139CHAPTER 14
Trauma Resuscitation
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Simulation-based learning occurs in an innovative fashion for baccalaureate and nurse practitioner students. Integrated simulation learning, used within the curriculum, serves as an adjunct modality and, for undergraduate nursing students, it serves as partial fulfillment of the clinical requirement. The objective of simulation-based pedagogy is to provide opportunities for baccalaureate and nurse practitioner students to acquire critical thinking skills before encounters in the clinical setting. In addition, the development of role acquisition in the context of interprofessional learning is a key feature unique to simulation. The application of high-fidelity simulation lends itself to providing safe practice that can occur in a nonthreatening environment with support from faculty and peers. Repetition of high-risk clinical situations desensitizes the anxiety of students responding and participating in the delivery of high-acuity trauma resuscitation. Also, the students develop an “algorithm of response”—learned behaviors of rapid assessment and nursing intervention, formulated on evidence-based practice that may be employed during any precode, code, or resuscitation occurrence.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The Nursing Department at Western Connecticut State University (WCSU) offers bachelor of science (BS), RN to BS, and master of nursing (MSN) degree programs. Two of the three simulation facilities used at WCSU, which are designed to mirror critical care bays, are available for nursing students to practice skills and enhance contextual learning. An additional intensive care unit (ICU) laboratory will be completed in the next fiscal year, supported by federal assistance. The ICU simulation facility used for the critical care course houses a hospital bed, ventilator, emergency equipment, and the human patient simulator (HPS) with remote personal digital assistant (PDA) access. There are two adjoining laboratories, a classroom for instruction, and a smaller room designed as a library with textbooks. At the Yale School of Nursing (YSN), the simulation laboratory has an attached debriefing room equipped with a one-way viewing mirror and has full computer access that can be broadcast into larger classrooms. The simulation rooms are of generous proportion, and there is space to divide the class reasonably and to provide a quiet, private environment to run the simulation and debriefing.
140C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The overall objective of integrating simulation within the framework of the course curriculum is clear: to enhance student proficiency in performing critical care assessments and skills and to acquire new roles that provide collaboration, improved communication, and efficiency. Basic proficiency of appropriate nursing responses to precoded situations is imperative. Student nurses may have an opportunity to develop these skills with the assistance of simulation. This alleviates anxiety and provides an arsenal of responsive techniques to employ when delivering care to critically ill patients. Role-play and alternating these assignments facilitates teamwork and communication while providing safe care. An additional objective for student performance while working with high-fidelity simulation is to formulate pertinent differential diagnoses. Although some would argue that this is not a function of the role of nursing or consistent with the students’ novice level, it is critical to assist students to anticipate nursing interventions based on the patient’s medical presentation. Providing case scenarios whereby students can process and synthesize medical diagnoses builds confidence and proficiency while delivering excellent nursing care.
D. INTRODUCTION OF SCENARIO
Setting the Scene and Technology Used
Students are introduced to the HPS with as much reality as possible. The sights, sounds, and smells of the trauma bay are difficult to replicate. One way to address this may be to play an audiotape of background sounds customarily heard during trauma resuscitation. For the purpose of this simulation, the patient is arrayed as a trauma patient would be. Access to all the medical equipment in the ICU lab is available. The technology available for use includes oxygen and emergency resuscitation equipment, stethoscopes, ventilator, cardiac monitor, hemodynamic monitoring lines, intravenous (IV) lines and IV pump, code cart, nasogastric (NG) tube, suction equipment, Pleurovac drainage kit, and Foley catheter.
Objectives
The objectives of the participants are as follows:
1. Recognize precode indicators leading to acute deterioration of the trauma patient
2. Perform basic trauma assessment
3. Identify factors that place the patient at risk for physiologic deterioration
4. Increase proficiency in performing critical care skills
5. Assume roles to enhance proficiency in the clinical area
6. Communicate effectively within the team framework
7. Participate in debriefing exercise
a. Identify stressors
b. Identify areas for improvement (assessment, intervention, reevaluation, communication, and team proficiency)
Description of Participants
Student nurse in medical–surgical didactic course: The student should be prepared in patient assessment techniques, including inspection, palpation, percussion, and auscultation. The student should be knowledgeable about the equipment and forms necessary to accomplish this task. The student should obtain the necessary tools and forms from the instructor before entering the patient’s room.
A 21-year-old White female patient brought into an emergency department (ED) trauma resuscitation bay (Level 1 Trauma Center): This role is played by a high-fidelity HPS found lying on a stretcher. The simulator operator answers brief questions initially supplying the voice of the patient. The simulator operator responds with short, simple answers to questions posed by the student and indicates that she does not understand when questions are not presented in clear, simple terms. The HPS becomes short of breath. The patient becomes quickly disoriented to time and place. His conditions deteriorate, indicating a degree of altered level of consciousness.
Instructor/facilitator running the scenario: The person running the scenario is also operating the HPS (a high-fidelity simulator), unless another qualified operator is available. In that case, the instructor running the scenario observes and take notes relative to scenario objectives.
Family member: None present at this time.
E. RUNNING OF THE SCENARIO
Students are introduced to assigned ED roles. They are offered a clipboard and record data on a mock critical care flow sheet and medication record. Professional observers would be assigned to record elapsed time and interventions. Data from the trauma scenario is introduced as a “call in” from the paramedic as the trauma patient is transported to the ED. The “nursing staff” have only minutes to set up emergency equipment necessary for the first few minutes of initial resuscitation. Written resource materials are not readily available apart from IV drip calculation sheets. Access to learning resources is kept minimal, as this is similar to that experienced in a live resuscitation.
The trauma patient is unmasked, and the resuscitation is in play. Students are expected to proceed using available technology resources and personnel. Trauma resuscitation knowledge is based on previous lecture content. The instructor provides patient data sequentially outlined in the scenario template. Coaching and cues are offered as the scenario unfolds. Typically, assistance in recognizing differential medical diagnoses is provided. Additional prompts include timeliness of interventions, recognition of elapsed time, and communication. Proficiency in the basic resuscitation skills seems sound overall, although additional assistance is provided to novice nurses with directions offered for lifesaving activities. Positive reinforcement is consistently offered with the completion of appropriate assessments, recognition of differential diagnoses, successful nursing interventions, and effective communication.
F. PRESENTATION OF COMPLETED TEMPLATE
Twenty-four undergraduate students were divided into two groups and were introduced to the assignment. Groups of 12 students were considered large and, as a result, several students were assigned roles as extra observers. To offset the large class size during simulation, several trauma simulations were run, and roles were rotated. Groups of four to six students are considered to be ideal and have been used among the nurse practitioner cohorts at YSN. Additional exercises aimed at identification of cardiac dysrhythmias, hemodynamic waveforms, and instability were offered within the scenario.
Title: Trauma Resuscitation
Clinical Nursing Practice III, Nursing 335 (Critical Care Curriculum)
142Focus Area
This is an emergency department trauma scenario for seniors and second-semester juniors and nurse practitioner students.
Scenario Description
This chapter introduces the concepts and techniques of physical assessment in the context of the nursing process. High-fidelity simulation provides opportunity for these undergraduate nursing students to apply advanced health assessment skills and delivery of care in the context of an acute, high-risk trauma resuscitation. Simulation may be paused during intensely stressful periods of time in order to provide reflective thought and corrective action or the scenario can continue to the end and reflection is provided afterwards in the debriefing.
Client profile: Sally is a 21-year-old White college student brought into the ED on Friday night after crashing her Jeep Cherokee Sport on I-84. Emergency medical technicians report that Sally, the restrained driver, sustained anterior chest injuries. The airbag was deployed, and vomit was detected on the dashboard. Sally smelled of alcohol. At the scene, Sally was found alert but disoriented to place and short of breath, with acute chest pain of 7/10 radiating to the thoracic area. Interventions at the scene include applying a cervical collar and backboard, O2 at 4 L per minute, and a large bore peripheral IV of Lactose Ringer (LR) at 125 mL per hour. The initial Glasgow Coma Scale indicates a score of 14, blood pressure (BP) of 90/60 mmHg, pulse (P) 126 beats/minute and irregular, and respiratory rate (RR) of 30 breaths/minute; respirations are shallow and decreased to the right mid and lower lobe. Sally is taken by ambulance to the ED trauma bay of a nearby level I trauma center.
On arrival to the ED, paradoxical breathing and hemoptysis are present. Breath sounds are absent to the right midlobular region. It is determined that a chest tube should be placed to the right thorax. The chest tube immediately drains 200 mL of sanguinous fluid, and the Pleuravac is placed to 20 cm of suction. The patient is writhing on the hospital bed and moaning, “My chest hurts bad.” Her level of consciousness deteriorates, and she begins to vomit. A blood gas is drawn and demonstrates a PaO2 of 86%. The patient is given IV sedation by the certified registered nurse anesthetist (CRNA) and is nasally intubated. Bibasilar breath sounds are present. In order to monitor her, a Swan–Ganz catheter is placed to the left subclavian region with LR wide open. BP is 84/50 mmHg, P is 144 beats/minute, and RR is 12 breaths/minute and regular; O2 saturation is 98% on FiO2 of 40%, no positive end-expiratory pressurre (PEEP). The cardiac monitor shows sinus tachycardia with premature ventricular contractions. Jugular venous distention is present and is accompanied by muffled heart sounds. Faint peripheral pulses are palpable, and the skin is cool and moist. A suprapubic abrasion with a red, 5 × 8-cm line of demarcation is noted. An NG tube is inserted and placed at 60 cm continuous suction. A right radial arterial line is inserted by the CRNA. A 16 French indwelling Foley catheter is placed to straight drainage with a preset 200 mL of serosanguinous tinged urine output. Soft wrist restraints are placed on the patient to avoid self-discontinuation of treatment modalities. An arterial blood gas (ABG) is drawn, complete blood count (CBC) with differentials, chemistry panel, serum troponin, type and cross 4 units of packed red blood cells, and blood alcohol level are drawn from the arterial line. An EKG reveals ST elevation in anterior leads. A cervical-spine radiograph and chest x-ray (CXR) are taken. The Swan–Ganz catheter and nasal endotracheal tube are confirmed to be properly placed on CXR. A resolving hemothorax to the right midlobe is present on CXR. Focused abdominal sonography for trauma and an abdominal and pelvic ultrasound are ordered.
Verbally provide the following information about the patient to the students: Patient’s name, demographics (gender, age, race, religion, occupation, height, and weight); past medical, surgical, family, social, and psychiatric history; immunization status; allergies; current medications; tobacco/alcohol/substances; presenting symptoms. Note style of the following patient data form.
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