Clinical Scenario/Part I

NURS 5328
Tracy Nash, Robin Roberts, Cheryl Sheffield, and Elizabeth Tilley
Over Sedation/Respiratory Depression Clinical Scenario
This clinical simulation scenario is devised for the beginning nursing student in a
general medical/surgical acute care setting. The lesson is centered on team-based
learning (TBL), a structured, student-centered learning strategy that focuses on three
essential phases/steps to promote student accountability and engagement - preparation,
readiness assurance, and application-focused class activities (Ching-Yu et a., 2014; Clark,
Nguyen, Bray, & Levine, 2008; Mennenga & Smyer, 2010; Sisk, 2011). This respiratory
depression scenario incorporates instruction for student preparation, pre-briefing,
expectations of the student nurse (learning objectives), patient history (problem, vital
signs, diagnostic study results, psychosocial issues, spiritual condition, family support),
patient background (mental, physical, and social conditions), explanation of the scenario,
script of a sample dialogue, and debriefing exercises.
Components of the Simulation Scenario
Preparation
The three-step process of team-based learning begins with student preparation.
According to Clark et al. (2008), students are required to complete assignments prior to
coming to class. This includes reading assignments followed by a Readiness Assurance
Test, which is often a multiple-choice quiz that tests the students understanding of key
concepts from the reading assignments (Mennenga & Smyer, 2010). To promote student
accountability in this clinical scenario, the student is required to complete the following
preparation tasks:

1.) Read the following journal articles:

a) D'Arcy, Y. (2013). Turning the tide on respiratory depression. Nursing, 43(9), 3846. doi:10.1097/01.NURSE.0000432909.39184.e1
b) Dawson, R., Von Fintel, N., & Nairn, S. (2010). Sedation assessment using the
Ramsay scale. Emergency Nurse, 18(3), 18-20.
c) Pawasauskas, J., Stevens, B., Youssef, R., & Kelley, M. (2014). Predictors of
naloxone use for respiratory depression and oversedation in hospitalized
adults. American Journal of Health-System Pharmacy, 71(9), 746-750.
doi:10.2146/ajhp130568
2.) Take a brief quiz.
Pre-briefing
The students are expected to have read the journal articles presented, taken the
quiz, and discuss the information. Based on these journal articles it is appropriate for the
students to ask, What could be brainstormed as potential nursing diagnoses or
interventions? A discussion of all supplies and materials expected should be brought up.
The purpose of the pre-briefing is to allow the students to brainstorm about potential
patient problems in a safe and non-threating environment. During this time, they can
decide which role each team member will play in the scenario and discuss options related
to nursing interventions and likely patient responses. It is important that the instructor
not give the central meaning of the scenario away, but try to keep the students on track
and maintain a professional level of critical thinking.

Student Nurses Roles/Expectations

`
It is expected that the student nurses in the scenario will complete a full
assessment on the clinical patient and act just as they would in a clinical setting. They
must adhere to all school and facility code of conduct rules and maintain a professional
demeanor throughout the scenario. Students are expected to perform vital signs and
obtain information from the patient just as they would in a clinical setting. The
simulation is steered by the student nurses interaction with the manikin and the manikin
will respond to intervention that the nurses performs. It is appropriate and expected that
the student nurse will call the physician or other members of the care team as needed in
response to the patients symptoms and vital sign trends (Miller & Bull, 2013).
1.) Expectations will include, but are not limited to all of the following;
a) Adherence to school and facility dress code.
b) Perform full assessment of the patient.
c) Bring all supplies (stethoscope, hemostat, scissors, pin light) just as required on a
clinical day.
d) Adherence to school and facility code of conduct.
e) Maintenance of professional demeanor and speech.
f) Contact MD or other care team members as needed.
g) Maintain record of vital signs of patient.
h) Maintain record of all medications given.
i) Document any hand off report given to another nurse or department.
j) Document notification to MD as appropriate.
k) Work professionally as a member of a team.

l) Delegate to other team members as needed.

Student Learning Objectives
1.) Recognize deterioration/changes in client
2.) Provide appropriate interventions for respiratory support
3.) Communicate with the interdisciplinary health care team, patient, and family
regarding patients condition.
Patient History
The patient history includes an overview of the problem, vital signs, diagnostic study
results, psychosocial issues, spiritual condition, and family support. This brief summary
paragraph includes key highlights from the scenario.
Mrs. Sue Jones was admitted to the hospital for a hysterectomy due to
abnormal bleeding and fibroid disease. Her most recent vital signs are snoring
respirations at 10/min, BP 132/72. HR 100, sat 92%, and she does not arouse to
verbal stimuli. An EKG was completed and interpreted by the doctor to be
normal sinus rhythm. Mrs. Jones has been married to her husband, Mr. Jones, for
20 years and they have one daughter (age 25) and one son (age 27). Mrs. Jones
does smoke and has smoked one pack per day for the last 30 years. She is a
practicing Baptist and attending church regularly on Sundays, and on Wednesdays
attends a womens bible study class. She states she is strong in her faith and
God will help her through this to the off-going nurse prior to your shift. Both of
her children live within 1 hour away and her son was at the bedside most of the
night. Their daughter just had a baby (1 month old) and is unable to visit her
mother at the hospital at this time. Mr. Jones states they have great family

support and even have church family. As Mrs. Jones becomes more and more
unresponsive in the scenario, Mr. Jones calls a church pastor and they begin to
pray for her over the phone. He stays at the bedside the entire scenario, but is
visibly shaken and concerned by seeing his wife in this condition. When Mrs.
Jones regains LOC after administration of required medications, she immediately
holds her husbands hand and they pray together stating, thank you God, thank
you.
Patient Background
Mrs. Jones has no history of mental illness or depression. During hospital
admission she states that she deals will things by praying all the time. Physically, the
uterine fibroids have caused her a lot of pain over the years and she is happy to get them
out. Mrs. Jones does state on admission that the most difficult thing will be the doctor
taking away my cigarettes for this surgery. Her physician has talked to her about
possibly using a nicotine patch in the hospital, but she says, If I cant smoke it, I dont
want it. Socially, Mrs. Jones has the support of her husband and two children (a 25 year
old daughter and a 27 year old son). Her son is in the military, but has taken a leave to
spend time with her during her recovery. Her daughter just had her first grandchild (1
month old) and is unable to visit at the hospital, but Mrs. Jones says I talk to Jenny
almost every day, she is my sweet girl. The Jones have attended the same Baptist
church in town for over 15 years and state our church family is very big. They both
express thankfulness for their church family and have adequate social support therein.

Simulation Scenario
Date: November 2014

Level 1 Medical/Surgical Simulation

Over Sedation/ Respiratory Depression

Brief Time: 5 min

Sim Time: 10-15 min

Admit Date: 11/10 /2014

Todays Date: 11/11/2014
Brief Description of Patient:
Name: Sue Jones Gender: F Age: 47
Height: 55 Weight: 247# (112kg)
Religion: Baptist
Next of Kin: Spouse (Ken Jones)
Phone: (903) 288-6700

Debrief Time: 20-30 min

Psychomotor Skills Required prior to

simulation:
Physical Assessment
IV Fluid Administration/
Abnormal Vital Sign Recognition
Abnormal Lab Value Recognition

Allergies: PCN, Tylenol

Immunizations: Current
Attending Physician: Dr. Strong
Surgeon: Dr. Sharp
PMH: Thyroidectomy, Cholecystectomy,
sleep apnea
History of Present Illness: Hysterectomy
related to abnormal bleeding and uterine
fibroid disease.
Social History: 1ppd/30yr smoker, denies
regular alcohol use, denies recreational
drug use.

Cognitive Activities Required prior to

Simulation: i.e. independent reading
(R), video review (V), computer
simulations (CS), Lecture (L)
Students should review the following:

Primary Medical Diagnosis: postoperative vaginal hysterectomy

Setting/Environment: Medical/Surgical
Unit
Simulator Manikin/s Needed:
Sim-Woman (High fidelity manikin)
Trained Operator of Sim equipment
Props:
Manikin

Medications and Fluids:

IV
NS at 125cc/HR
Morphine via PCA
Oral
IVPB
Ancef 1 GM Q 6 HRS
IV Push

Naloxone
Equipment attached to manikin:
IV Pump with primary line infusing
at 125cc/HR
PCA pump (morphine)
ID Band
Allergy Band (PCN, Tylenol)
Spo2 monitor
Foley Catheter
Equipment available in room:
Fluids (Normal Saline)
IV start kit/catheters
IV tubing
Oxygen cannula and NRB mask
BVM device
Emergency Medication Box with
syringes/needles
Roles / Guidelines for Roles
Primary Nurse
Secondary Nurse
MD available by phone
Important Information related to roles:
Critical Lab Values: none noted

Physician Orders (only available upon

request)

Oxygen via NRB at 100%

Administer Naloxone 0.4-2mg IV
x1
Repeat Naloxone every 2-3 min as
needed with max 10mg.
Discontinue PCA use
ABGs
CPap machine per RT

Diagnostics Available
Labs
ABGs
12-Lead
Other_______

Documentation Forms
Admit Orders/ MD Orders
Medication Record
Vital Sign Flow Sheet

Student Information Needed Prior to

Scenario:
Has been oriented to simulator
Understands
guidelines/expectations for scenario
Has completed all pre-simulation
assignments/requirements
All participants understand their
assigned roles
Has been given time frame
expectations

Scenario Background
Report given at nurses station during shift change:
Bed 5222, Mrs. Jones had a vaginal hysterectomy yesterday. She has complained
of abdominal pain today and is using her PCA frequently. Her husband is at the bedside
and has been very concerned about her pain and seems upset that she still has some pain
even when using the PCA. The nurse has instructed the patient to use her PCA more
frequently when her pain becomes worse. The patient needs a lot of encouragement and
is hesitant to get up to the chair and walk. She refused to have her catheter removed
today so Dr. Sharp said the nurse could leave it one more day. The patient did not sleep
well last night due to post-op nausea which is now resolved. She has started clear liquids
today and is tolerating them well. Her VSs are HR 88, R 18, BP 138/77, Spo2 97%,
T 97.8 F. She seems sleepy and has dozed off a couple of times; her husband is at the
bedside. IV NS hanging at 125/hr and IVPB Ancef Q 6 hours is ordered.
Scenario Progression Outline
Timing
(Approximate)
1 Minute

1-2 Minutes

1-2 Minutes

2 Minutes

Manikin Actions
Snoring Respirations at
10/min. HR 100, sat 92%
Does not arouse to verbal
stimuli
Snoring resp at 8/min., Sat
88 remains unresponsive
HR 110
Pulse Ox
Up to 90% if oxygen
applied, drop to 86 if not
Pulse ox 88% Resp.
decreased to 6/min

Expected Interventions
Student will introduce self to patient
and family, notice patient does not
respond
Student will use verbal and tactile
stimulation to awaken patient
Raise HOB
Apply oxygen via NRB mask at
100% and continue to stimulate
patient
Call for assistance (staff, charge
nurse, MD or RT) Do or delegate
assisting patients respirations with
BVM
Obtain order for Naloxone/ or use

2 Minutes

2-3 Minutes

Patient improves LOC and

respirations increase to
16/min , sat 98%, HR 92
after Naloxone
administration

standing order
Draw correct dose of Naloxone and
administer IVP. Continue to assist
and monitor patient.
Express need for RT and possible
Cpap. Notify MD of incident.
Possibly move patient to higher level
of care for closer monitoring.

Sample Dialogue
PN: PRIMARY NURSE (STUDENT NURSE #1)
You are the primary nurse. It is your responsibility to run this clinical scenario.
You may delegate other tasks to participants as needed. You will need to communicate
information to the secondary nurse, MD, husband, etc.
SN: SECONDARY NURSE (STUDENT NURSE #2)
You are the secondary nurse. It is your duty to be available to the primary nurse
in administering care to the patient. You may help the primary nurse think through the
situation, but ultimately need to take direction from the primary nurse.
MD: DR. STRONG
You are the MD; available by phone. You may need to ask questions, such as
VS, etc. And will need to give medication, transfer or other orders to the nurse.
Script of Sample Dialogue
PN: At 0800, entering the patients room she states she will now do her morning
assessment and wants to asses her pain level again. Walking over to the patients bed she
calls: good morning Mrs. Jones. Again she says louder GOOD MORNING Mrs.
Jones as she puts both hand on her shoulders a gently shakes her. PN raises HOB. She
reaches for the NRB mask as she pushes the nurse call light and states I need an RN now!

SN: Entering the room, she rushes to the patients side.

PN: (tells the SN) Ms. Jones is in for a hysterectomy POD#1, has a morphine PCA
pump, VS are stable right now, and 02 sat is at 90% with 100% NRB mask.
SN: Turns to the patients husband who is pacing in the corner and asks, Do you
remember the last time your wives eyes where open and you were talking to her? He
tells the SN that was at about 0700, when the nurses were changing shifts.
PN: Begins to assist patient with respirations using the BVM; tells the SN to go get the
ordered dose of Narcan.
SN: Returns to room and verifies that PN is ready for the 1 mg Narcan IV to be given; it
is administered.
PN: Lays down BVM. Gently shaking patient says Mrs. Jones, Mrs. Jones can you hear
me. Patient opens eyes and begins to be restless.
PN: (to secondary nurse) please stay here, I am going to call MD to infer of any more
orders.
PN: (to MD) Hi Dr. Strong I am taking care of Mrs. Jones in room 5222, a 58 y/o female
POD#1 hysterectomy, she was unresponsive this AM at 0800 VS remained stable with
dropping O2 sat, started the patient on 100% NRB and assisted respirations with BVM,
administered standing order of 1 mg Narcan. Patient LOC increased but is still very
drowsy; VSS. Are there any further orders you have for this patient?
MD: (to PN) Yeah, Continue oxygen via NRB at 100%. Repeat Naloxone every 2-3 min
as needed with max 10mg. Discontinue her PCA. Obtain ABGs. Cpap machine per RT.
Transfer patient to ICU; I will be up in a little while to check on her. Thanks.

SN: Mrs. Jones I think you had a little too much pain medicine, we had to give you IV
medicine to get it out of your system, try and relax and talk to us, we will stay by your
side until you are feeling okay. Here is your husband (motions to husband) he can come
right here and hold your hand while we are waiting on MD orders.
PN: (entering room) Okay, I just talked to Dr. Strong, he wants to move you to ICU for a
little while so that your breathing can be closely monitored. He will come see you later
today. Do you or your husband have any questions?
Debriefing/Guided Reflection Questions for Simulation (Approximately 20-30
minutes)
A systematic review of the literature provides evidence that the effect of
debriefing in simulation exercises is an integral component of the learning experience for
student nurses (Levett-Jones & Lapkin, 2014). Debriefing provides students with the
opportunity to review their actions, reflect on their clinical decisions, discuss alternative
actions, and focus their discussion on what went right, what went wrong, and what could
be done differently in the next simulation (Jeffries, Dreifuerst, Aschenbrenner, Adamson,
Schram, 2015). Although many methods can be used to facilitate debriefing, reflection is
an essential component utilized to solidify learning (Dreifuerst, 2009; Garrett, MacPhee,
& Jackson, 2011; Jeffries et al., 2015). More specifically, in a pilot test conducted by
Lavoie, Pepin, and Boyer (2013), participants reported that reflective debriefing helped
them understand their cognitive processes during the simulation and contributed to
clinical judgment development and to their care prioritization and assessment
capabilities (p. 36).

To help guide discussion during the debriefing process and complete the final
phase/step supported by TBL (class focused activity) for this simulation scenario, the
following open-ended questions will be presented to the students:
1.) What did you learn today?
2.) How did you feel about completing this simulation experience?
3.) What were your primary concerns in this scenario?
4.) What information about this patient was most helpful from the shift report you
received?
5.) What changes in patient directed your actions to call for help?
6.) What knowledge/skills helped you manage this patient?
7.) What role did Mrs. Jones husband play in the clinical scenario?
8.) What did you do well in this scenario?
9.) Given the same opportunity again, what would you do differently?
Finally, students will be asked to fill out an anonymous evaluation survey at the
end of the debriefing session to provide the educator with additional feedback that can be
used to improve future simulation scenarios.
Clinical Reasoning
The professional nurse requires an extensive breadth and depth of knowledge to
care for the diversity of U.S patient populations, including the ability to reason through
problems to make sound clinical judgments (Marchigiano, Eduljee, & Harvey, 2011;
Sedgwick, Grigg, & Dersch, 2014). Research has demonstrated that engaging in clinical
reasoning is not effected by the number of years of clinical experience, but associated
with nurses self-awareness and how their thinking takes place (Sedgwick et al., 2014).

Clinical reasoning may be defined as the cognitive processes and strategies used to
understand the significance of patient data, and identify and diagnose patient problems to
provide positive outcomes (Fonteyn & Ritter, 2008). Since clinical reasoning is
dependent on critical thinking (Marchigiano et al., 2011; McCarthy, 2003), the following
activities were designed to help cultivate these skills in the novice nursing student.
Learning Exercises to Promote Clinical Reasoning
Here you will find a variety of activities to expand your critical thinking and
clinical reasoning skills. Please select two of the three activities listed below. Carefully
follow the directions and email faculty with questions or clarifications, should they be
needed. Submit your work via email by the identified assignment due date. Extra credit (5
points) will be awarded to those student who complete all three learning activities.
Due Date: December 1, 2014 at 11:59 CST
a.) Reflective Learning Activity
Reflective learning is described as the rational analytical process utilized to
develop knowledge from experience (Maree & Van Rensburg, 2013, p. 44). Research
has provided evidence that reflective learning in nursing education contributes to the
development of a critical thinking and problem-solving skills, thereby promoting clinical
reasoning and professional growth (Ayan & Seferoglu, 2011). Now that youve had the
opportunity to participate in the clinical simulation scenario, you are asked to reflect upon
your experience and share your opinion to the following question:
Consider Mrs. Jones physical decline. Reflect on the activities that took place
prior to her episode of respiratory depression. Think about her psychological and
emotional status, along with her social support system in the hospital. Other than

self-medication (her use of the PCA pump), what possible situations at the
bedside could have contributed to her episode of respiratory depression? Support
your answer.
b.) Concept Map Activity
Concept maps are metacognitive tools that visually represent students thinking
(Marchigiano et al., 2011, p. 144) and are used to help synthesize, organize, and
prioritize data in a logical sequence (Wilgis & McConnell, 2008, p. 119). Concept
mapping (CM) has been shown to help promote nurses critical thinking skills (Abel &
Freeze, 2006; King & Shell 2002; Vacek, 2009; Wilgis & McConnell, 2008) and develop
higher-level cognitive functions that support clinical reasoning (Wilgis & McConnell,
2008). If you google the words concept maps, you will find a variety of examples to
serve as guides for this learning activity. Also, there are many free websites for you to
utilize to easily design your own concept map. Three examples are provided below:
https://bubbl.us/
http://simplemapper.org/
http://www.educatorstechnology.com/2012/06/18-free-mind-mapping-tools-forteachers.html
You just entered Mrs. Jones room for your initial assessment and find her
unresponsive. Prioritize and organize your actions in a concept map. Use one of
the free websites to create your assignment. You may find it helpful to sketch out
your map before selecting a website. This assignment should reflect a detailed
account of your step-by-step strategy to provide care to Mrs. Jones.

c.) Journal Activity

Clinical journaling is described as a subjective and objective written expression
of cognitive learning experiences, attitudes, and feelings (Ruthman et al., 2004, p. 120)
and serves as an excellent mode of communication between students and faculty during
clinical nursing education. Journal writing has been demonstrated as an effective teaching
methodology to expand student awareness, promote critical thinking skills, and provide
students with a constructive way to express their thinking strategies throughout their
entire clinical experience (Daroszewski, Kinser, & Lloyd, 2004; Ruthman et al., 2004).
You just finished caring for Mrs. Jones in the clinical simulation laboratory and it
is time to report your findings in your journal. Please record your responses to both of the
following questions:
Consider your medical, psychological, and social assessment of Mrs. Jones.
Name and explain three factors that may have contributed to her current
respiratory depression episode?
Consider Mrs. Jones feelings about smoking. What would be an effective
teaching strategy to educate her about the dangers of this habit?
Describe your evaluation of the care you provided. If you were faced with the
same scenario again, what would you do the same? What would you do
differently?
LEAVING ROOM FOR 4B INFORMATION>>>

Evaluation

Performance S
Criteria
Able to identify
potential reasons to
be on alert for this
patient

Able to identify
important
assessment
parameters to
monitor

Able to identify
potential

Clearly able to
identify reason to
be on alert with this
patient.
Expected answer:
This patient is on
PCA morphine,
which is a high risk
medication. It is
essential to assess
this patient for
reactions to
morphine as well as
potential postsurgical
complication, such
as bleeding or
infection.
Clearly identifies
important
assessment data
that requires
monitoring.
Expected answer:
This patient is
receiving PCA
morphine, so her
vital signs (heart
rate, blood
pressure,
respiratory rate,
oxygenation, pain
level, etc) must be
monitored closely,
as well as mental
status.
Clear identifies
possible

NI

Only able to scantly

describe reason for
alertness.
Expected answer:
Morphine on a
pump can cause the
patient to act
loopy, so it is
important to assess
her.

Unable to identify
any potential
reasons to be on
alert.
Expected answer:
PCA morphine is
safe and there is no
reason to be alert
for this patient.

Description of
important
assessment data is
minimal.
Expected answer:
With PCA
morphine it is
important to assess
this patients
respiratory rate
every 4 hours.

Unable to identify
important
assessment
parameters.
Expected answer:
A patient on PCA
morphine does not
have any important
assessment
parameters.

Describes possible
complications at a

Unable to describe
any potential

complications

complications.
Expected answer:
A possible
complication is
respiratory
depression related
to the morphine
PCA. It is possible
that the patient
could be
compromised and
quickly decline
with decreasing
respiratory rate and
decreasing oxygen
saturation. She may
even become
unresponsive.

minimal level.
Expected answer:
This patient may
not be able to
oxygenate well and
could stop
breathing.

S-Satisfactory, NI-Needs Improvement, U=unsatisfactory

Adapted from (Oermann, 2015, pg. 355-356)

complications.
Expected answer:
This patient has no
risk of potential
complications.

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