Medical-Surgical Simulation: Caring for Post-CABG PatientTopic/Lab: Caring for Post-CABG PatientExpected Simulation Run Time: 30 minutesDebrief /Guided Reflection Time: 30 minutesAdmission Date: 4/13/08Todays Date: 4/15/08

Patient Description: Name: James Timmins Age:65Gender: Male Race: CaucasianDate of Birth: 10/13/41Weight:_85.5__kg. Height: 57Religion: CatholicPhone: 605-123-4567Major Support/Contact Person: Spouse Katherine Timmins

Physician: Dr. Jackson/Surgeon, Dr. Moore/ Cardiologist

Allergies: NKA

Immunizations: Flu shot 10/07,

Past Medical History:CAD MI in 2003 with 3 stents in RCA, angioplasty in 2000Hypercholesterolemia, Type II DM, Hypertension, Past surgical history appendectomy

History of Present Illness:Chest pain with exertion/relief with nitro X4 in past two months. Angiogram 4/6/08 multiple blockages in RCA and LCA.

Social History: History of smoking, quit 2006, occasional drink

Primary Medical Diagnoses: S/P Coronary Artery Bypass Graft

Surgeries/Procedures & DatesCABG four vessel 4/13/08

Area of Focus:Cardiac outputDysrhythmia Pain

Learning Objectives:

Patient Centered Care Knowledge: Identify common complications and priorities related to the care of a post cardiac surgery patient. Skill: Perform targeted post-CABG assessment. Attitude: Value the patients health concerns.

Safety Knowledge: Integrate understanding of universal medication safety strategies and utilization of SBAR. Skill: Demonstrate effective use of medication safety strategies. Demonstrate effective use of SBAR. Attitude: Value nursing role in preventing errors.

Teamwork and CollaborationKnowledge: Describe own strengths, limitations, and values in functioning as a member of a team. Discuss effective strategies for communicating with patient, family members, and members of health care team. Skill: Implement therapeutic communication techniques with post-op client. Communicate with team members, adapting own style of communicating to needs of team and situation.Attitude: Value the importance of adapting communication style to each unique health care situation.

Setting/Environment ER Med/Surg Peds ICU OR/PACU Womens Center Behavioral Health Home Health Pre-Hospital Other_Step-Down unit________________

Medications and Fluids IV Fluids:D5LR at TKO

Oral Meds:

Famotidine 20 mg po bidMetoprolol 200 mg po qdOmega-3-acid 2g po bidRosuvastatin calcium 20mg po qdEnteric coated ASA 325 mg po qdPercocet 7.5/325 2 tabs po q4h prn

IVPB:

Cefazolin sodium 1g IV q6h prn

IV Push:

IM or SCSliding scale insulin

Diagnostics Available: LabsCBC, electrolytes, glucometer checks X-Rays 12 Lead EKGOther___________________

Roles/Guidelines for Roles Primary Nurse Charge Nurse Clinical Instructor Family Member #1 Family Member #2 Observer/s Recorder Physician/Advanced Practice Nurse Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy Unlicensed Assistive Personnel Code Team Other__________________

Information Related To Roles:Faculty played the role of the Patient and physician using wireless microphone from hidden location.

Psychomotor Skills Required prior to simulation: *Adult Post-Surgical Assessment *IV Medication Administration *Identify Common Dysrhythmias *Communication

Cognitive Activities Required prior to Simulation: *Physical Assessment *Focused Cardiac Assessment *Communicating with Patients, significant others *Communicating with members of the healthcare team *Patient/significant others teaching *Dosage calculation *Assurance of patient safety

Props/Equipment Required: Fluids D5LR @ TKO on pump Incentive Spirometer at bedside IV Start kit supply area IV tubing supply area IVPB tubing supply area IV pump - bedside Medication Cart Nurses Station Nurses Station O2 Delivery Device - NC Clothing for student in role of patients spouse Labels for Patient medications Patient Medical Record with completed forms (MAR, lab results, physician orders, patient assessment forms Other: Nurses station setting with laptop or other prop representing cardiac monitor, telephone, patient chart, paper/pens and other supplies to simulate nurses station

Mode for Simulation (manual or programmed):Low-fidelity manikin used. Faculty played role of patient and physician using wireless microphone from hidden location.

Simulator Programming: Temperature 98.8 Blood Pressure 120/70 Breathing Rate 28 Abdominal sounds - Hypoactive

Equipment needed to be attached to manikin: IV tubing with primary line__D5LR @ TKO__Fluids running at __________ml/hr FoleyCatheter__100ml___output cl amber urine IVPB with Cefazolin 1g___at _____50ml @ 100_ml/hr O2__3_________L ID Band Allergy Band Position__supine HOB elevated 30 degrees_____________ Pulse Ox Other___Telemetry attached________

Documentation Forms: Physician Orders Admit Orders Flow Sheet Medication Administration Record Kardex Graphic Record Shift Assessment Triage Forms Code Record Anesthesia/PACU Record Standing orders Transfer orders Other___________________

Significant Lab Values:CBC, electrolytes, Glucometer check results

Pertinent Student Information Needed Prior to Simulation: Standard of care for post-CABG patients Understanding of common complications associated with CABG surgery Report students will receive before simulation/Script Cards:

Primary Nurse/Student #1:It is 9AM and you will be administering Mr. Timmins scheduled 9AM dose of Cefazolin.

You have already completed your AM assessment at 8AM. You assessed the following at that time:Vital Signs:T 98.8F, P 78, BP 120/70, R 28C/O pain 7/10, Percocet 2 tabs given poLung Sounds: bibasilar crackles, scattered wheezes throughout, dyspneic with conversation. O2 @ 3L/NC, O2 Sat 93%Heart tones: strong, regular, telemetry - NSRAbdomen: firm, hypoactive bowel sounds X 4 quadrants, passing minimal flatusNo edema noted, 2+ pedal pulses palpable bilateralThoracic incision dressing intact, no drainage noted. Dressing intact to drain site in left chest area. 30 cc serosanguinous drainage noted.Dressing to left leg incisions intact, no drainage noted, Thigh-high TED hose to left legGlucometer reading: 152 @0700 5 Units Regular insulin administered

You will be collaborating with the Charge Nurse to respond to unfolding events and implement care.

Charge Nurse/Student #2:It is 9AM. You will start the simulation by reviewing Mr. Timmins chart at the nurses station. You are aware that Mr. Timmins is two days post-four vessel CABG. He has been complaining of severe pain in his left chest area near the drain insertion site. He has also been dyspneic with minimal exertion. You will Mr. Timmins medical record and respond to events as they unfold. (Charge Nurse also receives a copy of the AM assessment findings)You will collaborate with the Primary Nurse to implement care as needed.

Spouse/Student #3:As the scenario unfolds, Mr. Timmins will experience some complications and new meds. Your role is to act as a concerned/nervous spouse and ask the following questions at appropriate points during the scenario:What happened?What does this mean? Will he have to go back to surgery?Does this mean his bypass isnt working?What is this drug you are hanging?What does it doHow does it work?Will he have to be on this medication forever?

References, EBP Guidelines, Protocols, Algorithms: Eagle, K.A. et al (2004). ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: A report of the American College of Cardiology/American Heart Association task force on practice guidelines.

Martin, C.G., & Turkelson, S.L. (2006). Nursing care of the patient undergoing coronary artery bypass grafting. Cardiovascular Nursing, 21(2), 109 117.

Moghissi, E. (2004). Hospital management of diabetes: Beyond the sliding scale. Cleveland Clinic Journal of Medicine, 71(10), 801-808.

Mullen-Fortino, M. & OBrien, N. (2008). Caring for a patient after coronary artery bypass grafting. Nursing 2008, 38(3), 46-52.

Timing(Approximate)Manikin Actions(Faculty respond via wireless mic/hidden location, manikin programmed for VS, LS, BS)Expected Interventions

Key Concepts

Primary nurse enters room to hang IV antibiotic/

Charge nurse at nurses station reviewing chart

5 - 7 minResponds to questions from student

Manikin:DyspneicVS: T 98.8F, P 78, BP 120/70, R 28

Student introduces self, checks patient identification

Asks appropriate questions about patients condition.

Administers scheduled medication safely.Patient identification

Focused assessment

Alarm sounds at nurses station(Faculty cue pre-programmed alarm, atrial fib rhythm strip placed on cardiac monitor)

Next 3 minutesI dont feel quite rightCharge nurse/Student #2 responds to alarm, interprets dysrhythmia, goes to assess patientIdentification of dysrhythmia

Therapeutic communication with patient, family, team

Charge nurse and primary nurse consultNext 5 7 minutesResponds to questions

Wife becomes agitated/anxious, asks questions about what is happeningStudents should perform focused assessment, obtain VS Notify physician using SBAR (uses telephone at nurses station)

Receives new orders from physician (faculty member acting as physician): Initiate Amiodarone drip. Give a loading dose of 150 mg in 10 minutes followed by a drip at 1 mg/minute.Recognition of common complication

Therapeutic communication

Use of SBAR

Safe documentation of new orders

Primary contacts pharmacy regarding new ordersNext 5 minutesResponds to questions

Wife asking multiple questions about what is happening/

AnxiousEducates patient and spouse regarding atrial fib, new medicationTherapeutic communication

Patient teaching

Primary nurse prepares to hang Amiodarone drip.

Consults with charge nurse as needed.

Next 10 15 minutesPatient and spouse ask questions regarding afib, new medResearches new medication

Recognizes drug-drug incompatabil-ity and need for separate IV site

Calculates drip rate correctly

Performs appropriate assessment during administration of drug

Answers questions regarding afib, new medication

Medication safety

Communication

Debriefing/Guided Reflection Questions for This Simulation

1. How did you feel throughout the simulation experience?2. Describe the objectives you were able to achieve?3. Which ones were you unable to achieve (if any)?4. Did you have the knowledge and skills to meet the objectives?5. Were you satisfied with your ability to work through the simulation?6. How was SBAR utilized in the simulation? If not implemented, how should it have been used in this situation?7. To Observer: What areas of strength did you note? How did participants react to unexpected events? Could the nurses have handled any aspects of the simulation differently?8. To Family Member: How did you feel during the simulation? Did you feel included? Receive information as needed?9. How were the patients values and concerns addressed?10. How were medication administration safety standards implemented in this simulation? Were any safety issues identified? If so, what could have been done to prevent them?11. Describe the communication that occurred during the simulation. How could communication between team members and between team members and the client have been improved?12. If you were able to do this again, how could you have handled the situation differently?13. What did the group do well?14. What did the team identify as the primary concerns during the simulation?15. What were the key assessments and interventions?16. Is there anything else you would like to discuss?

Post-CABG Physician Orders(To be incorporated into schools format)

Date:Transfer to Post-Coronary Unit1800 Calorie ADA dietMedications:Cefuroximine 750 mg IV q 12 hFamotidine 20 mg po bidMetoprolol 200 mg po qdOmega-3-acid 2g po bidRosuvastatin calcium 20mg po qd Enteric coated ASA 325 mg po qdPercocet 325 mg 1 2 tabs po q4h PRN painSliding Scale insulin Glucometer checks qidIncentive spirometer q 2 h while awakeAlbuterol Nebulizer q 6 hO2 2 4L saO2 > 93%VS q 4 hAmbulate per cardiac rehabHOB elevated 30 degrees at all timesChest huggerI&O q 12 hDaily weightChange dressing q 48 hThigh high Ted hose to unaffected legCBC, Electrolytes in AM