms. I also have a terrible headache. |
Are you dizzy, do you have blurred vision? | State: Yes. |
Are you having trouble breathing? | State: I cannot take a deep breath, it hurts too much. |
When was the last time you went to the bathroom? | State: I guess it was before I came to the hospital yesterday. |
• Headache, especially if the headache continues and is not being addressed by the nurse: “Should the doctor know about the headache? I am worried about this because I heard that people can have strokes if they have a severe headache with sickle cell.”
• If Jack/Jackie needs help with coughing, help him or her up to cough and breathe deeply.
Formative Evaluative Criteria
See Appendix A for the critical actions that are expected to be demonstrated by the two students who actively participated in the scenario.
SCENARIO 2
D. INTRODUCTION OF SCENARIO
Setting the Scene
Scenario 2. A young child with an asthma exacerbation
Technology Used
Simulator: Pediatric high-fidelity HPS—young child (toddler)
Equipment needed: This scenario includes simulator, video-recording device, medical equipment (e.g., patient monitor, oxygen setup, bandages, pulse oximetry meter, blood pressure cuff, and stethoscope), medical record (electronic or paper) as well as items listed in Exhibit 21.4.
Resources needed: Drug Guide for Nurses or access to an online drug formulary, such as the Lexicomp Online | Clinical Drug Information (www.wolterskluwercdi.com/lexicomp-online)
Exhibit 21.4 Equipment Needed
Toddler-sized HPS in crib with VS monitor with intravenous access in arm |
Lubricant for nose to create nasal mucus |
O2 at 1 L/min with a pediatric nasal cannula |
Nasal bulb syringe |
Percussor |
Suction canister hooked to wall suction, with catheters available |
Bottle of sterile water |
At bedside, a spacer with a mask (aero chamber); student will add medication from medication cart |
Medication cart with medicines as identified in orders |
Report in ISBAR format and orientation to surroundings (Thomas, Bertram, & Johnson, 2009) |
Physician order sheet |
IV pump for fluids and medication to be used when student calls physician and receives order for IV fluids and methylprednisolone |
ISBAR, identify, situation, background, assessment, recommendation; IV, intravenous; VS, vital signs.
241Objectives
1. Perform an assessment of a child in the hospital in an acute asthmatic situation
2. Perform nursing interventions in a prioritized manner related to patient’s asthma to ensure physical safety
3. Effectively communicate with family members during scenario to reduce their fears and concerns and increase their understanding of their child’s health status
4. Safely administer medications related to the care of the patient described in the scenario
5. Communicate with other health care providers as needed
Description of Participants
Two students collaborate to provide care. An actor plays the role of the child’s mother who is at her child’s bedside (could be another student or standardized patient; a script is provided as follows). Other students involved in this simulated learning experience will be in the role of observers. The faculty member (facilitator) plays the role of physician or a health care provider who is called during the scenario.
E. RUNNING OF THE SCENARIO
A toddler who is in respiratory distress has been admitted to the pediatric inpatient setting with the admitting diagnosis of asthma exacerbation. The two direct care providers are at the patient’s bedside to address physical and psychosocial care needs based on meeting physiological safety needs, followed by psychosocial care needs of the mom, in an effort to practice family-centered care.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
A Toddler With an Asthma Exacerbation
Senario Level and Focus Area
Senior-level course: Health Care of Children and Adolescents
Scenario Description
Jake is a 13-month-old child hospitalized with the diagnosis of asthma exacerbation. He has been receiving continuous nebulizer treatments and has now transitioned to nebulizer treatments every 2 hours. The 8 a.m. assessment revealed a 95% pulse oximetry reading in room air, respiratory rate (RR) of 36 breaths per minute, and overall, Jack appeared comfortable. As Jake’s nurse, you enter the room at 10 a.m. to administer the 10 a.m. nebulizer treatment and perform a focused assessment.
Setting the Scene and Scenario Implementation
The setting is a hospital room in an acute care pediatric-based medical health care system. The toddler who is experiencing an asthma exacerbation and has recently transitioned from continuous nebulizer treatments to nebulizer treatments every 2 hours. As the patient’s direct health care provider, the student nurses enters the room to provide care. Exhibit 21.6 provides the settings for the human patient simulator at the start of the scenario.
Prebriefing: 10 minutes
Expected activity run time: 20 minutes
Debriefing: 30 minutes
242Clinical Course of the Simulated Scenario
Students are expected to come prepared, having completed the written preparation questions (see text that follows). Prebriefing includes an orientation to the environment, reviewing expectations, determining roles, and getting a patient report. Following prebriefing, the facilitator, who is usually a faculty member, is in the control room.
Students should know the following information before the simulation:
1. For a child with asthma, what are the important questions to ask regarding the past history and why?
2. What are the important details of a respiratory assessment for a child with asthma and why?
3. What are the critical nursing interventions for a child with asthma?
4. Why is epinephrine administered and why is it administered subcutaneously?
5. What is important about continuous Ventolin nebulizer treatment for a patient with asthma?
6. Discuss oxygen therapy for the asthmatic child.
7. What is important about fluid therapy for a patient with asthma?
8. What is methylprednisolone (SoluMedrol)? Why is it often administered to a child experiencing an acute exacerbation of asthma?
Students receive the following SBAR (situation, background, assessment, recommendation; Exhibit 21.5) report before starting the scenario:
