Sickle Cell Spring 21 - vsim PDF

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Clinical Replacement SIM: Brittany Long The goal for this week’s virtual clinical replacement is to perform a comprehensive assessment, recognize the signs of the patient’s deteriorating status, and be able to implement prioritized interventions in a safe and effective manner, including administering fluid and preparing for blood products.

Learning Objectives General: · · · · · · · · · · ·

Identifies the primary nursing diagnosis Identifies relevant patient history information Identifies physical findings and diagnostics related to patient condition Prioritizes nursing interventions Identifies developmentally appropriate and culturally competent nursing interventions based on patient care needs Implements provider orders appropriately Implements patient safety measures Provides family-centered education Recognizes therapeutic and confidential communication techniques Reports findings directly and accurately to interprofessional team members Utilizes members of the health care team when appropriate

Scenario-focused: · Identifies signs and symptoms in a patient with acute splenic sequestration crisis · Identifies significant laboratory findings and emergency treatment · Implements blood administration protocol · Provides patient teaching on risks of infection and on prevention and treatment of recurrent episodes of splenic sequestration

Pre-SIM: Prep work/“Ticket to Sim”: must be completed 24 hrs. prior to the start of your scheduled SIM to be allowed attend/participate vSim Brittany Long (Core Case 7) Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long ❖ ❖ ❖ ❖ ❖

Review “Suggested Reading” content/topics within your didactic text and the links within the first page Complete the Pre-quiz for core simulation Complete the Core simulation until you achieve an 80% or higher Complete the Core post-quiz until you achieve an 80% or higher Complete the “Medication sheet” for all medications relevant to this SIM scenario - this can be found at the end of this document. Submit this med sheet to Blackboard via the hyperlinked SIM title

Intra-SIM: Join your instructor-facilitated synchronous vSIM clinical via the Zoom link found in your BB clinical course banner What will we be completing during our synchronous clinical time? ● Debrief the core simulation ● Work through the Complex simulation including blood transfusion protocols ● Review the Clinical packet and Concept Map

Post-SIM: due within 72 hours post clinical replacement SIM Finish Vsim Brittany Long (Complex case 8) ❖ Complete the Complex simulation until you achieve an 80% or higher if not achieved/completed during synchronous time ❖ Complete the Complex post-quiz until you achieve an 80% or higher if not achieved/completed during synchronous time ❖ Complete the ‘Clinical Packet’ provided at the end of this instructional document if it was not completed during synchronous time. Submit this to Blackboard via the hyperlinked SIM title This completed clinical packet should include all required elements for the Complex vSIM: ● “Concept Map Worksheet” ● “vSIM ISBAR Activity” ● “Clinical Worksheet” ● “Documentation Assignments” ● “Guided Reflection Questions” ▪ Add Last Question-What is your final take away? ________________________________________________________________________________________________________________ _

Medication Sheet (to be completed and submitted to BB 24 hours prior to clinical) Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long

Medication

Mechanism of Action

Brand name Generic name Classification

Action Therapeutic effect

Rights Dose Range Route

Medication Sheet Labs Side Effects Labs Why are they needed?

Most common

Nursing Implications Include: monitoring for drug effects or reactions, focus assessments, etc.

Teachings Patient & Family: Explain why RX is prescribed, discharge teaching

Morphine (IV and PO) Opioid analgesic

Binds with opioid receptors in the CNS, altering perception of and emotional response to pain.

PO, IM, intranasal

May increase amylase level. May decrease Hb level (morphine sulfate). May decrease platelet count. May cause abnormal LFT values (morphine sulfate).

Dizziness, headache, respiratory depression, diaphoresis, nausea, vomiting, constipation

Monitor RR Monitor for S/S of serotonin syndrome Monitor for signs of withdrawal when tapering off

Have patient report side effects Report dizziness Warn patient about constipation

Ketorolac NSAIDS Sprix

May inhibit prostaglandin synthesis to produce anti-inflammatory, analgesic, and antipyretic effects.

PO, IM, intranasal

May increase ALT and AST levels. May decrease Hb level and hematocrit. May increase bleeding time. May lead to false-positive aldosterone/renin ratio.

Headache, dizziness, tinnitus, dyspepsia, nausea, vomiting, constipation, renal impairment, diaphoresis

Correct hypovolemia before administering Carefully observe patients on anticoagulants This drug may mask signs of infection

Tell patient to discard nasal spray within 24 hours of the first dose, even if medication remains in the bottle. Advise patient to take a sip of water after using nasal spray to decrease throat sensation. Teach patient to read package insert and full directions for use of nasal spray bottle. Warn patient not to

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long take ketorolac with other NSAIDs. Advise patient to maintain adequate fluid intake. Tell patient to promptly report edema and weight gain.

Folic Acid vitamin

Stimulates normal erythropoiesis and nucleoprotein synthesis.

Children younger than age 4: Up to 0.3 mg PO, IV, IM, or subcut daily. children age 4 and older: 0.4 to 1 mg PO, IV, IM, or subcut daily. After anemia caused by folic acid deficiency is

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

May produce falsely low serum and RBC folate levels with the Lactobacillus casei assay method in patients on antiinfectives such as tetracycline.

Confusion, anorexia, nausea, abdominal distension, erythema

Teach patient the warning signs and symptoms of hepatotoxicity Warn patient to report Most CNS and GI adverse reactions occur all adverse reactions to at higher doses, such as prescriber. 15 mg daily for 1 month. Teach pregnant patients the importance Patients with smallof taking folic acid bowel resections and during pregnancy. intestinal malabsorptio n may need parenteral Teach patient about administration. proper nutrition to prevent recurrence of anemia. Stress importance of follow-up visits and laboratory studies. Teach patient about foods that contain folic acid: liver, oranges, whole wheat, broccoli, and Brussels sprouts. Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long corrected Infants: 0. 1 mg PO, IM, I., or subcut daily.

Acetaminophen Analgesic Para-aminophenol derivatives

Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain receptors. Drug may relieve fever through central action in the hypothalamic heatregulating center.

IV, PO Dosing is based on weight

May increase AST level. May decrease glucose, potassium, phosphorus, magnesium, albu min, and Hb level and hematocrit.

Headache, insomnia, nausea, vomiting, constipation, oliguria, anemia, hypoglycemia, hypokalemia, hypomagnesemia , dyspnea, uticaria

May decrease neutrophil, WBC, RBC, and platelet counts. May cause falsepositive test result for urinary 5hydroxyindoleac etic acid. May falsely decrease glucose level in home monitoring systems.

Ibuprofen NSAID

May inhibit prostaglandin

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Children 12-17:

May increase BUN, creatinine,

Consider reducing total daily dose and increasing dosing intervals in patients with hepatic or renal impairment. Be sure to base dose on weight for patients weighing less than 50 kg, to properly program infusion pump, and to ensure that total daily dose of acetaminophen from all sources doesn’t exceed maximum daily limit

Advise patient or caregiver that many OTC products contain acetaminophen and should be counted when calculating total daily dose Tell patient to consult prescriber for fever lasting longer than 3 days or recurrent fever. Caution patient to contact health care provider if signs and symptoms of liver damage Warn patient to stop drug and seek medical attention immediately if rash or other reactions occurs while using acetaminophen.

Dizziness, headache,

Check renal and hepatic function

Tell patient to take with meals or milk to Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects.

max 2,400mg daily Children 6mo-12: max is 40mg/kg or 2,400mg, whichever is less

ALT, AST, and potassium levels. May decrease glucose and Hb levels and hematocrit. May decrease neutrophil, WBC, RBC, platelet, and granulocyte counts.

nausea, vomiting, diarrhea, constipation, acute renal failure, hypokalemia, hypoglycemia, hematuria

periodically in patients on long-term therapy. Stop drug if abnormalities occur and notify prescriber. Monitor BP because drug can lead to newonset HTN or worsening of preexisting HTN, which may contribute to the increased incidence of CV events. Because of their antipyretic and antiinflammatory actions, NSAIDs may mask signs and symptoms of infection. Monitor patients for signs and symptoms of GI ulceration and bleeding. Monitor patient for signs or symptoms of aseptic meningitis (fev er, headache, sensitivity to light, vomiting) and report immediately if they occur.

reduce adverse GI reactions. Teach patient to watch for and immediately report to prescriber signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee-ground vomit; and black, tarry stool. Tell patient to contact prescriber before using this drug if fluid intake hasn’t been adequate or if fluids have been lost as a result of vomiting or diarrhea . Warn patient to avoid hazardous activities that require mental alertness until effects on CNS are known. Tell patient taking ibuprofen not to take other OTC NSAIDs, such as naproxenor Aleve, as these are in the same class. Advise patient to wear sunscreen to avoid

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long

Docusate Sodium Dulcolax, Colace Surfactant laxative

Stool softener that reduces surface tension of interfacing liquid contents of the bowel. This detergent activity promotes incorporation of additional liquid into stools, thus forming a softer mass.

Children 2-11: 50150mg daily PO or one enema daily

None

Mild cramping, diarrhea, dependence

Before giving drug, determine whether patient has adequate fluid intake, exercise, and diet. Drug is laxative of choice for patients who shouldn’t strain during defecation, including patients recovering from MI or rectal surgery, those with rectal or anal disease that makes passage of firm stools difficult, and those with postpartum constipatio n.

Children 12 and older: 50360mg daily PO until normal BM; or give enema

hypersensitivity to sunlight. Teach patient about dietary sources of fiber, including bran and other cereals, fresh fruit, and vegetables. Instruct patient to use drug only occasionally and not for longer than 1 week without prescriber’s knowledge. Tell patient to stop drug and notify prescriber if severe cramping occurs. Advise patient not to use OTC formulations for more than 7 days or when abdominal pain, nausea, or vomiting is present.

Clinical Packet

(to be completed during clinical, finalized and submitted to BB within 72 hours post clinical replacement SIM) Concept Map Worksheet Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

Sickle cell anemia is an inherited, autosomal recessive disorder characterized by an abnormal form of hemoglobin in the RBC. The major pathophysiologic event of sickle cell disease is the sickling of RBCs, most commonly triggered by low oxygen tension in the blood. Hypoxia of the RBCs can be caused by infection, high altitude, emotional or physical stress, surgery, and blood loss. Sickled RBCs become rigid and crescent shaped. Sickled cells cannot easily pass through capillaries and can cause vascular occlusion, leading to chronic tissue injury. Circulating sickle cells are hemolyzed by the spleen, leading to anemia. Sickle cell crisis is a severe, painful, acute exacerbation of RBC sickling, causing a vaso-occlusive crisis. As blood flow is impaired by sickled cells, vasospasm occurs, further restricting blood flow. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS

-peripheral blood smear -CBC -hemoglobin electrophoresis -chest x-ray (to detect infection or organ dysfunction) -MRI (to detect stroke) -reticulocyte

PATIENT INFORMATION

Brittany Long is a 5-year-old African American female with a history of sickle cell disease, diagnosed at 6 months old. She was brought to the ED during the night by her mother, who stated that the patient has been complaining of R lower left pain over the past 2 days.

ANTICIPATED PHYSICAL FINDINGS

-pain -jaundice/pallor -dactylitis -delayed growth -tachycardia -hepatomegaly/splenomegaly -leg ulcers -joint complications -hematuria -systolic and diastolic murmurs -fever

ANTICIPATED NURSING INTERVENTIONS

-encourage the child to talk about fears and concerns -encourage adequate fluid intake -administer IV fluid replacement therapy -administer analgesics and antipyretics as necessary -encourage bed rest with head of the bed elevated -oxygen therapy Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long -monitor respiratory rate, depth, and use of accessory muscles -monitor vital signs -teach and demonstrate the use of relaxation techniques

vSim ISBAR Activity Introduction Your name, position (RN), unit you are working on

Situation

Ashley Thompson Nursing student at Concordia University Emergency department Brittany Long is a 5-year-old African American female who was brought to the ED. The patient has been complaining of right lower leg pain over the last 2 days.

Patient’s name, age, specific reason for visit

Background Patient’s primary diagnosis, date of admission, current orders for patient

Brittany has a history of sickle cell disease and was diagnosed at 6 months old. She has been prescribed regular folic acid supplement. She has had a pain crisis before, mostly managed at home with acetaminophen and ibuprofen. She has been hospitalized twice, once at age 4 for vaso-occlusive crisis episode and once at age 3 for a fever.

Assessment

Brittany rated her pain as a 3 on the FACES Scale. She has not had an appetite in the

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

last 24 hours but has taken small amounts of oral fluids and continues to receive intravenous maintenance fluids at 52 mL/hr. When examined this morning, her blood pressure was 101/70 and her temperature was 99 degrees F. Shows signs of dehydration.

Recommendations

Recommend bolus of normal saline and PRBC due to her suspects sickle cell anemia crisis.

Any orders or recommendations you may have for this patient

Clinical Worksheet Date: 2-5-21 Initials: BL

Diagnosis: Sickle cell disease

Student Name: Ashley Thompson HCP: Dr. Smith

Age: 5yo

IV Type: peripheral Location: lower left arm

M/F: F Code Status: Full Code

Length of Stay: 1 day

Consults: Hematologist

Critical labs: CBC Blood smear BMP PLT Reticulocyte

Assigned vSim: Brittany Long complex Other services: N/A

Consults needed: Hematologist

Fluid/Rate: 52 ml/hr

Allergies: NKA

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long Why is your patient in hospital (Answer in your own words and include the History of present illness): Pt was brought to emergency department during the night by her mother, who stated that the patient has been complaining of right lower leg pain over the last 2 days Health History/ Comorbidities (that relate to this hospitalization): Pt is a 5-year-old African American female with a history of sickle cell disease, diagnosed at 6 months old, and has been prescribed regular folic acid supplement. She has had pain crisis before, mostly managed at home with acetaminophen and ibuprofen. She has been hospitalized twice, once at age 4 years for a vaso-occlusive crisis episode and once at age 3 years for a fever. Shift Goals/ Patient Education Needs: 1. Vital signs 2. Administer morphine as necessary 3. Assess right lower leg 4. Educate patient and parent on therapeutic pain management Plan to Discharge: Pt will demonstrate improved ventilation/oxygenation as evidenced by respiratory rate within normal limits, clear breath sounds, pt will participate in ADLs without weakness and fatigue, pt will verbalize relief or control of pain, pt will maintain adequate fluid balance Path to Death or Injury: Pt will not demonstrate adequate ventilation/oxygenation, pt will continue to express pain, pt will not maintain adequate fluid balance, pt will not have good skin turgor or prompt capillary refill, pt will be fatigued and weak

Learning Objectives, Laerdal Scenario Cloud 12/10/20 Version 1.0.1, Publication Date 2020-11-27

Modified by C.Ingulli

Clinical Replacement SIM: Brittany Long Alerts: What are you on alert for with this patient (signs & symptoms) 1. Confusion 2. Change in vitals 3. Pain

Management of Care: what needs to be done for this patient today? 1. Vital signs 2. Head-to-toe assessment 3. Pain assessment (FACES scale) 4. Administer pain medication 5. Encourage fluid intake 6. Educate patient and parent about therapeutic pain management

Priorities for Managing the Patient’s care today? What assessments will focus on for this 1. Vitals patient? (how will i identify the above signs & 2. Pain assessment symptoms?) 3. Administer pain medication 1. Monitor changes in level of 4. Educate patient and parent about therapeutic pain manage...