Running Head: CARDIAC DYSRHYTHMIAS

Cardiac Dysrhythmias Simulation Scenario and Overview Retina Attaberry, Josip Benko, Shannon Greenberg, Autumn Lyons, and Saeromy Kim Andrews University

CARDIAC DYSRHYTHMIAS Abstract The primary purpose of this paper is to fabricate a health care scenario regarding the care of a patient experiencing myocardial infarction and to elicit acceptable responses from nursing students based upon the QSEN competencies set forth by

the American Association of Colleges of Nursing 2013. In the following scenario we will be utilizing and implementing the QSEN competencies of patient centered care, safety, as well as evidence-based practice. Through this means, book knowledge can be applied to a practical situation. Students will demonstrate: professionalism and professional values, information management and application of patient care and technology, and basic organizational and systems leadership for quality care and patient safety as set for in the Essentials for Baccalaureate Education for Professional Nursing Practices. Students comprehension and preparedness can be assessed based on accurate and timeliness of responses. Through usage of this scenario, weaknesses and strengths can be evaluated as a pathway towards improvement.

CARDIAC DYSRHYTHMIAS SCENARIO OVERVIEW: Estimated Scenario Time: 30 minutes Guided Reflection Time: 30 minutes Target Group: Nurses Complex Case Brief Summary: This case scenario presents a sixty-five year-old man who presents to the

Emergency Room with severe chest pains, anxiety, pain in left arm, and shortness of breath. The student is expected to be able to recognize the atypical symptoms that men can present with when having cardiac problems. The man is experiencing MI upon arrival. The student should be able to recognize cardiac arrhythmias on the cardiac monitor and to implement appropriate interventions. The student should additionally maintain patient confidentiality and be aware of legal issues regarding patient autonomy and legal power of attorney. Learning Objectives: Perform through assessment Evaluate the assessment information as well as the vital signs of the patient Implement the appropriate safety measures Prioritize and implement the doctors orders correctly Demonstrate Effective teamwork Identify the appropriate nursing diagnoses and the primary diagnosis Implement therapeutic communication Implement appropriate patient teaching

CARDIAC DYSRHYTHMIAS Implement Restoration to the Image of God

Scenario Specifics: Implement NOPQRST characteristics of chest paint assessment due to MI Perform a thorough respiratory and cardiac assessment Implement appropriate cardiac respiratory monitoring Prioritize care based upon the ABCs Recognize myocardial infarction on the monitor Identify abnormal cardiac panel lab values Recall the specific treatments for a patient experiencing an MI Implement the appropriate care for a patient having an MI Identify adverse effects of morphine sulfate, respiratory depression, hypotension, bradicardia, and severe vomiting Implement proper treatment for morphine sulfate toxicity Naloxone 0.20.8mg IV Perform proper reprofusion therapy Recall the specific uses and side effects of various medications given for MI Implement appropriate patient education Identify barriers to learning

CARDIAC DYSRHYTHMIAS EQUIPMENT NEEDED: Equipment Standard precautions equipment Stethoscope Blood pressure cuff

SpO2

Thermometer ECG monitor 12 ECG electrode cables ECG electrodes Oxygen supply source Oxygen delivery device (nasal cannula and ambu bag) Suction device and suction catheter IV Pump IV tubing Emesis basin AED General supplies for administering medications PREPARATION OF SIMULATOR: Emergency Room

Medications and Fluids 1 liter 0.9% Normal Saline IV Nitroglycerin tablets: 0.3-0.4 mg SL, may repeat in 3-5 minutes up to 3 doses maximum Aspirin tables: 160-325mg chewed P.O., as soon as MI is expected, continue maintenance dose of 160-325mg P.O. daily for 30 days post MI. After 30 days, consider further therapy for prevention of MI Morphine Sulfate: 2-10mg dose IV every 5-15 minutes until the maximum prescribed dose is reached or patient experiences relief or signs of toxicity Naloxone 0.2-0.8mg IV Documentation Forms Patient Information Card Physician Orders Data Collection Form Diagnostic Tests Cardiac Markers Panel (CK-MB, Troponin) EKG Chest Radiograph

Dress manikin in mens clothes dress suit, dress shirt, tie, dress shoes Place manikin in Semi-Fowlers position on the gurney Secure ID Band to the patient with name, DOB and MR#

CARDIAC DYSRHYTHMIAS PARTICIPANTS: Student Roles: 1 primary nurse 3 secondary nurses Patients Wife 1 Child

Instructor Roles: 1 ER Physician

REPORT TO STUDENTS: Time: 10:30am James Elias is a sixty-five year-old married lawyer with a history of hypertension who smokes, and lives with his wife and two kids. He was brought to the Emergency Department by his wife who states that he has been complaining of chest pains and pain in his left arm that radiates upwards. He is also complaining of nausea and dizziness, and he has shortness of breath. Clinical Signs Immediately Present: Fast, Shallow breaths Anxiety Clutching chest with right arm

MEDICAL HITORY AND ADDITIONAL INFORMATION: Patient Data: Male. Age: 65. Weight 127kg. Height 170cm. DOB: 6/12/49 MR# GRX123887

CARDIAC DYSRHYTHMIAS Prior Medical History: Diagnosed with HTN 5 years ago and was prescribed lasix. His wife says that he does not take it because it makes him feel weak and tired.

Patient is obese, and has no history of cardiac problems. Patient smokes half pack of cigarettes per day and denies alcohol consumption. Patient is allergic to penicillin and sulfa drugs. Recent Medical History: Patient denies recent changes in medical history. Time 5 Minutes Monitor Settings (Instructor) Initial State: RR: 24 HR: 52, faint pulse Rhythm: Sinus Bradycardia with elevated ST BP: 95/65 SpO2: 90% Temp: 100.1 F Patient/Manikin (Actions) Auscultation Sounds: Crackle Vocal Sounds: My chest really hurts, God must be punishing me! Student Interventions (Events) Wash Hands Identify Patient Introduce Self Obtain Vital Signs, SpO2, and LOC Apply ECG leads Auscultate heart and lung sounds Call for help Apply Oxygen Administer 0.4mg nitroglycerine Obtain IV access Draw labs for cardiac markers panel Increase oxygen level Administer 0.4mg nitroglycerin Communicate lab values with physician Run normal saline according to doctors orders Cue/Prompt Role member providing cues: Wife Cue: Is he going to be alright?

5 to 10 Minutes

If no action within 4 minutes: RR: 30 HR: 48, faint pulse Rhythm: Sinus Bradycardia with elevated ST BP: 90/60 SpO2: 85%

Vocal Sounds: Moaning

Role member providing cues: Physician Cue: Order for labs and morphine sulfate

CARDIAC DYSRHYTHMIAS 10 to 20 Minutes When aspirin is given: RR: 30 HR: 48, faint pulse Rhythm: Sinus Bradycardia with elevated ST BP: 90/60 SpO2: 85% Vocal Sounds: None Monitor patients response to treatment Reassess vital signs Administer 2mg morphine sulfate IV Start additional IV site two 18 gage peripheral IV lines (1 fibrinolytic agent, 2 other drugs) Start fibrinolytic drugs Monitor vital signs (response to treatment) Maintain patient confidentiality and information security Assess patient pulses and lung sounds Teach wife about the importance of the patient taking prescribed medication Teach wife about healthy living patient should quit smoking Ask family if they would like prayer

8 Role member providing cues: Child Cue: Whats happening to dad?

20 to 30 Minutes

When Vocal Sounds: fibrinolytic Audible Respirations drugs implemented: RR: 28 HR: 58 Rhythm: Normal Sinus BP: 115/72 SpO2: 92%

Role member providing cues: Wife Cue: Is he ok now?

CARDIAC DYSRHYTHMIAS Correct Treatment: Initial patient contact: wash hands, introduce self, identify patient Obtain vital signs, including SpO2 Apply ECG leads Assess LOC Auscultate heart and lungs Call for help Apply Oxygen Administer nitroglycerin Communicate labs with physician Run normal saline following the five rights Monitor response Administer morphine sulfate Start additional IV line (two 18 gage peripheral IV) Start fibrinolytic drugs Monitor Vital signs Maintain patient confidentiality Asses heart and lung sounds Provide patient education (to family) Ask family if they would like prayer

Nursing Diagnosis: Ineffective tissue profusion related to impaired transport of oxygen as evidence by chest pain and SpO2 (90%)

CARDIAC DYSRHYTHMIAS Risk for spiritual distress related to challenged beliefs. Knowledge deficit related to disease management and progression AEB questions of what is happening, current acute situation, and importance of taking medication as prescribed. Debriefing/Guided Reflection Overview: Acute myocardial infarction is the medical term for an event commonly known as a heart attack. MI refers to prolonged ischemia caused by an imbalance between oxygen supply and oxygen demands.

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Typical signs and symptoms include: skin is cool and moist, low-grade fever, hypertension, and tachycardia from increased sympathetic tone or hypotension and bradycardia from increased vagal tone. Pulse may be irregular and faint.

Other signs and symptoms: Chest pain heaviness, squeezing, choking or smothering sensation; pain can radiate to neck, left arm, back or jaw.

Rapid transport to the Emergency Department is essential Initial management of an MI includes cardioversion, supplemental oxygen, vascular access and ECG monitoring.

Aspirin and fibrinolytic agents are the drugs of choice Percultaneous coronary intervention (PCI) within 90 minutes After initial stabilization, follow-up should include: referral to a cardiologist, admission for monitoring, and further studies.

CARDIAC DYSRHYTHMIAS

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Beta-blocker medication should be administered and monitoring of the drug regiment is necessary upon implementation

Magnesium and potassium levels should be monitored A low-cholesterol diet, low-salt diet Regular exercise should ne encouraged Patient should be encouraged to quit smoking Patient should be encouraged to explore spiritual implications

Physician Order Patient Name: James Elias Diagnosis: Myocardial Infarction DOB: 6/12/49 MR# GRX123887 Age: 65 Gender: Male Height: 170cm Weight: 127kg Allergies and Sensitivities: Penicillin and sulfa Date Time PHYSICIAN ORDER AND SIGNATURE Emergency Department Order Cardiac Monitoring Vital signs every 5 minutes Oxygen to maintain SpO2 greater than 92% Chemistry Profile IV access saline locked Administer nitroglycerine 0.4 mg SL every 3-5 minutes up to 3 doses PRN Administer 160mg aspirin tablets Administer 2mg morphine sulfate IV every 5-15 minutes until the maximum PHYSICIAN/PROVIDER SIGNATURE

Running Head: CARDIAC DYSRHYTHMIAS Patient Name: James Elias Case: Diagnosis: Myocardial Infarction History: Smoking, HTN Type of Operation: Height: 170cm Consultation: Consent obtained: Monitoring: X I&O X Vital signs every 4 hours X Telemetry X SpO2 ___Neuro checks X Neurovascular Age: 65 Gender: Male Physician: Dr. Nick Holden Advanced directives: Diet: Regular Fall precautions: Restraints: Isolation precautions: Respiratory: ___Incentive spirometry ___O2 ___Cannula ___Oxygen Mask ___Nonrebreather Mask ___Bag-mask ventilator ___Nebulize Drains: ___Foley to downdrain ___Nasogastric tube ___LCS ___LIS ___Hemovac ___Feeding Tube ___Chest tube ___Dressing Change Diagnosis Studies: X Lab ___X-ray X 12 lead ECG ___CT Scan Medications brought from home: none Activity of daily living: X Independent ___Assisted ___Total Care Discharge Planning: Schedule nutrition education Schedule appointment with cardiologist Allergies: Penicillin and sulfa drugs Unit: ER Major support: Wife Phone: 555-555-5555 Immunizations: Current

Weight: 127 kg

Medication: X IV access X IV fluid X Oral Medication Nitroglycerin, aspirin X IV Medication Morphine sulfate ___IM/subcutan medication

Social History: Lawyer Married, 2 kids, does not exercise Smokes pack/day, denies drinking alcohol Race/religion: African American, Catholic

Running Head: CARDIAC DYSRHYTHMIAS

References: Criddle, L. M., & Derr, P. (2011). Emergency & Critical Care pocket guide ACLS Version. Burlington: Jones & Bartlett Learning. Dugdale, D. (2012, June 6). Heart attack: MedlinePlus Medical Encyclopedia. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000195.htm Fontaine, D. K., & Morton, P. G. (2013). Critical Care Nusing: A holistic Approach. Philidelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins Lippincott Williams & Wilkins, & Wolters Kluwer Health (2012). Nursing 2012 drug handbook. Philadelphia, Pa: Wolters Kluwer Health/Lippincott Williams & Wilkins. Mayo Clinic (2013, May 15). Heart attack Risk factors - Diseases and Conditions Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseasesconditions/heart-attack/basics/risk-factors/con-20019520