295CHAPTER 25
The Older Adult in an ICU With Acute Respiratory Failure: Critical Care Nursing Senior-Year Elective
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
This three-credit course is a fourth-year last-semester elective in a baccalaureate program called “Critical Care Nursing.” The course combines theory and clinical laboratory courses that are offered concurrently with the students’ transition-to-professional-role course. This transition course has the student paired with a nurse preceptor for 165 hours in the inpatient clinical setting. The students taking critical care nursing are working with their preceptor on critical care units, step-down units, and acute care medical and surgical units.
This course is an introduction to critical care nursing. The nursing diagnoses and management of patients focus on cardiovascular, pulmonary, gastrointestinal, renal, neurological, and multisystem alterations. Common problems of critical care patients, such as sleep, pain, nutritional and psychosocial difficulties, are also discussed. Palliative care issues are also described in each of the systems mentioned. Frequently used medications and relevant nursing implications are addressed. Basic EKG interpretation is covered and significant nursing interventions are addressed.
The students gain many of their skills in the college laboratory practice sessions and then apply their knowledge from class, clinical rotations, and work experience in carrying out simulated case scenarios. They volunteer for one of the simulation scenarios, such as the respiratory care case discussed in this chapter, and work in a group of four students practicing the case. Then each group carries out the scenario for the class. The students welcome the challenge of working with simulated critically ill case scenarios given the difficulty level of the skills, high patient acuity, and need for expanded theory compared to what the students have received in their medical and surgical courses, and in most situations, they lack clinical experience with the critically ill patient and with providing palliative care to critically ill patients. This process of learning by reading assigned text and articles related to the topic, listening and participating in class regarding application of the knowledge to case studies, seeing demonstrations and practicing specific skills on models in the college laboratory, obtaining firsthand clinical experience in rotations if possible, maintaining a reflective practice log on patient experiences, and participating and observing simulated case scenarios allows maximum critical thinking and problem solving for the students to gain as much new knowledge as possible.
296B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
This simulation experience can be made to fit the long-term subacute facility or even the home setting, as many patients who are not able to be weaned are on a ventilator outside of the critical care area. It is important that there are enough students and/or faculty to assume the roles of nurse, family member(s), and intensivist so that there can be a collaborative discussion as well as health teaching with the family members. Perhaps the most difficult aspect of this scenario is the communication between the wife and children regarding the patient’s do-not-resuscitate/do-not-intubate (DNR/DNI) status. Using the critical care area of the learning resource center at the Fairfield University School of Nursing makes it easy to carry out the critical care scenarios as monitor, bed, oxygen and suction equipment, ventilator, and all types of intravenous (IV) lines and medications are already set up. The high-fidelity human patient simulator (HPS) is handled by a teaching assistant who is able to run the controls and software. This handler has already been apprised by the faculty of the appropriate EKG tracing, respiration rate (RR), blood pressure (BP), and pulse parameters to have displayed on the monitor during the various aspects of the scenario. All of the equipment, as stated previously, has been checked and labeled for the students involved in the scenario. There is even a telephone and area for the family/significant others to sit in while waiting for their 10- to 20-minute visit in the intensive care unit.
This scenario also covers a palliative care focus for the students, and this DNR/DNI information could be extracted and applied to a patient with respiratory difficulty who is facing death if she or he is not intubated. Setting this up as a less acute experience would also be beneficial for the students to practice talking about death with members of the health care team, patient, and family/significant others. There are multiple resources for the palliative care focus available from the American Association of Colleges of Nursing (AACN) End-of-Life Nursing Education Consortium (ELNEC) website (www.aacn.nche.edu/elnec); The Palliative Care of Dying Critically Ill Patients’ Algorithm (Grossman, 2013) also assists nurses in steps to follow when providing palliative care.
C. SPECIFIC OBJECTIVES OF SIMULATION USAGE WITHIN A CRITICAL CARE NURSING ELECTIVE COURSE AND THE OVERALL PROGRAM
Overall Course Objectives
The overall purpose of the course is for students to gain increased knowledge, clinical reasoning, clinical skills, case management, and awareness of their communication skills in an ICU. The goals for this complex scenario are for students to gain experience in managing the care of a patient on a ventilator, as the students do not get this opportunity in the clinical area, as well as to experience collaborating with the physician, other nurses, and family regarding the patient’s needs related to comfort and satisfaction with the end life.
Student Learning Activities
Many students voice serious anxiety about suctioning, airway maintenance, working with a patient on a ventilator, and caring for someone who is terminal and may die during the students’ assigned time with the patient. Perhaps the most important outcome from this practice of skills is the self-confidence one usually achieves after performing well in the scenario, and this increased confidence in clinical skill performance was demonstrated with simulation by Fisher and King (2013).
297D. INTRODUCTION OF SCENARIO
Setting the Scene
This scenario was developed for final-semester senior baccalaureate nursing students. They have completed their medical and surgical, pediatric, geriatric, mental health, and women’s health specialty courses. They are concurrently taking their Public Health and Transition to Professional Role course. The following is the scene for this end-stage chronic obstructive pulmonary disease (COPD) patient.
Eighty-one-year-old Mr. Whisper is ventilated and attempting to talk around his endotracheal (ET) tube. He is Irish, married, and a retired judge with a strong Catholic faith. He has three grown children and 12 grandchildren who all come to visit regularly. His current diagnosis is COPD exacerbation secondary to emphysema with bilateral lower lobe pneumonia, dyspnea, a long history of atrial fibrillation, aortic valve replacement, coronary artery disease (CAD), hyperlipidemia, and hypertension. He receives lisinopril (Zestril) 10 mg, metoprolol (Lopressor) 100 mg, hydrochlorothiazide 12.5 mg, tiotropium (Spiriva) inhaler qd, levofloxacin (Levaquin), warfarin (Coumadin), and fluoxetine (Prozac). He receives morphine sulfate (MS) 2 to 10 mg IV as needed for anxiety. This is his fifth admission to the hospital in 3 months, and his children have brought up the option of DNR/DNI with him. His wife has been against this option until this admission, but now she is in agreement with their children that Mr. Whisper should not be intubated again. He is having multiple high-pressure alarm problems because of his emphysema pathology and large amount of mucus plugging from the pneumonia.
Technology Used
The scenario takes place in the critical care area; the patient is a high-fidelity HPS lying in a bed connected to a ventilator and cardiac/hemodynamic monitor and there is also an area where the wife/family can sit. A phone is nearby in case the nurse wants to call for help or discuss an issue with the respiratory therapist or physician or another nurse. An electronic health record is in front of the bed for the student to use for charting or to find any patient information.
Objectives
After completing the scenario simulation exercise the students are able to do the following:
1. Communicate with the patient and his wife about the patient’s condition regarding his palliative care measures.
2. Communicate with the nurse giving the previous shift report, along with other health care team members.
3. Demonstrate oral, closed, and open endotracheal (ET) suctioning and hyperventilation on a ventilated patient.
4. Assess breath sounds on a COPD patient with pneumonia.
5. Assess and manage premature ventricular contractions (PVCs) on the patient’s cardiac monitor.
6. Troubleshoot a ventilated patient with high-pressure alarm problems.
7. Administer MS to an anxious patient according to evidence-based protocols.
8. Facilitate the wife’s participation with her three children in preparing for a palliative care family meeting and revise the patient’s advance directives to reflect his wishes.
9. Manage the IV, being sure to have two access sites and to monitor fluid intake.
10. Assist with insertion of a central line and follow evidence-based protocols before using the newly established line.
298Description of Participants
Mr. Whisper: He is generally a simulated manikin, but a student or faculty member could perform this role.
Mrs. Whisper: She could be a faculty member or a student. It seems the student gains much from being in this role and having to handle the family and patient regarding DNR/DNI.
Nurse assigned to Mr. Whisper: This student is responsible for performing the care; assessing the patient; collaborating with the health care team and family about DNR/DNI issues; and talking to the patient, who is intubated. A magic slate or a pad and pencil are used.
Nurse going off shift: A student can do this role easily and still participate in the rest of the scenario by moving to the side and noting any concerns or mistakes she or he sees. This student can offer this information in the debriefing.
Experienced nurse: This is a student who acts more comfortable in the ICU setting and assists the assigned nurse in caring for the patient when necessary.
ICU intensivist: A student generally takes this role and has to participate in talking with Mrs. Whisper and Mr. Whisper regarding his plan of care.
Teaching assistant: This person runs the simulator from the control room.
A faculty member is observing in the critical care area of the learning resource laboratory during the scenario to be best able to evaluate the student’s performance, but does not offer any hints or assistance until the students join the rest of the class for debriefing after the scenario.
E. RUNNING OF THE SCENARIO
Students have read the required materials on caring for acute care respiratory patients, had a class discussion regarding this same topic, and have accomplished the ventilator demonstration laboratory module. They also completed all of the undergraduate ELNEC components and reviewed The Palliative Care of Dying Critically Ill Patients’ Algorithm (Grossman, 2013); at least two of the students have worked with a ventilated patient in clinical. All the students have also worked in the critical care area of the learning resource center for skill practice, so they are familiar with working with the monitor, bed, oxygen, and the suction.
The equipment set up on a bedside table consists of a central line kit, central line dressing kit, bedpan, toilet paper, suction catheter, sterile gloves, tray, stethoscope, gloves, and saline solution. All medications, syringes, and needles needed are in the medication Pyxis machine next to the patient. The patient is connected to two IV lines, the ventilator, monitor, and oxygen, and suction is available in the adjacent wall.
This is a 20-minute scenario planned for class presentation by four students. Students have practiced as a group three times and even once with their instructor, so they are prepared to present the scenario to the class.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
The Older Adult With Acute Respiratory Failure in an ICU
Scenario Level
Senior baccalaureate nursing students
Focus Area
Critical care nursing, therapeutic communication, health assessment, medical–surgical nursing, palliative care
299Scenario Description
Patient history: This scenario takes place in the medical ICU where the patient, Mr. Whisper, has been intubated and on a ventilator for some time. He is not doing well and is requesting a change in his DNR/DNI status. His wife is in the process of agreeing with this change now, and their children have supported their father’s wishes. A meeting is planned with his family to make some plans for his death. The scenario involves the difficult suctioning and runs of premature ventricular contractions (PVCs) that occur with people who have end-stage COPD who are on ventilators, but who are not progressing to recovery. Mr. Whisper is quite anxious, dislikes all of the ventilator and cardiac alarms, and has prolonged periods of dyspnea when he has mucus plugs. This causes his wife also to be very upset. Students participate in this scenario for communication, critical care, and palliative care experience.
Health assessment results: Physical assessment reveals the following significant findings:
Skin: thin with multiple abrasions, decreased turgor, decreased moisture of oral mucosa
Heart: displaced point of maximum impulse (PMI), atrial fibrillation
Respiratory: barrel chest, unequal chest excursion, scattered rhonchi throughout, rales and decreased breath sounds in lower lobes
Medication record: He receives lisinopril (Zestril) 10 mg, metoprolol (Lopressor) 100 mg, hydrochlorothiazide 12.5 mg, tiotropium (Spiriva) inhaler qd, levofloxacin (Levaquin), warfarin (Coumadin), and fluoxetine (Prozac). He receives morphine sulfate (MS) 2 to 10 mg IV as needed for anxiety.
Scenario Objectives
Key Elements From NCSBN
Since the last edition of this book a landmark study through the National Council of State Boards of Nursing (NCSBN) by Hayden, Smiley, Alexander, Kardong-Edgren, and Jeffries (2014), found that up to 50% of clinical hours of the undergraduate programs could be substituted by simulation pedagogy, and in 2015 the “NCSBN Simulation Guidelines for Prelicensure Nursing Programs” was published (Alexander et al., 2015). The National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan categories and subcategories (NCSBN, 2015) addressed in the simulation are as follows:
Safe and effective care environment: Management of Care, Safety and Infection Control; Health promotion and maintenance; Psychosocial integrity; physiological integrity: Basic care and comfort, Pharmacological and parenteral therapies, Reduction of risk potential, Physiological adaptation.
Key Elements From BSN Essentials
The AACN (2008) has created nine BSN Essentials that are used as a guide to developing curriculum for baccalaureate nursing programs. The Essentials document states “Simulation experiences augment clinical learning and are complementary to direct care opportunities essential to assuming the role of the professional nurse” (p. 4). The Essentials that are addressed in this simulation by objective are listed as follows:
Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety
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