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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


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.


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


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


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)


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?


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


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.


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



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.


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



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


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?


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


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:


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


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


How to set up a working IV for a Simulated Patient


Appendix B

http://www.aspeducators.org/