Fall

08
Fall
11

NUR 101 Simulation # 1

John A. Sims
The following scenario is for the end of semester skills check-off for the first
semester PN student. The skills include vital signs, physical assessments,
Foley catheterization, IV initiation and medication administration.

McDowell Technical Community College Practical Nursing

Education
 NUR 101 Simulation #1

John Sims

Supply List

1. Pre-scenario work sheets

2. Objectives
3. Case study – John Sims
4. Chart with- MD orders, MAR, Laboratory Report, CXR Report, Medical Hx
(separate file)
5. Vita-Sims
6. BP cuffs, O2 sat monitors, thermometers
7. IV start kits, #22g IV catheters, Saline locks and Flushes
8. Meds: ASA 325mg, NTG 0.4mg SL, Digoxin 0.5mg po, Furosemide 40 mg IV,
9. Foley catheter kits
10. Simulation grading checklist
11. Debriefing form
 McDowell Technical Community College

Practical Nursing Education

Pre-Scenario Work Sheet

Name___________________________________________

Date_____________________________________________

Scenario________________________________________

You are preparing to do a clinical scenario for clinical make-up, remediation or just as a
scheduled simulation day. To help your time in the simulation lab to be a more valuable
learning experience, please complete the following prior to coming to lab. This will count
as one hour of prep time for your scenario.

1. Define the patient’s diagnosis (primary an/or secondary) of _____________.

2. List at least two problems appropriate for this patient.

3. What major symptoms would you expect to see with this diagnosis?

4. What major complications may occur with this diagnosis?

5. Look up the patient’s ordered medications (safe dose, compatibility, major side
effects, nursing considerations, and other information pertinent to the
medications).

6. Wear your clinical uniform (including stethoscopes, etc.) to do scenarios in the

lab.
 Objectives
NUR 101 Simulation #1

Objectives:
1. Assessment and recognition of abnormal signs and symptoms.
a. Assess vital signs
b. Assess for adventitious breath sounds
c. Assess for abnormal heart sounds
d. Assess intake and output and other signs of fluid retention
2. Initiate interdisciplinary collaboration in a hospital setting.
a. Report changes in the patient’s condition to the charge RN and/or
Physician
b. Implement new orders received from the physician
c. Chart findings using the appropriate methods and documents
3. Select appropriate interventions
a. Check vital signs appropriately
b. Oxygen- Apply 2-4 L/min nasal cannula as ordered
c. Insert a Foley catheter
d. Complete a shift and ongoing assessments
e. Administer correct medications using the six rights of medication
administration
4. Monitor therapeutic response to interventions (outcomes)
a. Monitor that patient will not have difficulty breathing and will
maintain oxygen saturations at ≥ 90%
b. Monitor urinary output

Case Study:
You are working the day shift at McDowell Technical Simulation Hospital. John
Sims, a seventy-five year old male came into the ER early this morning and was admitted
to your unit with hypertension, peripheral edema, and shortness of breath. He has a past
history of Heart Failure. He was started on oxygen at 4 L/min via nasal cannula in the
ER. Chest x-ray done in ER showed bilateral effusions in both lower lobes of his lungs.
The ER doctor sent preliminary orders and said his primary care doctor would be in to
write further medication orders. In report the ER nurse told you that Mr. Sims had taken
his digoxin and aspirin this morning before coming to the ER. It is now 0930, begin your
care of Mr. Sims by performing your shift assessment and initiating orders from the MD
order sheet.
 NUR 101 Simulation #1
John Sims
Instructor Grading Checklist

Student_______________________________
 HPS Settings/
Time Complete Points Educator Considerations
Interventions
(Beginning Steps: 10% of points) Inform student of start and
** Wash Hands 1 stop time
**Introduce self to patient and 1 Start__________________
explain
plan of care 1 Stop___________________
**Check patient identification (2
forms) 1 Students may have
**Provide privacy 1 difficulty getting started
**Don gloves or PPE when and may need a few
appropriate prompts for progression
Assessment: (30% of points)
Alert, oriented; answers questions
appropriately 1
**Denies pain/discomfort “0” 1
**Skin pale, dusky; cyanosis on lips
and nail beds 1
No nausea, not hungry “just ate
lunch” 1
**States shortness of breath at rest 1 Student should be
Vital signs- have students obtain performing assessment and
manually 1 gathering information to the
**HR-regular, 90 per/min no murmur 1 left.
**Resp.-24/min, labored; some 1
shortness of breath, so have this 1
function on
**Lung sounds-coarse rales
bilaterally 1
**Temp- 100.0 F tympanic
**Blood pressure- 180/90
**Oxygen saturations- 88% on RA
oxygen cannula on wall mount unit; 1
if observed, the patient states, “I 1
forgot to put it on after visiting
the restroom.” 1
**Student should reapply oxygen at
ordered rate of 4 L/min NC; sats will
increase to 93%; turn off SOB
function
Bowel sounds- present in all 4 quads
and normal
**3+ pitting edema bilaterally in
lower extremities
**Urine in urinal 150ml dark amber;
patient states, “I get so short of
breath getting up to the
bathroom.”
**Tissue- clear sputum, productive
freq. cough
Pedal pulses difficult to obtain

Verbal report (10% of points) Report is The following verbal orders

Student will need to inform the comprehensive and may be given by Dr Hope:
charge RN and phone the physician is clearly 5 Have students write verbal
regarding: lab values, K+ 2.9; report communicated: orders on a blank
decreased oxygen saturation on Report is lacking 2.5 physician’s order following
room air – returned to 93% with key information: correct read back and
oxygen application. If the student Report lacks several confirm procedure.
does not offer a patient update, key components MD orders-
 NUR 101
John Sims Simulation
Debriefing

1. What were your primary nursing concerns in this scenario?

2. What nursing interventions did you use?

3. What outcomes did you measure?

4. Did you miss anything in report?

5. What did you do well in this scenario?

 6. Did you have the necessary knowledge and skills to manage this
situation?

7. If you were able to do this again, what would you do differently?

Bibliography
Butler Community College. (n.d.). Butler Community College. (D.
Sanner, Ed.) Retrieved December 28, 2010, from Skills check-off
Scenarios Scenario: htp://www.ksbn.org/cne/simsceanrio4.pdf

Hale, T., & Ahlschlager, P. (2011). Simulation scenarios for Nursing

Education Instructor Resource. Clifton Park , New York, USA: Delmar
Cenage Learning.