Algorithm Quick Card

Initial settings:
T = 100.6 F (38.1 C) BP = 132/72
P = 100 RR = 28
O2 Sat = 88% (room air)
• Heart sounds: Regular
• Lung sounds: Crackles bilaterally
• Abdominal sounds: Present
• Pulses: 2+ (Normal)
• Maurice states, “I used the urinal
(deep breath); tried to hang it on
bedrail (deep breath); spilled it on
bed and floor (deep breath); I feel
badly for making this mess (deep
breath); my oxygen came off (deep
breath) as I reached for the urinal
(deep breath).”
Phase I expected student performance:
1. Conducts initial and focused assessments.
2. Recognizes abnormal findings (shortness of breath, anxiety and frustration, tachypnea,
decreased oxygen saturation level, elevated temperature, crackles in lung fields).
3. Notes urine spilled on floor and bed.
4. Utilizes therapeutic communication to address patient concerns.
If oxygen is administered and head of
bed is elevated:
T = 100.6 F (38.1 C) BP = 126/70
P = 98 RR = 24
O2 Sat = 89% (2 L/min via nasal cannula)
• Maurice states, “I feel a little better (deep
breath), but I still can’t catch my breath.”
O2 Sat = 91% (3 L/min via nasal cannula)
• Maurice states, “I feel a little better (deep
breath), but I still can’t catch my breath.”
O2 Sat = 94% (4 L/min via nasal cannula)
• Maurice states, “I can breathe much
better now.”
Phase III expected student
performance:
1. Evaluates patient’s response to
interventions.
2. Monitors patient closely.
3. Provides emotional support to patient
and son.
4. Documents all findings, interventions,
and patient responses.
S IMULATION LEARNING SYSTEM
Transition after 5 minutes:
T = 100.6 F (38.1 C) BP = 142/80 P = 108 RR = 30 O2 Sat = 86% (room air)
• Maurice states, “I’m sorry about the mess (deep breath); I’m so embarrassed
(deep breath); feel so weak (deep breath).”
Phase II expected student performance:
1. Prioritizes respiratory interventions over personal hygiene interventions.
2. Raises head of bed and repositions patient.
3. Administers oxygen via nasal cannula to maintain oxygen saturation
level above 92%.
4. Explains need to decrease oxygen demands (e.g., minimal talking, rest).
5. Changes bed linen and cleans patient.
6. Maintains dignity and privacy.
7. Cleans urine spill on floor.
If oxygen is administered but the head of
bed is NOT elevated:
T = 100.6 F (38.1 C) BP = 134/78
P = 105 RR = 28
O2 Sat = 88% (2 L/min via nasal cannula)
• Maurice states, “I feel a little better with the
oxygen on (deep breath), but it’s still so hard
to breathe.”
O2 Sat = 90% (3 L/min via nasal cannula)
• Maurice states, “That oxygen is helping some
(deep breath), but it’s still so hard to breathe.”
O2 Sat = 91% (4 L/min via nasal cannula)
• Maurice says, “I feel better, but I still can’t
really catch my breath (deep breath). Is there
anything else you can do to help me breathe
easier (deep breath)?
If oxygen is NOT administered
but the head of bed is elevated:
T = 100.6 F (38.1 C)
BP = 148/86
P = 110
RR = 32
O2 Sat = 87% (room air)
• Maurice states, “At least (deep
breath) I’m not lying flat (deep
breath), but I still can’t breathe
(deep breath).”
Algorithm
Quick Card
Thursday 1600
Maurice Arviso
MR: 7736871
Age: 60
DOB: February 22
NKA
If oxygen is NOT administered
and the head of bed is NOT
elevated:
T = 100.6 F (38.1 C)
BP = 156/88
P = 112
RR = 34
O2 Sat = 84% (room air)
• Maurice states, “Help (deep
breath); breathing worse (deep
breath); call doctor (deep
breath).”
Debriefing
Copyright © 2011 by Elsevier Inc. All rights reserved.
Scenario 8