Standardized Simulation NR442
Asthma Management/Nabiha Meer
Chamberlain College of Nursing: Nursing Students

We want to thank you in advance for your active participation in this standardized simulation. Our purpose is to immerse you in a high quality clinical experience that will enhance critical thinking, decision-making, and prepare you as you move forward in the curriculum and transition into practice.
The following material can be used in scenario preparation. You will find preparation documentation that includes course and student learning outcomes as well as general scenario information and resources. A brief patient history will be provided in addition to the most recent physician orders. Be prepared to document your assessment findings, administration of medication, and nursing notes. A medication administration record, laboratory results and patient education material will be provided for you during the simulated experience.
One of the most important aspects of simulation is the assessment of performance and debriefing. Keep in mind that the purpose of participation is to enhance your learning and allow you to identify areas of needed remediation. There is no high-stakes testing. We are only asking that you engage in the learning experience and begin to use the feedback provided to enhance your practice. We want you to be able to self-reflect on your actions and interventions and remediate areas that you identify.
An assessment matrix has been created that will be used to evaluate your assigned teams’ performance. The
PREPARED™ Assessment Tool was developed to provide a comprehensive mechanism for evaluating expected behaviors that contribute to advanced critical thinking and decision-making. The tool is simple to use and will be shared by the faculty during the debriefing period. It facilitates a very organized and focused approach to reflecting on your performance. P = Problem

Given the data presented and your assessment, what did you identify as the main problems associated with caring for the patient?

R= Report

Who do you need to report your findings to? What resources do you need to access? Was the report given in an organized manner?

E = Execute

What independent nursing interventions can you perform?

P = Prioritize

What actions should be prioritized in caring for the patient?

A = Anticipate

What can you anticipate and prepare for as you continue caring for the patient?

R = Reasoning Do you understand the reasoning behind your decision-making and if not, why not?
E = Evaluate

What interventions or assessment findings do you need to continue re-evaluating as you care for the patient? D = Discuss

Self-reflect on your performance and identify areas of needed remediation.

The debriefing component of the simulation is organized in the same fashion. It will be very user-friendly and you, in conjunction with the faculty, will have a positive mechanism for self-reflection, discussing positive behavior and identifying areas of needed remediation.
Thank you again for participating. We believe that these scenarios will provide a progressive medium for collaboration and enhanced learning.

SIMULATED CLINICAL EXPERIENCE: ASTHMA
MANAGEMENT OF THE PATIENT IN THE HOME
CARE SETTING STUDENT VERSION
Today’s date: 10/16/2013

Name of Lead Scenario Developer: Deb Long/Laura Fero

GENERAL SCENARIO INFORMATION
Estimated Briefing Time:
Est. Scenario Time:
Est. Debriefing Time:
Course #: NR 442
15-30 minutes
30-45 minutes
45-60 minutes
Key Concepts
• Communicable Diseases; Hospice; Death
• Please keep in mind that although each scenario has the potential to be used in various courses and contains multiple potential objectives, the placement of each SCE is aligned with specific focus and leveled purposefully to meet the needs of students at this particular point in their learning.
Program Outcomes Level III
• Provides comprehensive care with increasing autonomy to individuals, families, aggregates, and communities in a variety of healthcare settings based on theories and principles of nursing and related disciplines. • Demonstrates leadership skills and collaboration with consumers and other healthcare providers in direct care of delegation of responsibilities within all levels of health care.
• Demonstrates effective communication and professional relationship skills in providing and/or managing health care of individuals, families, aggregates, and communities.
• Revises goals and interventions based on evaluation of patient responses, new data, and alternative strategies. • Develops a plan for continued personal, professional, and educational development.
• Practices within the legal, ethical, and professional standards established for professional nursing.
• Practices in professional nursing roles in a variety of health care settings under supervision of faculty and/or selected nurse preceptors.
• Utilizes and applies research findings as a basis for solutions and interventions designed to improve patient outcomes. Course Outcomes
• Provide comprehensive care with increasing autonomy to individuals, families, aggregates, and communities in a variety of healthcare settings based on theories and principles of nursing and related disciplines (PO#1)
• Integrate clinical judgment in professional decision-making and implement the nursing process in the community health setting (PO#4)
• Implement professional nursing standards by practicing within the legal definitions of nursing practice and act in accordance with the nursing code of ethics and the American Nurses’ Association (ANA) standards of practice (PO#6)
• Communicate effectively with client populations and with other healthcare providers in managing the healthcare of individuals, families, aggregates, and communities (PO#3)
• Practice in established professional roles to provide cost-effective, quality healthcare to consumers in structured and unstructured settings (PO#7)
• Demonstrate leadership skills and collaborate with consumers and other healthcare providers in direct care or in the delegation of responsibilities within all levels of healthcare (PO#2)
• Incorporate evidence-based practice in the provision of professional nursing care to individuals, families, aggregates, and communities (PO#8)

Module 4 Student Learning Outcomes
• Assess health needs of various vulnerable populations (CO1)
• Appreciate different cultural perspectives (CO 4,7)
• Practice culturally competent communication techniques (CO 4,7)
Module 7 Student Learning Outcomes
• Assess health risks of individuals, families, and communities (CO 1,2,4,5,6)
• Educate individuals, families, and communities about health issues (CO 2,4,6,8)
• Teach individuals, families, and communities methods to improve health (CO 2,4,6,8)
• Demonstrate an understanding of the difference between health promotion and health protection (CO 2,4)
SimChart™ Outcome
• Record assessment findings, procedures and patient outcomes accurately, as appropriate for role
Prerequisite Knowledge Reflecting Previous Curricular Content
• NR222: Professional role, communication, individual health and wellness, holistic health and wellness strategies, • NR224: Nursing process, thermoregulation-temperature (vital signs), assessment, oxygenation, medication
• NR226: Nursing process, professional practice, coping and stress tolerance
• NR281: Respiratory system
• NR282: Interrelations of pathophysiological processes
• NR291: Pharmacologic principles, respiratory drugs, professional nursing role
• NR292: Technological roles
• NR302: Health assessment, interview, physical assessment, respiratory assessment
• NR304: Focused assessment
• NR320: Therapeutic communication, anxiety disorders, abuse
• NR324: Respiratory system alterations, professional nursing role
• NR325: Professional nursing roles impacting adult health and wellness

PREBRIEFING INFORMATION
Required Knowledge & Reading (assigned a minimum of one week prior to simulation): Per faculty assignment
Consider using all or some of the following questions in preparation for the scenario:
1. Discuss the pathophysiology of asthma.
2. Discuss the educational points that should be included when implementing standard education for the asthma patient.
3. What components of the patient’s asthma management plan should be monitored during a home visit? 4. Explain the stepwise approach and how it is utilized in care of the asthma patient.
5. Describe the tools that should be used to assist the asthmatic patient in managing her disease.
6. What are the common devices used to monitor and administer medications for asthma?
Describe the technique for proper use.
7. What are the medications that are currently recommended for the management of asthma?
List the actions and major nursing considerations of these medications.
8. Discuss the emphasis and roles of the home healthcare nurse.
9. What are the warning signs of domestic violence?
10. Describe the interventions that are necessary when the nurse suspects domestic violence.
11. Describe the basic values that tend to be universal beliefs of Muslims and how these may influence health care delivery.
12. Discuss interventions that can enhance healthcare delivery when dealing with cultural diversity.

SCENARIO INFORMATION
Setting: Cluttered and dusty home
Student Roles: Charge Nurse, Assessment Nurse, Medication Nurse, Documentation Nurse, Observer
Patient Name: Nabilha Meer

Gender: ☐ M ☒ F

Age: 54 ☒ years ☐ months

Height: 64 ☒ in ☐ cm

Allergies: None

Social History: No significant social history noted. Weight: 75 ☐ lbs. ☒ kg
Code Status: Full
Past Medical History (including medications): 8 year history of asthma, recent hospitalization 2 weeks ago. Home medications include: Budesonide 200 mcg per inhalation, 2 puffs every morning.
Salmeterol 25 mcg per inhalation, 2 puffs every 12 hours.
Rescue medication: Albuterol inhaler 1-2 puffs for symptoms every 20 minutes, not to exceed three doses.
After one dose, may use 1 unit dose of albuterol nebulizer treatment one time only.
If using rescue medications more than once per day, notify healthcare provider.
Pre-Briefing Report:

Situation:

The patient is a 54-year-old Muslim female who was hospitalized two weeks ago due to a severe exacerbation of her asthma. The one-week follow up visit for today is to evaluate the patient’s status and management of her treatment plan.

PROVIDER ORDERS
Chamberlain Community
Hospital
DATE

NAME: Meer, Nabiha
DOB: 12/07/58
MR#: 982345123
Physician: Jake Thomas M.D.

CHART COPY OF ORDER

HOUR

Diagnosis: Moderately persistent asthma (on stepwise approach scale)
Discharge medications:

•
•
•

Budesonide 200 mcg per inhalation 2 puffs every morning
Salmeterol 25 mcg per inhalation 2 puffs every twelve hours
Rescue medication: Albuterol inhaler 1-2 puffs for symptoms every 20 minutes, not to exceed three doses. After one dose may use 1 unit dose of albuterol nebulizer treatment one time only. If using rescue medications more than once per day, notify healthcare provider

Discharge self-management instructions for action plan:

•

Monitor peak flow numbers in the morning soon after awakening, before and 15 minutes after using rescue medications

•

Patient’s peak flow goal (personal best) - 420 L/minute

Green Zone Level 1: Able to do usual activities; usual medications are controlling asthma: •
•

Peak flow is 420-336 (100% to 80%)
Medications: budesonide 200 mcg per inhalation 2 puffs every morning, salmeterol 25 mcg per inhalation 2 puffs every 12 hours

Dr. Jake Thomas

TIME

FAX (√)

DEA NO.
PROVIDER

ORDERS

Chamberlain Community
Hospital

DATE

NAME: Meer, Nabiha
DOB: 12/07/58
MR#: 982345123
Physician: Jake Thomas M.D.

CHART COPY OF ORDER

HOUR

Yellow Zone Level 2: Increasing symptoms, awakening at night, usual activities somewhat limited, increased need for rescue medication

•
•
•

Peak flow is 336-210 (80% to 50%)

•

Continue for three days after this; call if symptoms persist

Medications: Increase budesonide to 2 puffs every morning and every evening.
Add prednisone 40 mg PO once every day until symptoms are alleviated and peak end flow value has normalized.

Red Zone Level 3: Increased symptoms longer than 24 hours; usual activities are severely limited. Rescue medications have not relieved symptoms.

•
•

Peak flow is less than 210 (less than 50%)
Medications: Increase budesonide to 3 puffs every morning and 3 puffs every evening. If no relief after rescue medications, or can’t reach healthcare provider, seek emergency treatment

Notify healthcare provider of any changes in level of treatment
Conduct standard asthma education
Home health nurse to follow patient after discharge for assessment and standard asthma education

Dr. Jake Thomas

DEA NO.
TIME

FAX (√)

ROLES AND RESPONSIBILITIES
Charge Nurse
The Charge Nurse is responsible for the overall organization of safe, quality patient care. You are the team leader and serve as a resource to all interdisciplinary members and are responsible for appropriate delegation of duties. You will serve as the point person for communication and can anticipate speaking with the physician or other primary care provider, ancillary support services, and others directly involved with the care being provided. You must be knowledgeable about the patient’s condition and able to dictate orders obtained and assist with implementation if needed. Additionally, be prepared to prioritize care and anticipate future needs.
Assessment Nurse
The Assessment Nurse is responsible for overseeing a comprehensive assessment of the patient. This includes but is not limited to obtaining vital signs, head-to-toe assessment of all systems, and psych/social assessment of the patient. You will be prioritizing care, executing independent interventions, collaborating with interdisciplinary team members, anticipating the needs of the patient/family, and re-assessing or continually monitoring the patient for any changes in condition. You are responsible for implementing all non-medication related interventions, verbalizing your finding to the team, and recommending any actions/interventions required. Additionally, you will be providing appropriate education to the patient and family/significant others.
Medication Nurse
The Medication Nurse is responsible for all actions and documentation related to safe administration of medications. You will identify and correct any medication errors related to prescribing or distribution. This may include speaking with the physician or primary care provider. Prior to administering medication, you will assure the “Rights of Medication Administration”. You must be knowledgeable regarding the action and expected effects of the medications being administered and are responsible for monitoring and reporting any adverse reactions or unforeseen consequences of administration. Part of your role includes verifying medication calculations with a colleague and identifying any incompatible drug combinations.
Documentation Nurse
The Documentation Nurse is responsible for recording of all patient event activities during the simulation with the exception of medication administration. You are responsible for documenting assessments, interventions, and outcomes on the designated tool (paper or electronic). Be prepared to read back and verify your documentation when requested and/or clarifying the details. Additionally, you will be part of the interdisciplinary team and will contribute observational assessment findings to include but not limited to changes in vital signs, alerts, psychosocial needs, and anticipated care.
Observer
The Observer is a non-participant role and will not communicate directly with the simulation team. Instead, you will be given an observation guide to complete during the simulation. The data you collect will help the team during the debriefing process and facilitate an open and active discussion regarding the simulation experience. You will be an active participant in the debriefing and will be encouraged to share your observations and thoughts. Please keep in mind that your observations should be conveyed in a respectful, educational manner. The goal is to work together as colleagues in providing safe and effective care.

Asthma
WHAT YOU SHOULD KNOW:
Asthma is long-term inflammation and narrowing of the airways in your lungs. This causes less air flow to your lungs and makes it hard to breathe.

AFTER YOU LEAVE:
Medicines:
•

Inhaled short-acting bronchodilators: These are given to help open your airways quickly. They start to work right away and are used to relieve sudden, severe symptoms, such as trouble breathing. They are called relievers or rescue inhalers.

•

Steroids: These help decrease swelling and open your airways to help you breathe easier. They may be given as pills or in an inhaler. After an asthma attack, you may need steroid pills for several days. Inhaled steroids are used for long-term control.

•

Combination inhalers: These include a long- acting bronchodilator and a steroid. They help open the airways over time, and are used to decrease and prevent breathing problems.
They are only used when your asthma is not controlled with other medicines. They are not helpful during an asthma attack.

•

Take your medicine as directed: Call your primary healthcare provider if you think your medicine is not helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill bottles to follow-up visits .
Carry your medicine list with you in case of an emergency.
Inhalers:

•

Metered dose inhaler: This is a small, tube-shaped device. You hold the open end inside your mouth. The medicine comes out as a mist when you press a switch. Breathe in deeply to get the right amount of medicine.
You can use a spacer with this inhaler. A spacer is a large tube that holds the mist before you breathe it in.

•
•

Nebulizer: A long tube goes from the machine to a small round container that holds asthma medicine. The liquid turns into a mist once the machine is turned on. You breathe in this mist through a mouthpiece.

•

Dry powder inhaler: This is a small tube or disc-shaped device that contains powder asthma medicine. You hold the open end inside your mouth. The powder is released when you press a switch. With this type of inhaler, you must breathe in hard to suck in the powder.
Make an asthma action plan:
This is a set of instructions to follow when you have an asthma attack. Work with your primary healthcare provider to develop an asthma action plan. List any medicines you take and how much or how often you take them. Also list your triggers. Write down your signs and symptoms and what to do if you have an attack. List emergency phone numbers. Update your plan when you have a new attack. Carry your asthma action plan with you at all times.

From http://www.drugs.com

Asthma Action Plan/Peak Flow Numbers
Develop an Asthma Action Plan with your doctor. An Asthma Action Plan can help you manage your asthma symptoms. It is based on your symptoms and peak flow numbers, which you use to find your
“zone.” Your doctor will write the medicine to take in each zone.

Name:

Date:

Doctor:
Phone

for

doctor

or

clinic:
Emergency: Call 911

My best peak flow reading when I am feeling fine is:

Green
Breathing is good.

Medicine

How much to take

When to take it

Medicine

How much to take

When to take it

• No cough or wheeze
• Can work and play
Peak flow reading above

Yellow
You are having a flare-up. • Cough or wheeze
• Tight chest
• Waking up at night
Peak flow reading between

And

Red
You are having a serious flare-up.

Get help from a doctor now!
Medicine

How much to take

When to take it

• Quick-relief (rescue)

medicine isn’t helping

• Breathing hard and fast
• Can’t walk or talk well
Peak flow reading below

This material was developed by GlaxoSmithKline.
© 2006 The GlaxoSmithKline Group of Companies

All rights reserved.

Printed in USA.

HCM874R0

June 2006

RADAR: A DOMESTIC VIOLENCE INTERVENTION

R = ROUTINELY SCREEN FEMALE PATIENTS
Victims of violence are very likely to disclose abuse to a Health Care Provider, but only if they are asked about it.
Always interview the patient alone.

A = ASK DIRECT QUESTIONS
Ask simple direct questions in a non-judgmental way. “Is there anyone who has physically or sexually hurt or frightened you?” “Have you ever been hit, kicked, or punched by your partner?” “Does your partner try to control your activities or your money?” “I notice you have a number of bruises; did someone do this to you?” “Because violence is so common in many women’s lives, we’ve begun to ask about it routinely.”

IF PATIENT ANSWERS YES, SEE OTHER SIDE FOR RESPONSES
AND CONTINUE WITH THE FOLLOWING STEPS:
D = DOCUMENT YOUR FINDINGS
Record a description of the abuse as she has described it to you.
Use statements such as “the patient states she was…” If she gives the specific name of the assailant, use it in your record.
“She says her boyfriend John Smith struck her…” Record all pertinent physical findings. Use a body map to supplement the written record. Offer to photograph injuries. When serious injury or sexual abuse is detected, preserve all physical evidence. Document an opinion if the injuries were inconsistent with the patient’s explanation.

A = ASSESS PATIENT SAFETY
Before she leaves the medical setting, find out if she is afraid to go home. Has there been an increase in frequency or severity of violence? Have there been threats of homicide or suicide? Have there been threats to her children or pets? Is there a gun or other weapon present?

R = RESPOND, REVIEW OPTIONS & REFER
If the patient is in imminent danger, find out if there is someone with whom she can stay. Does she need immediate access to a shelter? Offer her the opportunity of a private phone to make a call. If she does not need immediate assistance, offer information about hotlines and resources in the community (see other side). Remember that it may be dangerous for the woman to have these in her possession. Do not insist that she take them. Make a follow-up appointment to see her.
© 2002 RADAR Pocket Card developed by The Institute for Safe Families. Philadelphia, PA, 215-843-2046, www.instituteforsafefamilies.org
RADAR acronym developed by the Mass Medical Society. © 1992 Mass Medical Society

IF THE PATIENT ANSWERS "YES":
ENCOURAGE HER TO TALK ABOUT IT.

“Would you like to talk about what has happened to you” or “Would you like help?”

LISTEN NON-JUDGMENTALLY.

This serves both to begin the healing process for the woman and to give you an idea of what kind of referrals she may need. VALIDATE HER EXPERIENCE.

“You are not alone.” “You do not deserve to be treated this way.” “You are not to blame.” “What happened to you is a crime.” “Help is available to you.” “The violence is likely to get worse, and I am worried about you.” “If you are not safe, your children may not be safe.”

IF THE PATIENT ANSWERS NO,
OR WILL NOT DISCUSS THE TOPIC:

BE AWARE OF ANY CLINICAL SIGNS THAT MAY INDICATE ABUSE:

Injury to the head, neck, torso, breasts, abdomen, or genitals; bilateral or multiple injuries; delay between onset of injury and seeking treatment; explanation by the patient which is inconsistent with the type of injury; any injury during pregnancy; prior history of trauma; chronic pain symptoms for which no etiology is apparent; psychological distress such as depression, suicidal ideation, anxiety, sleeping or eating disorders; a partner who seems overly protective or who will not leave the woman’s side; frequent health care visits; substance abuse.
If any of these clinical signs are present, ask more specific questions. Make sure she is alone:
“I
am worried about you. It looks as though someone may have hurt you. Can you tell me how it happened?” “Sometimes when people feel the way you do, it may be because they are being hurt at home. Is this happening to you?” If the patient denies abuse, but you strongly suspect it, document your opinion, and let her know there are resources available to her should she choose to pursue such options in the future. Make a follow-up appointment to see her.

RESOURCES
866 . SAFE . 014
Philadelphia Domestic Violence Hotline
(866 . 723 . 3014)
215 . 686 . 7082
. 242 . 2235

Women Against Abuse Legal Center 215 . 985 . 3333

Menergy – For men who are abusive

267 . 625 . 6135
215 . 564 . 0488
215 . 496 . 0707

Menergy en Español – For men who are abusive

Men’s Resource Center – For men who are abusive
Children’s Crisis Treatment Center
Trauma focused therapy for children
215 . 438 . 9070 Anti-Violence Partnership
Trauma focused therapy for children

Women Organized Against Rape 215

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