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Perinatal Clinical Academy_ SCE OB Hypertension Management ‐ 1
PHS AND AFFILIATES
SCE: OB Hypertension Management Perinatal Clinical Academy
Simulated Clinical Experience and Facilitator Guide
Last Revision: July 12, 2016
Perinatal Clinical Academy_ SCE OB Hypertension Management ‐ 2
Malika Kupoor Age: 35 Weight: 80.9 kg
Learner Information The learner’s will be providing care for a 35‐year‐old female who was admitted to the labor and delivery unit from her healthcare provider’s office. She is a G1 P0000, currently 38 weeks gestation. She was sent to triage for complaints of lethargy, irritability, and increased swelling in her hands and face in conjunction with increased BPs in the 140s/90s. This SCE is intended to assist the learner to care for an obstetric patient with hypertension and manage this patient during induction and administration of Magnesium sulfate according to policy.
Facilitator Information At the beginning of the SCE, learners are expected to complete comprehensive physical assessment of both maternal and fetal patient’s. Learners should demonstrate new assessment skills with comprehensive neuro exam/interview, DTRs/Clonus exam and lab interpretation. Following assessment, learners should communicate to the patient signs and symptoms to report (indicative of worsening hypertensive disorder). Per LIP Orders, learners will set up and initiate administration of Pitocin, LR and magnesium sulfate according to Protocols/Standards. Learners will titrate Pitocin appropriately for labor induction. Following initial magnesium sulfate bolus, learners administer maintenance dose. Learners are expected to recognize elevation in maternal BP, notify LIP and administer the ordered labetalol appropriately.
Next, the learners should demonstrate ongoing assessments for maternal and fetal patients. They are titrating Pitocin, noting improvement in maternal BP and recognize her need to void.
NOTE: This Scenario is designed to use a simulated/standardized patient whenever possible. Be sure and educate your patient and learners on simulated patients prior to beginning this experience. It is best that your patient wear comfortable clothing such as stretch pants and a t‐shirt that can be worn under a gown. For more resources on using simulated patients please see Appendix B.
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Pre SIM Preparation Required
Patient: Malika Kupoor Age: 35 Weight: 80.9 kg
Overview The learner’s will be providing care for a 35‐year‐old female who was admitted to the labor and delivery unit from her healthcare provider’s office. She is a G1 P0000, currently 38 weeks gestation. She was sent to triage for complaints of lethargy, irritability, and increased swelling in her hands and face in conjunction with increased BPs in the 140s/90s. This SCE is intended to assist the learner to care for an obstetric patient with hypertension and manage this patient during induction and administration of Magnesium sulfate according to policy.
Assesses and maintains safe and complete care of both mother and baby
Performs Head to Toe physical assessment and focused assessments as indicated
Evaluates the patient’s condition and response to interventions and modifies the nursing care in timely manner
Identifies signs and symptoms of pre‐eclampsia using a systematic process
Identifies outcomes of interventions ordered and proceeds appropriately
Demonstrates safe and comprehensive administration of fluids, magnesium sulfate and oxytocin infusions
Maintains precise intake and out take records
Utilizes the Nursing Process
Maintains effective closed loop communication with all members of the health care team
Demonstrates safe and comprehensive medication administration
Provides a culture of safety for all patients
Demonstrates awareness of clinical environment, infection control, aseptic technique, fall prevention, skin care, behavioral health , pain management, and hugs tag safety
Demonstrates caring and advocacy for patient and family Preparation required: Review the following medications and be prepared to administer:
Magnesium Sulfate
Calcium Gluconate
Hydralazine
Labetalol
Oxytocin
Review the following Evidence Based Practice (EBP) and institution specific policies around:
Hypertension in Pregnancy
Antihypertensive Medications: Severe Hypertensive Disorders of Pregnancy
Magnesium Sulfate: Intravenous Administration
Magnesium for Preeclampsia
Induction or Augmentation of Labor with Oxytocin
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SIM Set Up Checklist SCE: OB Hypertension Management Print patient labels with correct birthdate and MRN, then label patient, labs, orders appropriately.
Standard Room Supplies‐ may differ by facility
Family observer clipboard and SAFETY /QUALITY OBSERVER CHECKLIST
Oxygen regulators x2 with Adult ambu bag hanging and Non rebreather mask on O2 regulator
Suction regulators, canister, suction tubing and yankuar in package sitting on top x2
Adult and Newborn Stethoscopes x4
Bathroom: peri‐care supplies (Pink bucket with Mesh panties, chuks pads x4, large pads x2, small pads x2, peri bottle) and urine hat
Call Bell, thermometer (oral and temporal), flashlight, reflex hammer
Code cart in hallway with first responder box on top
Extra pillows
IV pump
Monitor
Neonatal code cart in hall
Over‐the‐bed table
WOW
Supplies for OB Hypertension Management Simulation
Standardized Patient Set‐Up
Standardized/simulated patient in bed
Gown, patient ID band, BP cuff, sat probe: start having it off the patient, laying in the bed
Moulage: o Non‐Slip Socks o Bilateral lower Edema (3+) o Pregnant belly prosthesis with fetal monitors applied using belly
bands
Simulated fetal monitoring capability if available
See appendix for instructions‐ Simulated Patient IV o IV (18 gauge) in R arm: Standardized patient IV System o IV (18 gauge) extra standardized patient IV System
IV pump on pole
Microphone earpiece and speaker‐ to communicate with standardized patient
Emesis basin on bedside table
Cup filled with water on bedside table
Urine “hat” and 100cc dark yellow urine available in bathroom Tech Recording equipment ready‐ if available
Manikin specific control software ready to go
Facilitator guide Medication and Supplies – Place in “med room”
Magnesium Sulfate Maintenance Bag
Magnesium Sulfate Bolus Bag
Oxytocin (Pitocin)
Labetalol in the box
Ondansetron
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Calcium Gluconate
Trifuse extension (red/white/blue) Runner: Supplies to be placed in control room
Facilitator guide (marked as revision guide)
Handoff/SBAR
Labs Conference Room Flipchart and Markers
Facilitator Guide
Learners Roles and Responsibilities
FOR DEMONSTRATION: o Pump(s) o LR, Magnesium bolus, Magnesium Maintenance and Oxytocin bags o Primary pump tubing x 3 o Trifuse extension (red/white/blue) o Reflex hammer(s)
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PREBRIEF
Introduce yourself
Check in with residents
o Have you had experience with a hypertensive patient in OB?
o What do you remember about hypertensive disorders from your class?
o Facilitator possibly offers a case study or personal experience here.
Review: WHAT ARE THE MAJOR DIFFERENCES BETWEEN GESTATIONAL HTN, PRE‐ECLAMPSIA, AND
ECLAMPSIA?
Review: WHAT DOES THE PATHOPHYSIOLOGY LOOK LIKE IN THESE CONDITIONS?
Review: WHAT ARE THE LAB TESTS USUALLY INDICATED IN THIS TYPE OF PATIENT AND WHAT IS
HAPPENING PHYSIOLOGICALLY THAT CAN ILLICIT ABNORMAL RESULTS?
WHAT IS HELLP SYNDROME?
HOW MIGHT IT LOOK DIFFERENT THAN THE OTHER CONDITIONS?
WHAT IS THE EFFECT ON THE FETUS AND EFM?
HOW DO WE “CURE” PRE‐ECLAMPSIA/HELLP?
HOW LONG IS THE PATIENT POTENTIALLY AT RISK?
Review: WHAT MEDICATIONS ARE USED TO TREAT PRE‐ECLAMPSIA, WHAT ARE THEIR MECHANISMS
OF ACTION, AND WHAT ARE SOME THINGS TO CONSIDER WHEN ADMINISTERING THESE
MEDICATIONS?
Review: IS SEIZURE PREVENTION AND/OR CONTOL OF SEIZURES THE ONLY WAY MAGNESIUM SULFATE
IS USED FOR OBSTETRIC PATIENTS?
WHAT IS INCLUDED IN YOUR ASSESSMENT OF A PATIENT WITH PRE‐ECLAMPSIA?
DEMONSTRATE DEEP TENDON REFLEX AND CLONUS ASSESSMENTS (use Reflex hammers)
Review: WHAT COMPLICATIONS ARE THE PRE‐ECLAMPTIC PATIENT AND BABY AT RISK FOR AND
WHAT PRECAUTIONS DO WE TAKE AS A RESULT?
Review: HOW DOES CERVICAL RIPENING/PITOCIN INDUCTION ADD RISK TO MOM AND BABY?
WHAT KINDS OF PRECAUTIONS DO WE TAKE AS RNS WHEN ADMINISTERING MAGNESIUM SULFATE?
DISCUSS ADMINISTRATION:
o REFER TO PROTOCOL: “MAGNESIUM SULFATE: IV ADMINISTRATION (PERINATAL)”
o WHAT IS INCLUDED IN YOUR ASSESSMENT OF A PATIENT ON MAGNESIUM SULFATE THERAPY?
o HOW FREQUENT ARE THESE ASSESSMENTS?
o WHAT SHOULD YOU DO IF YOUR ONGOING ASSESSMENT CHECKLIST CANNOT BE COMPLETED?
o WHAT CAN YOU EXPECT FOR LIP ORDERS FOR MANAGEMENT OF MAGNESIUM SULFATE?
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o Review: WHAT ARE COMMON SIDE EFFECTS/COMPLICATIONS OF RECEIVING MAGNESIUM
SULFATE:
o Review: HOW CAN YOU HELP MANAGE SIDE EFFECTS?
o WHAT DOES MAGNESIUM TOXICITY LOOK LIKE?
o DO YOU NOTICE ANY SIMILARITIES IN THE COMMON SIDE EFFECTS OF MAG AND MAG
TOXICITY?
o Review: WHAT IS THE ANTIDOTE FOR MAGNESIUM SULFATE AND HOW IS IT ADMINISTERED?.
HOW DO WE PREPARE FOR AN ECLAMPTIC SEIZURE?
WHAT DOES AN ECLAMPTIC SEIZURE LOOK LIKE?
HOW DO WE MANAGE AN ECLAMPTIC SEIZURE?
OBJECTIVES OF THIS SIM:
Assesses and maintains safe and complete care of both mother and baby
Performs Head to Toe physical assessment and focused assessments as indicated
Evaluates the patient’s condition and response to interventions and modifies the nursing care in timely manner
Identifies signs and symptoms of pre‐eclampsia using a systematic process
Identifies outcomes of interventions ordered and proceeds appropriately
Demonstrates safe and comprehensive administration of fluids, magnesium sulfate and oxytocin infusions
Maintains accurate and precise intake and out take records
REVIEW THE EXPECTATION OF SIMULATION
When in doubt, “treat it as real”
Operate as a TEAM
Think OUT LOUD
Use SBAR for all communication
Educate the patient and family member
Demonstrate caring and compassion
Demonstrate excellent safety practices o Patient identification o Infection prevention “Gel in Gel out” o Skin management o Pain management o Fall prevention o Medication safety and double checks
Care for yourselves o Wear gloves o Protect your body
ASSIGN ROLES FOR SIMULATION
See Appendix for Roles descriptions
Give reminder about EPIC (signed and held orders, if applicable) and send to learners to break. Please let
support staff know you are on break so they can finish preparation for SIM
Perinatal Clinical Academy_ SCE OB Hypertension Management ‐ 8
Overview Chart of SIM Highlights
State 1‐ Initial Assessment
Maternal Patient: VS: HR 90’s, BP 150/90, RR 20s, SPO2 98% on RA, Temp 98.4 DTRs: 3+ bilat LEs, 2+ bilat UEs Clonus: 1 beat in L foot, none in R Cervix: 3 cm/80% effaced/‐1 station, anterior and soft
Baby: FHR: 120 with moderate variability, accels, no decels Uterus: no contx
Learners Facilitator Patient TECH
All entering room should gel hands
1. Introduce self to patient
2. Begin comprehensive assessment VS, neuro, breath sounds, pain level, Urine output, DTRs/clonus, edema; FHR/contx
3. Explain and communicate with patient about POC
4. Offers Mag Sulfate and Oxytocin specific Education
5. Accurately set up and initiate oxytocin, LR and magnesium sulfate in a timely manner
6. Continue appropriate
assessment of both mom and baby after mag and oxytocin initiation
7. Documents information
Cues tech to transition to State 2‐After Magnesium sulfate when meds are up and started (Magnesium and Pitocin).
Voice of Patient responding to RN’s questions
If asked: Denies headache, blurry vision, epigastric pain
Pain 0/10
“I have so much swelling my legs!”
“I was really not ready for this at all—the nursery isn’t even set up at home and I am worried about my baby!”
Talk about your birth plan: “I really wanted to have an un‐medicated labor and delivery”
That says sulfate…I am allergic to Sulfa!!
How does my baby look?
Announce after medications are infusing “20 minutes have passed and the Magnesium Sulfate bolus is complete”
RUNNER: Give ISBAR Report. State that LIP Orders are in the chart.
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State 2‐ After Mag Bolus, PT Hypertensive (bolus has infused, now on maintenance)
Maternal Patient: VS: HR 90’s, BP 160/100s, RR 20s, SPO2 98% on RA, Temp 98.4 DTRs: 3+ bilat LEs, 2+ bilat UEs; Clonus: None
Baby: FHR: 125 with moderate variability, no accels, no decels Uterus: Occasional mild 2 CTX in 10 minutes
Learners Facilitator Patient TECH
All entering room should gel hands
1. Recognizes patient’s BP remains not WDL
2. Changing over to maintenance mag (per LIP order/protocol), increasing oxytocin ( per LIP order/protocol)
3. Provides for patient comfort with cold washcloths, ice packs, or fan.
4. Using ISBAR calls provider for additional instructions related to elevated BP
5. Administers Labetalol taking appropriate precautions and evaluates patient for effects
6. Continues assessment of mom and baby per magnesium and oxtocin protocols
7. Documents data
Cue tech to transition to State 3‐ Labetalol administered
Voice of Patient responding to RN’s questions
Nauseous and sleepy
Be very insistent: “It is so hot in here! I feel like I’m burning up!”
“I’m not really feeling any contractions, when does this medicine start working?”
LIP ORDERS: Labetalol 20 mg IVP x 1 Now. Call back if BP > 140/90 10 minutes after Labetalol.
Perinatal Clinical Academy_ SCE OB Hypertension Management ‐ 10
State 3‐ After labetalol‐ On Maintenance Mag Maternal Patient: VS: HR 90’s, BP130/80s, RR 20s, SPO2 98% on RA, Temp 98.4 DTRs: 2+ bilat LEs, 2+ bilat UEs Clonus: None
Fetus: FHR: 125 with minimal variability, no accels, no decels Uterus: Occasional mild ctx
Learners Facilitator Patient TECH
All entering room should gel hands
1. Recognizes patient’s BP is improving.
2. Continues assessment of mom and fetus per magnesium and Pitocin protocols
3. Discusses Cat II FHR with LIP. Requests an order to titrate Pitocin with current FHR.
4. Increases Pitocin.
5. Recognizes I &O, asks if pt needs to void bedpan, or gets foley order.
Simulation Complete! Pain with Ctx 3/10
It’s still so hot
How is my baby doing is he hot too?
“I’m not really feeling any contractions, when does this medicine start working?”
Urine cues? Either foley or bedpan with urine to use. Only 40cc out
Can I get up? Be insistent that you want to get OOB.
*Calm down once you get great fall precaution education
RUNNER:
LIP ORDERS: Okay to continue Pitocin with current FHR
Perinatal Clinical Academy_ SCE OB Hypertension Management ‐ 11
DEBRIEF
The goal of the debrief is to provide the opportunity for the residents to share and reflect as a group on areas for improvement and recognize practice behaviors that demonstrate excellence. Remember to:
Remind residents that the debrief is a safe place and the purpose is for them to learn from their experiences
Try to use the video ( if applicable) when it fits
Ask the family member their observations
Use standards as needed for clarity/guidance
Use “what if” questions
Embrace the silence
END with: What one thing are you going to take away from this experience?
The template below is available for groups that struggle to facilitate the debrief on their own… REVIEW OBJECTIVES FOR THIS SIM
• Assesses and maintains safe and complete care of both mother and baby • Performs Head to Toe physical assessment and focused assessments as indicated • Evaluates the patient’s condition and response to interventions and modifies the nursing care in timely
manner • Identifies signs and symptoms of pre‐eclampsia using a systematic process • Identifies outcomes of interventions ordered and proceeds appropriately • Demonstrates safe and comprehensive administration of fluids, magnesium sulfate and oxytocin
infusions • Maintains accurate and precise intake and out take records
General
What worked, what didn’t work and what will you do differently next time?
What was the experience like for you?
What happened and why?
What did you do and was it effective?
Discuss your interventions (technical and non‐technical). o Were they performed appropriately o Were they performed in a timely manner?
How did you decide on your priorities for care and what would you change?
How did patient safety concerns influence your care? What did you overlook?
In what ways did you personalize your care for this patient and family members (recognition of culture, age, concerns, anxiety)?
Discuss your teamwork. How did you communicate and collaborate?
WHAT ARE YOU GOING TO TAKE AWAY FROM THIS EXPERIENCE?
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APPENDIX
References:
Micromedix
AWHONN. (2014). Perinatal nursing. (4th Ed.). Simpson, K.R. and Creehan, P.A. (Eds.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Levi, M. (2009). Disseminated intravascular coagulation (DIC) in pregnancy and the peri‐partum period.
Thrombosis Research, 123. doi:10.1016/s0049‐3848(09)70013‐1
Nick, J. M. (2004). Deep Tendon Reflexes, Magnesium, and Calcium: Assessments and Implications.
Journal of Obstetric, Gynecologic & Neonatal Nursing, 33(2), 221‐230. doi:10.1177/0884217504263145
Preeclampsia Toolkit. (n.d.). Retrieved June 23, 2016, from https://www.cmqcc.org/resources‐tool‐
kits/toolkits/preeclampsia‐toolkit
Perinatal Clinical Academy_ SCE OB Hypertension Management ‐ 13
SAFETY /QUALITY OBSERVER CHECKLIST
As the safety and quality observer, it is your job to watch for the safety and quality of care given to
the patient, as well as ask questions and advocate for the patient. Please make note of the following
safety/quality behaviors, plus any other observations you think could enhance the learning of your
team.
Were they observed? How often? What was done well, what could have been done better?
RN1 RN2 Data
Hand washing
Introduction to patient
Bedside report
Whiteboard
Initial safety check &
ID checks
Assessment of skin, pain,
environment, falls risk, etc.
Appropriate choice of
equipment/supplies
Medication administration &
Medication double checks
(using the 5 rights)
Aseptic technique &
Infection control
Explanation & education to
patient
Sharing of information
Team communication &
delegation
Other notes to share with the team:
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Learners Roles and Responsibilities
Role Responsibility
RN 1
Primary nurse assigned to the patient
Coordinates overall care of the patient including triage and focused assessments Demonstrates effective and efficient collaboration and communication with team
members Obtains history/admit information in the EPIC ED Navigator Delegates interventions and tasks appropriate for situation Family and patient support and education Utilizes resources appropriately
(charge nurse, RT, preceptors, providers, code teams)
RN 2
Partners with primary nurse to provide patient care
Actively assists with triage assessments and admit tasks Prioritizes interventions and tasks Gathers supplies and equipment as needed Family and patient support and education Demonstrates effective and efficient communication Utilizes resources appropriately
(charge nurse, RT, preceptors, providers, code teams)
RN 3 & Data Collector
Facilitates
communication and participates as
additional support
Performs and manages patient care as directed by primary nurse Gathers supplies and equipment as needed Family and patient support and education Demonstrates effective and efficient communication Ongoing data collection and documentation (included but not limited to assessment,
labs, observations) Analyzes data collected for trends and missing information
Family Member
Patient Advocate and Safety Observer
Advocates for patient and self Asks questions and expects services, support, and education Acts as Safety Observer: May prompt team if gaps are noted Examples: Safety
Hand hygiene Patient identifiers Medication administration Environmental awareness
Patient satisfiers Introductions completed by all staff / name and role Pain management Receives information regarding treatment plan
Communication Delegation Closed loop communication Sharing of information
Expected to report back to team observations during debrief
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Initial Lab Results
Procedure Pt results Reference Ranger per Facility
HCT 38
Platelet Ct 110
ABO B
RH Positive
Antibody Screen Negative
Urea Nitrogen 10
Creatinine 0.9
AST (GPT) 60
ALT (GOT) 63
Hep B Surf AG Negative
Uric Acid 6
GB Strep DNA Negative
Rubella IGG Immune
HIV Negative
RPR Negative
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How to set up a working IV for a Simulated Patient
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Appendix B
http://www.aspeducators.org/