Adult Health I Simulation Passport
In order to prepare for the simulation excursion, please complete the following student guide. After completion, upload to the NRS 3015 Simulation Passport assignment link on eSpace prior to your scheduled simulation excursion. Noncompliance with this assignment will be communicated to your clinical FOR.
Simulation Learning Objectives
1. Provide individualized family-centered care by:
• Using developmentally appropriate, therapeutic communication techniques.
• Performing focused health assessment in an effort for early identification of the systemic inflammatory response characteristic of sepsis.
• Understand the specific care considerations for LGBTQ individuals and their families in the acute care setting.
2. Function as an effective member of the health care team by:
• Demonstrating relevant and timely inter-professional communication and collaboration.
• Include questions that are LGBTQ specific during health assessments.
3. Apply best available standards of care for the patient by:
• Identify historical findings that are correlated with an increased risk for sepsis.
• Recognizing abnormal data and assessment findings.
• Recognize the systemic inflammatory responses related to sepsis.
• Prioritizing and implementing nursing interventions which correspond to assessment findings.
4. Promote safety for patient, self, and others
5. Identify factors that influence quality of care by:
• Early identification of goal directed interventions.
• Evaluating patient response to interventions.
• Recognize the diversity of subpopulations within the LGBTQ community and their specific health needs.
Simulation Overview
You will be caring for Leah Draper, a 21-year-old female admitted for R/O pneumonia last evening. She has a history of actinic keratosis and non-prescribed subcutaneous testosterone drug use.
Patient was transported by ambulance from residence to EC by EMS upon finding the patient with self-inflicted wound of the left breast, febrile state, and reports of malaise and SOB.
You will be caring for the patient at 0700 at the start of a 12-hour shift on the morning after her admission. The simulation scenario is the initial encounter with the patient where you will perform a focused assessment based on the patient’s medical/surgical condition and any other presenting assessment findings, as well as develop a plan of care for your shift.
Social History: The patient is employed as a free-lance artist and lives with a partner of 6 months.
Review Pathophysiology for Sepsis
What is sepsis?
What are possible reasons that an individual may develop sepsis?
What are clinical manifestations of a person with sepsis (subjective and objective assessment findings)?
As the nurse, caring for a patient with sepsis, identify your care priorities.
Identify topics that should be included in patient education for sepsis.
Sepsis is diagnosed on the basis of the SIRS criteria. Review the SIRS article by Comstedt, Storgaard and Lassen.
What does SIRS stand for?
S __________________________________
I __________________________________
R __________________________________
S __________________________________
What is included in the SIRS criteria?
How does septic shock differ from sepsis?
Complete the following drug card for Vancomycin.
Generic name Trade name
Classification
Dose Route Time/Frequency
Peak Onset Duration Normal Dose Range
Drug Indications;
For IV meds, compatibility with IV drips and/or IV solutions:
Mechanism of action/indications:
Nursing implications: contraindications:
Common adverse effects:Interactions with other drugs/OTC/herbal substances:
Lab value alterations caused by medication:
Nursing Assessment:
Ongoing Assessment:
Evaluation:
Communication is a primary responsibility of the nurse. The nurse will be called to therapeutically communicate with her patients and their families. In addition, a logical, systematic and organized form of communication with peers and other members of the health care team will benefit care provisions.
Review the PDF for ISBAR Communication and the ISBAR template on eSpace.
As the nurse, you have determined it important to communicate with your patient’s admitting physician.
Prioritize the following information and complete an ISBAR for your newly admitted patient:
– 21- year- old female
– Lives with an identified partner for the past six (6) months
– Self-inflicted L breast wound
– Non-prescribed testosterone drug use
– Admitting diagnosis: R/O pneumonia
– Febrile
ISBAR COMMUNICATION REPORT FORM (Use this fillable table to complete your ISBAR communication)
I
S
B
A
R
