Vital Signs Assessment for Nursing Scenario Set. Consolidated Instructor Manual. Frances W. Lee, DBA

Transcription

1 Vital Signs Assessment for Nursing Scenario Set Consolidated Instructor Manual Frances W. Lee, DBA Scenario Authors: Frances W. Lee, DBA Heidi H. Schmoll, RN, MSN-Ed Donna Kern, MD

2 Table of Contents Curricular Information 3 Faculty Information 4 Setup and Equipment 7 Case Information 9 Student Information 20 Debriefing Information 36 2

3 Curricular Information This scenario is one in a set of 23 scenarios written for use with the HealthCare Simulation South Carolina (HCSSC) course, Vital Signs Assessment for Nursing. All of the scenarios in this set can be licensed from the SimStore. Additional information about this course can be found on the HealthCare Simulation South Carolina website The Vital Signs Scenario Set has three components: 1. Vital Signs Procedural Steps (1 scenario) 2. Vitals Signs Measurement (4 scenarios, A, B, C & D) 3. Vitals Signs Assessment (18 scenarios, divided into groups A1 A6, B1 B6, & C1 C6) These scenarios are designed to follow a progression of learning. First, the students will demonstrate mastery of the procedural steps in taking vital signs, using the Vital Signs Procedural Steps scenario. Next, the students will demonstrate the ability to obtain the correct vital signs measurements using the Vital Signs Measurement Scenarios. Finally, the students will demonstrate clinical reasoning, using the Vital Signs Assessment scenarios. 3

4 Faculty Information Instructions for Running Vital Sign Procedural Scenarios: 1. Set the vital sign values on the manikin. Note: you can change the values for each student, if desired. 2. Click on START SCENARIO to begin. 3. Click on the - next to the folder to collapse it, if desired. 4. Observe the student and click on each menu item as the student completes it. If the student does NOT complete an item, do not click on it. A green check will appear when an item has been selected. 5. Click on END AND GRADE when the student completes the vital sign assessment. The following flag will appear on the patient monitor while the grade is being calculated. 6. Wait for the The End flag to appear on the patient monitor BEFORE you go to debriefing. 4

5 Instructions for Running Vital Sign Measurement Scenarios: 1. Click on START CASE 1 to begin a. Click on the + next to folder to expand it and show values. b. Click on the - next to the folder to collapse it. c. Green checks indicate that a menu item has been selected. Note: In these scenarios menu items may be used more than one time. You can ignore the green checks. 2. Click on the values for each case that are closest to the participants reported values. 3. Click END Case 1 to end the case and generate feedback that will appear on the patient monitor. Examples of Feedback: 4. Repeat for Cases 2 and 3. Note: Cases may be run in any order. 5

6 Instructions for Running Vital Sign Assessment Scenarios: 1. Click on START SCENARIO to begin. a. Folders will open with correct values and possible actions b. Click on the - next to the folder to collapse it, if desired. 2. Click on Patient Information to bring up case background on the monitor. 3. Observe the student and click on each menu item as the student completes it. If the student does NOT complete an item, do not click on it. A green check will appear when an item has been selected. a. Students must measure the correct BP, HR, and RR. They must also take the patient s temperature. They will then determine which of the following actions are appropriate: i. Document Findings ii. Reassess Vital Signs iii. Inform the Healthcare Provider iv. Call for Help 4. Click on END CASE when the student completes the vital sign assessment case. 5. Go to Debriefing to see correct and incorrect actions. 6

7 Setup and Equipment Procedural Scenario Logistics: Set the instructor monitor NOT equal to the student monitor in the software configuration. The facilitator must be able to see the vital signs. The patient monitor set up is saved so that the participant sees a blank screen. Calibrate the Blood Pressure on the manikin. (See manikin instructions) This should be done prior to each session. Scenario run time: approximately 5 minutes. Debriefing time: approximately 5-10 minutes in practice; may be more for evaluation. Set up for small group practice (ideally 2-3 students per manikin). One facilitator can oversee multiple manikins, with participants running the scenario for each other via the programmed menu. Measurement Scenarios Set Logistics: Set the instructor monitor NOT equal to the student monitor in the software configuration. The facilitator must be able to see the vital signs. The patient monitor set up is saved so that the participant sees a blank screen. Calibrate the Blood Pressure on the manikin. (See manikin instructions) This should be done prior to each session. Scenario run time: approximately 30 minutes for three cases. o A group of three students can complete the three sets (9 cases) in approximately 1.5 hours. Debriefing time: none; scenario provides immediate feedback to students. The debrief log may, however, be saved as documentation of performance. Set up for small group practice (ideally 2 3 students per manikin). One facilitator can oversee multiple manikins. Participants will run the scenarios for each other. Assessment Scenarios Logistics: Set the instructor monitor NOT equal to the student monitor in the software configuration. The facilitator must be able to see the vital signs. The patient monitor set up is saved so that the participant sees a blank screen. Calibrate the Blood Pressure on the manikin. (See manikin instructions) This 7

8 should be done prior to each session. Scenario run time: approximately 5 minutes each. Debriefing time: approximately 2-3 minutes in practice; may be more for evaluation. Equipment Needed: 1. Oral Thermometer 2. Blood pressure cuff in the appropriate size and/or blood pressure setup on manikin 3. Sphygmomanometer 4. Stethoscope 5. Gloves 6. Water soluble lubricant (optional) 7. Pen/pencil and paper 8

9 Case Information Procedural Scenario This scenario can be modified and used for any adult patient. The scenario operator adjusts the vital signs manually. The participant is evaluated on the number and percentage of procedural steps completed correctly. Information provided within the scenario: Patient Name: Victoria Vital Age: kg cm Background: History of hypertension, dementia and degenerative joint disease. Long-term care facility It is 0800 and vital signs need to be obtained prior to medication administration. The charge nurse asked for you to assess her vital signs. Measurement Scenarios The Vital Signs Measurement scenarios (A, B, C & D) are multi-case scenarios. Each scenario is designed to allow participants to take three sets of vital signs and receive immediate performance feedback. There is no associated patient information; these scenarios are designed for practice obtaining accurate vital signs measurements. Assessment Scenario Case A1 (Smith) Patient Name: Betty Smith Age: kg 160 cm Background: Annual physical examination with primary care provider Clinic Betty Smith is a 25-year-old female who is attending her annual physical examination with her primary care provider. She has no known allergies, no hospitalizations, surgeries, or diagnosis. She presently takes oral contraceptives. 9

10 Last appointment one year ago: BP = 125/80 HR = 62 RR = 14 Temp. = 98.4F Historical vital signs are normal; current vital signs are abnormal; reassessment vital signs are normal. Assessment Scenario Case A2 (White) Patient Name: Frank White Age: kg cm Male Background: History of diabetes and arrhythmias Emergency Department Frank White is a 63-year-old male who has been presented to the emergency department. Frank was mowing his lawn in 100-degree weather. On arrival to the ED, vital signs: BP = 122/76 HR = 96 RR = 18 Temp. = 98.9F Historical vital signs are normal: current vital signs are abnormal. Assessment Scenario Case A3 (Class) Patient Name: Christina Class Age: kg cm Background: History of hypertension, degenerative joint disease, hip replacement, and dementia. Long-term care facility 10

11 Christina Class is a 72-year-old patient who resides in the long-term care facility. You are making re-assessments of vital signs after morning medication administration to document in the progress notes of the medical record. Prior to medication administration at 0730: BP = 166/92 HR = 101 RR = 22 Temp. = 98.7F Historical vital signs are abnormal: current vital signs are normal. Assessment Scenario Case A4 (Perry) Patient Name: James Perry Age: kg cm Male Background: History of hypertension and coronary artery disease. Hospital James Perry is a 44-year-old male who is in the hospital for a fall. He is a smoker. He has routine vitals every four hours and it is time to assess his vital signs for At 1200: BP = 158/86 HR = 110 RR = 20 Temp. = 98.9F Historical vital signs are abnormal: current vital signs are abnormal. Assessment Scenario Case A5 (Little) Patient Name: John Little Age: kg cm 11

12 Background: Male History of erratic behavior. Emergency Department John Little is an 18-year-old male who was trying to cross the railroads tracks with an oncoming train. The train hit the motor vehicle and John was seriously injured. He has arrived by stretcher in the emergency department. You are the first nurse to assess vital signs. En route: BP = 102/58 HR = 68 RR = 14 Temp. = 98.0F Current vital signs indicate that this is an emergent situation. Assessment Scenario Case A6 (Vital) Patient Name: Victoria Vital Age: kg cm Background: History of hypertension, asthma, and degenerative disc disease. Long Term Care Facility Victoria Vital is an 82-year-old female in the long-term care facility. She has prior diagnosis of hypertension, asthma, and degenerative joint disease. It is 0800 and vital signs need to be obtained prior to medication administration. The nurse has asked for you to assess her vital signs. Yesterday s 0900 vital signs assessment: BP = 162/86 HR = 62 RR = 24 Temp. = 100.6F Historical vital signs are abnormal: current vital signs are borderline. 12

13 Assessment Scenario B1 (Sims) Patient Name: Jim Sims Age: kg cm Male Background: History of hypertension, hypercholesterolemia, and cerebral vascular accident. Care Center Jim Sims is a 56-year-old male in the long-term care center. His vital signs are checked daily at 1200 following 0900 medication administration. At 1200: BP = 162/84 HR = 112 RR = 18 Temp. = 99.1F Historical vital signs are abnormal; current vital signs are abnormal. Assessment Scenario B2 (Mine) Patient Name: Mary Mine Age: kg cm Background: No health history Emergency Department Mary Mine is an 18-year-old female who was a passenger in a motor vehicle accident. The car was hit on the passenger s side. She complains she is feeling dizzy and weak. You are assessing her vital signs as you just took over care of Mary. En Route: BP = 98/52 HR = 66 RR = 12 Temp. = 97.0F 13

14 Vital signs indicate an emergent situation. Assessment Scenario B3 (Smith) Patient Name: Lane Smith Age: kg cm Male Background: History of hypertension, asthma, and degenerative disc disease. Long-term care facility Lane Smith is a 66-year-old male in the long-term care facility. He has prior diagnosis of hypertension, asthma, and degenerative joint disease. It is 0800 and vital signs need to be obtained prior to medication administration. The nurse has asked for you to assess his vital signs. Yesterday s 0900 vital signs assessment: BP = 172/84 HR = 110 RR = 22 Temp. = 100.6F Historical vital signs are abnormal; current vital signs are borderline abnormal. Assessment Scenario B4 (Bass) Patient Name: Laurie Bass Age: kg 155 cm Background: Routine annual gynecological exam. Doctor s office Laurie is a 28-year-old female who is attending her annual gynecological exam. She has no known allergies, no hospitalizations, surgeries, or diagnosis. She takes a multivitamin and vitamin once a day. 14

15 Last appointment one year previously: BP = 118/62 HR = 72 RR = 16 Temp. = 98.0F Historical vital signs are normal; current vital signs are abnormal; reassessment vital signs are normal. Assessment Scenario B5 (Mallflower) Patient Name: Richard Mallflower Age: kg cm Male Background: History of dementia and cardiovascular disease. Clinic Richard Mallflower is a 72-year-old male who has been presented to the clinic for rhinitis and coughing. Last clinic visit: BP = 124/72 HR = 88 RR = 14 Temp. = 98.9F Historical vital signs are normal; current vital signs are abnormal. Assessment Scenario B6 (Stills) Patient Name: Stephanie Stills Age: kg cm Background: History of hypertension, sciatica, and high cholesterol. Hospital floor 15

16 Stephanie Stills is a 64-year-old patient admitted to the hospital for an emergent appendectomy. She is post-op day one. She was given pain medication at You are to reassess her vital signs vital signs: BP = 172/84 HR = 103 RR = 24 Temp. = 99.0F Historical vital signs are abnormal; current vital signs are normal. Assessment Scenario C1 (Allen) Patient Name: Michael Allen Age: kg cm Male Background: History of cardiac disease, gastroesophageal reflux, and gastric ulcers. Emergency Department Michael is a 35-year-old male who was admitted to the emergency department for acute pain in the gastric region. The prior nurse administered pain medication after the 0800 vital signs. You are reassessing his vital signs vital signs: BP = 180/86 HR = 110 RR = 26 Temp. = 100.0F Historical vital signs are abnormal; current vital signs are normal. Assessment Scenario C2 (Beal) Patient Name: Allison Beal Age: kg 16

17 Background: cm History of dementia, diabetes, hip replacement, and falls. Long-term care center Allison Beal is a 70-year-old female who was admitted to the long-term care facility for multiple falls in her home and monitoring. She has been complaining of dizziness and you are performing vitals per the physician s orders. You are to assess her vital signs for At 1200: BP = 176/88 HR = 108 RR = 16 Historical vital signs are abnormal; current vital signs are abnormal. Assessment Scenario C3 (Ripe) Patient Name: Ronald Ripe Age: kg cm Male Background: History of a fractured left leg while skiing two weeks ago. Emergency Department Ronald is a 55-year-old male admitted to the emergency department for shortness of breath. Ronald fractured his left leg while skiing two weeks ago. The fracture was surgically repaired. You are assessing his vital signs for the first time since he arrived in the emergency department. En Route: BP = 102/54 HR = 82 RR = 16 Temp. = 97.4F Current vital signs indicate this is an emergent situation. 17

18 Assessment Scenario C4 (Care) Patient Name: Cathy Care Age: kg cm Background: History of anorexia and bulimia. Hospital floor Cathy is a 22-year-old female admitted to the hospital for chest pain. Cathy has a history of anorexia and bulimia. She was attending an outpatient program and was released one month ago. You are assessing her vital signs per health care facility protocol. Last vital signs: BP = 82/42 HR = 110 RR = 22 Temp. = 96.8F Historical vital signs are abnormal; current vital signs are borderline. Assessment Scenario C5 (Longfellow) Patient Name: Misty Longfellow Age: kg cm Background: History of diabetes, peripheral, neuropathy, and cardiovascular disease. Long-term care setting Misty is an 81-year-old female admitted to the long-term care center for inability to manage her diabetes. She is to receive medications at You are to assess her vital signs prior to administration. Yesterday s 1200 Assessment: BP = 120/78 18

19 HR = 72 RR = 16 Temp. = 98.9F Historical vital signs are normal; current vital signs are abnormal. Assessment Scenario C6 (Weekson) Patient Name: Cathy Weekson Age: kg 162 cm Background: Admitted for abdominal pain. Hospital Cathy is a 35-year-old female admitted to the hospital for left lower quadrant pain. Presently, her pain is controlled and you are performing a routine vital signs assessment Assessment: BP = 124/68 HR = 80 RR = 12 Temp. = 97.9F Historical vital signs are normal; current vital signs are abnormal. 19

20 Student Information Procedural Scenario Procedure Steps: I. Procedure Preparation a. Check the medical record i. Check the patient s medical records for vital signs orders. ii. Verify health care organization s protocol for routine vital signs assessment. b. Patient Communication i. Introduce him/herself. ii. Explain to the client the purpose of vital signs and all steps in the assessment. iii. Screen for contraindications of vital signs assessment. Screen for use of drugs that may cause alteration in vital signs. For example: antipyretics will lower temperature and beta-blockers will slow heart rate resulting in a decreased pulse. iv. Screen health history for any conditions that may alter vital signs. For example, individuals with a history of a mastectomy or an arteriovenous fistula should not have blood pressure measured in the affected extremity. v. Identify patient using two identifiers. vi. Prepare the patient, including positioning into a supine or erect sitting position. II. III. Equipment List a. Required i. Oral, tympanic, or rectal thermometer ii. Blood pressure cuff in various sizes (i.e. extra small, small, or extra large) iii. Sphygmomanometer iv. Stethoscope v. Gloves vi. Optional-water soluble lubricant vii. Pen/pencil and paper viii. Clock or watch with second hand b. Special Considerations of Equipment Use -- Disposable stethoscopes are not recommended for students during the assessment as they may contribute to the inability to clearly auscultate the apical pulse. Procedural Steps Temperature 20

21 1. Don gloves in clean technique. 2. Reset the thermometer prior to use. 3. Apply probe cover for the thermometer. 4. Place the thermometer via oral, tympanic, axillary or rectal route as indicated. (Note: Steps for using the thermometers are listed in the following sections) 5. Wait approximately two to three minutes before removing unless the thermometer is electronic and provides indication when temperature has been measured. 6. Once the thermometer has indicated the reading has been obtained, remove from the selected cavity and note the temperature. 7. Dispose of the probe cover. 8. Perform hand hygiene. 9. Record temperature in the designated health care record. 10. If the assessment is greater than 10% in difference (higher or lower) from prior trends, report the assessment to the health care provider. Oral Thermometer a. Ask the patient if they have consumed food, drink, or tobacco products in the last 15 to 30 minutes. b. Ensure the client can close their lips around the thermometer. If lips cannot be closed around the thermometer to form a light seal, a lower temperature reading may occur. c. Encourage the client not to bite down on the thermometer. Note: Do not use the oral route if the client has an endotracheal tube or is unable to follow instructions to ensure an accurate reading. Tympanic Thermometer a. Turn the patient s head to right or left side. b. Pull the pinna up and back for an adult. c. Pull pinna down and back for a child. d. Insert the end of the thermometer directly into the ear canal. e. Do not force the thermometer, but make sure it is inserted completely into the ear canal. f. Tilt the thermometer slightly toward the nose to get an accurate temperature assessment. 21

22 Rectal Thermometer a. Position patient onto the right side, side-facing away from you. b. Apply lubrication to the last inch of the distal end of the thermometer. c. Spread the buttocks with the non-dominant hand exposing the anus. d. Insert the thermometer through the anus into the anal canal. Guide the thermometer perpendicular to the anus in all planes. Do not force the thermometer into the rectum if resistance is met. Insert the thermometer 1.5 inches in the adult or 1 in the child. e. Wait two to three minutes or until the thermometer has indicated temperature assessment is complete. f. Remove the thermometer from the rectum. Axillary Thermometer a. Insert the thermometer into the axilla, with the end resting in the middle area of the axilla. b. Have the patient rest their arm against the lateral aspect of the thorax covering the probe. c. Leave the thermometer in place until reading alarm sounds. Topical Thermometer a. Temporal artery thermometer: Sweep the across the forehead, across the temporal area of the cranium, and behind the ear as if you are outlining the posterior area of the ear. Wait until the thermometer "beeps," indicating the reading is complete. b. Topical thermometer (skin thermometer): Make sure the plastic of the thermometer is in full contact with the skin. c. Infrared thermometer: These are the most accurate thermometers. They require no contact with the skin or client. The thermometer is held at the distance from the body recommended by the manufacturer. The infrared thermometer uses a sensor detecting the energy expended by the body, surrounded ambiance, and uses a conversion to provide an accurate temperature assessment. Radial Pulse 1. Locate the radial artery on the underside of the lateral forearm near the wrist, sitting upon the distal lateral border of the radius bone. 22

23 Apical Pulse 2. Palpate the pulse. Place the index, middle, and ring fingers on the location of the radial artery. Hold fingers almost perpendicular to the patient's wrist. Fingers should not rest "flat" against the wrist. Apply enough pressure to feel the pulse. However, excessive pressure will obliterate the pulse. 3. The pulse is counted for 20 seconds and multiplied by three to calculate beats per minute. If any irregularity is present, the pulse should be counted for one full minute. For example, if a patient has atrial fibrillation, the pulse should be counted for one minute due to the irregular rhythm associated with the alteration. 4. Note pulse amplitude during palpation. 5. Record the findings. 6. If the assessment is greater than 10% in difference (higher or lower) from prior trends, report the assessment to the health care provider. 1. Locate the point of maximum impulse for the apical pulse over the apex of the heart (A). 2. Warm the stethoscope prior to auscultation with gloved hands. Use the bell of the stethoscope during the auscultation. 3. Auscultate the apical pulse at the PMI (B). 4. Once auscultation is occurring, begin counting the heart rate for one full minute. 5. Record the findings. 6. If the assessment is greater than 10% in difference (higher or lower) from prior trends, report the assessment to the health care provider. Blood Pressure 1. Select the correct size for the blood pressure cuff based on the size of the patient's arm. 2. Ask the patient to extend and relax the extremity of choice for blood pressure assessment. Avoid measuring blood pressure in an arm with extensive axillary node dissection or an arteriovenous fistula. 3. Expose the upper part of the patient's arm with palm upward, arm slightly flexed, with the whole arm supported at heart level. 4. Using the index, middle, and ring fingers, palpate the brachial artery. The brachial artery is located medially of the forearm in the bend of the elbow (medial aspect of the antecubital fossa). Do not apply too much pressure to the artery as you may cause occlusion resulting in the inability to palpate the brachial artery. 23

24 5. Place the stethoscope into the ears ensuring the ear tips are pointed toward the nose. 6. Tighten the screw valve on the air pump (turning to the right will tighten the screw valve and tightening to the left will loosen the screw valve). 7. Wrap the blood pressure cuff around the upper arm approximately 2 to 5 centimeters above the elbow. 8. Ensure the line designation for the artery on the blood pressure cuff is aligned with the brachial artery. 9. Palpate the brachial artery to ensure accurate placement of the stethoscope. 10. Ensure the sphygmomanometer gauge is at zero prior to cuff inflation. 11. Explain to the patient you will need to pump the blood pressure cuff to designated amount to ensure an accurate reading and the inflated cuff may cause a small amount of discomfort. 12. While palpating the brachial artery, squeeze the air pump to inflate the blood pressure cuff until you can no longer palpate the brachial artery. Further pump the cuff 30 mmhg above the number at which you can no longer palpate the brachial pulse. (For example: If palpation of the brachial artery ceases at 150 mmhg, continue to pump the cuff until 180 mmhg). 13. Place the diaphragm of the stethoscope where the index, middle, and ring fingers were palpating the brachial artery. 14. Slowly deflate the blood pressure cuff by loosening the screw valve on the air pump while watching the sphygmomanometer gauge. (Deflation of the cuff should occur slowly at 2-4 mmhg per second). 15. Monitor the sphygmomanometer gauge needle as the cuff deflates and auscultation occurs. When using a sphygmomanometer gauge, the blood pressure can only be measured in multiples of two. 16. Note the first Korotkoff sound heard through auscultation. The corresponding gauge reading is the systolic blood pressure. 17. Note the last Korotkoff sound heard, or cessation of Korotkoff sounds, through auscultation. The corresponding gauge reading is the diastolic blood pressure. 18. If re-assessment of the blood pressure is needed, wait at least two minutes before performing the assessment again. 19. Remove the blood pressure cuff from the client s arm. 20. Perform hand hygiene. 21. Record the blood pressure in the designated health care record. 22. If the assessment is greater than 10% in difference (higher or lower) from prior trends, report the assessment to the healthcare provider. Respirations After the radial pulse has been measured, continue to palpate the artery. 24

25 1. Begin counting respirations for one full minute by watching the chest rise and fall or by placing one hand on the chest. One chest rise and one chest fall is equaled to one respiration. Count 20 seconds and multiply times three, unless an abnormal breathing pattern is noted. If an abnormal breathing pattern is noted, count respirations for one full minute. 2. Compare inspiration to expiration to note any characteristics. 3. Observe the depth of respirations. 4. Observe the pattern of the respirations. 5. Note the quality of the respirations. 6. Perform hand hygiene. 7. Record in the designated healthcare record. 8. Report dyspnea, tachypnea, hypoventilation, or hyperventilation to the healthcare provider. Measurement Scenario 1. Click on START CASE 1 to begin a. Click on the + next to folder to expand it and show values. b. Click on the - next to the folder to collapse it c. Green checks indicate that a menu item has been selected. Note: In these scenarios menu items may be used more than one time. You can ignore the green checks. 25

26 2. Click on the values for each case that are closest to the participants reported values. 3. Click END Case 1 to end the case and generate feedback that will appear on the patient monitor. Examples of Feedback: 4. Repeat for Cases 2 and 3. Note: Cases may be run in any order. Assessment Scenario Case A1 (Smith) Patient Name: Betty Smith Age: kg 160 cm Background: Annual physical examination with primary care provider Clinic Betty Smith is a 25-year-old female who is attending her annual physical examination with her primary care provider. She has no known allergies, no hospitalizations, surgeries, or diagnosis. She presently takes oral contraceptives. Last appointment one year ago: BP = 125/80 HR = 62 RR = 14 Temp. = 98.4F 26

27 Assessment Scenario Case A2 (White) Patient Name: Frank White Age: kg cm Male Background: History of diabetes and arrhythmias Emergency Department Frank White is a 63-year-old male who has been presented to the emergency department. Frank was mowing his lawn in 100-degree weather. On arrival to the ED, vital signs: BP = 122/76 HR = 96 RR = 18 Temp. = 98.9F Assessment Scenario Case A3 (Class) Patient Name: Christina Class Age: kg cm Background: History of hypertension, degenerative joint disease, hip replacement, and dementia. Long-term care facility Christina Class is a 72-year-old patient who resides in the long-term care facility. You are making re-assessments of vital signs after morning medication administration to document in the progress notes of the medical record. Prior to medication administration at 0730: BP = 166/92 HR = 101 RR = 22 Temp. = 98.7F 27

28 Assessment Scenario Case A4 (Perry) Patient Name: James Perry Age: kg cm Male Background: History of hypertension and coronary artery disease. Hospital James Perry is a 44-year-old male who is in the hospital for a fall. He is a smoker. He has routine vitals every four hours and it is time to assess his vital signs for At 1200: BP = 158/86 HR = 110 RR = 20 Temp. = 98.9F Assessment Scenario Case A5 (Little) Patient Name: John Little Age: kg cm Male Background: History of erratic behavior. Emergency Department John Little is an 18-year-old male who was trying to cross the railroads tracks with an oncoming train. The train hit the motor vehicle and John was seriously injured. He has arrived by stretcher in the emergency department. You are the first nurse to assess vital signs. 28

29 En route: BP = 102/58 HR = 68 RR = 14 Temp. = 98.0F Assessment Scenario Case A6 (Vital) Patient Name: Victoria Vital Age: kg cm Background: History of hypertension, asthma, and degenerative disc disease. Long Term Care Facility Victoria Vital is an 82-year-old female in the long-term care facility. She has prior diagnosis of hypertension, asthma, and degenerative joint disease. It is 0800 and vital signs need to be obtained prior to medication administration. The nurse has asked for you to assess her vital signs. Yesterday s 0900 vital signs assessment: BP = 162/86 HR = 62 RR = 24 Temp. = 100.6F Assessment Scenario B1 (Sims) Patient Name: Jim Sims Age: kg cm Male Background: History of hypertension, hypercholesterolemia, and cerebral vascular accident. Care Center Jim Sims is a 56-year-old male in the long-term care center. His vital signs are checked daily at 1200 following 0900 medication administration. 29

30 At 1200: BP = 162/84 HR = 112 RR = 18 Temp. = 99.1F Assessment Scenario B2 (Mine) Patient Name: Mary Mine Age: kg cm Background: No health history Emergency Department Mary Mine is an 18-year-old female who was a passenger in a motor vehicle accident. The car was hit on the passenger s side. She complains she is feeling dizzy and weak. You are assessing her vital signs as you just took over care of Mary. En Route: BP = 98/52 HR = 66 RR = 12 Temp. = 97.0F Assessment Scenario B3 (Smith) Patient Name: Lane Smith Age: kg cm Male Background: History of hypertension, asthma, and degenerative disc disease. Long-term care facility Lane Smith is a 66-year-old male in the long-term care facility. He has prior diagnosis of hypertension, asthma, and degenerative joint disease. It is 0800 and vital signs need to be obtained prior to medication administration. The nurse has asked for you to assess his vital signs. 30

31 Yesterday s 0900 vital signs assessment: BP = 172/84 HR = 110 RR = 22 Temp. = 100.6F Assessment Scenario B4 (Bass) Patient Name: Laurie Bass Age: kg 155 cm Background: Routine annual gynecological exam. Doctor s office Laurie is a 28-year-old female who is attending her annual gynecological exam. She has no known allergies, no hospitalizations, surgeries, or diagnosis. She takes a multivitamin and vitamin once a day. Last appointment one year previously: BP = 118/62 HR = 72 RR = 16 Temp. = 98.0F Assessment Scenario B5 (Mallflower) Patient Name: Richard Mallflower Age: kg cm Male Background: History of dementia and cardiovascular disease. Clinic Richard Mallflower is a 72-year-old male who has been presented to the clinic for rhinitis and coughing. 31

32 Last clinic visit: BP = 124/72 HR = 88 RR = 14 Temp. = 98.9F Assessment Scenario B6 (Stills) Patient Name: Stephanie Stills Age: kg cm Background: History of hypertension, sciatica, and high cholesterol. Hospital floor Stephanie Stills is a 64-year-old patient admitted to the hospital for an emergent appendectomy. She is post-op day one. She was given pain medication at You are to reassess her vital signs vital signs: BP = 172/84 HR = 103 RR = 24 Temp. = 99.0F Assessment Scenario C1 (Allen) Patient Name: Michael Allen Age: kg cm Male Background: History of cardiac disease, gastroesophageal reflux, and gastric ulcers. Emergency Department Michael is a 35-year-old male who was admitted to the emergency department for acute pain in the gastric region. The prior nurse administered pain medication after the 0800 vital signs. You are reassessing his vital signs. 32

33 0800 vital signs: BP = 180/86 HR = 110 RR = 26 Temp. = 100.0F Assessment Scenario C2 (Beal) Patient Name: Allison Beal Age: kg cm Background: History of dementia, diabetes, hip replacement, and falls. Long-term care center Allison Beal is a 70-year-old female who was admitted to the long-term care facility for multiple falls in her home and monitoring. She has been complaining of dizziness and you are performing vitals per the physician s orders. You are to assess her vital signs for At 1200: BP = 176/88 HR = 108 RR = 16 Assessment Scenario C3 (Ripe) Patient Name: Ronald Ripe Age: kg cm Male Background: History of a fractured left leg while skiing two weeks ago. Emergency Department Ronald is a 55-year-old male admitted to the emergency department for shortness of breath. Ronald fractured his left leg while skiing two weeks ago. The fracture was 33

34 surgically repaired. You are assessing his vital signs for the first time since he arrived in the emergency department. En Route: BP = 102/54 HR = 82 RR = 16 Temp. = 97.4F Assessment Scenario C4 (Care) Patient Name: Cathy Care Age: kg cm Background: History of anorexia and bulimia. Hospital floor Cathy is a 22-year-old female admitted to the hospital for chest pain. Cathy has a history of anorexia and bulimia. She was attending an outpatient program and was released one month ago. You are assessing her vital signs per health care facility protocol. Last vital signs: BP = 82/42 HR = 110 RR = 22 Temp. = 96.8F Assessment Scenario C5 (Longfellow) Patient Name: Misty Longfellow Age: kg cm Background: History of diabetes, peripheral, neuropathy, and cardiovascular disease. Long-term care setting 34

35 Misty is an 81-year-old female admitted to the long-term care center for inability to manage her diabetes. She is to receive medications at You are to assess her vital signs prior to administration. Yesterday s 1200 Assessment: BP = 120/78 HR = 72 RR = 16 Temp. = 98.9F Assessment Scenario C6 (Weekson) Patient Name: Cathy Weekson Age: kg 162 cm Background: Admitted for abdominal pain. Hospital Cathy is a 35-year-old female admitted to the hospital for left lower quadrant pain. Presently, her pain is controlled and you are performing a routine vital signs assessment Assessment: BP = 124/68 HR = 80 RR = 12 Temp. = 97.9F 35

36 Debriefing Information The Vital Signs Procedural Steps and Assessment Scenarios are designed and programmed for debriefing using the Diagnostic Educational Objective-based Reflection (DEOR) methodology. Dr. John Schaefer, HealthCare Simulation South Carolina (HCSSC), developed DEOR to provide objective-based feedback to scenario participants. More information about using the DEOR method of debriefing can be found at the HCSSC website In addition, the Vital Signs Procedural Steps Debrief Log shows the calculated number and percentage of correct steps. This grade provides specific, evaluative feedback to participants. 36

37 Sample Debrief Log with grading: 37

38 Measurement Scenarios These scenarios are designed to give participants immediate feedback and do not require debriefing. However, the debrief file may be saved as a record of student performance. Sample Vital Signs Measurement Debrief Log: Sample Vital Signs Assessment Scenario Debrief Log: 38