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Home > Simulations > Simulation 8: El Salvador

Scenario #8: El Salavador, Juan Dominguez

Learner Group: Male Nurse, Female PT

Environment: Acute Care Inpatient Hospital

Authors: Lindsay Patton and Karen Panzarella

Facilitator directions

Main focus

  1. On-site two HCPs to jointly prioritize patient care issues
  2. Identify and understand cultural barriers that could influence patient compliance and plan for care
  3. Nurse and PT to Communicate regarding patient's cultural preferences
  4. Nurse and PT jointly determine Plan of Care with patient

Performance measures

1 T Nurse to perform routine vitals and dressing check
2 C Nurse to respond to patient's request for a female nurse.
3 C PT to explain purpose of assessment
4 B Nurse and PT to discuss how to proceed with patient requests
5 B Team to detect raise in temperature
6 B Team to report findings to MD

Skills/tasks/procedures

  1. Situational Awareness/Cultural considerations
  2. Team Planning
  3. Patient Involvement
  4. Accessing Resources
  5. Decision Making

Imbedded challenges

  1. Nurse and PT need to manage patient's request for a female nurse
    Team to detect rise in temperature
  2. Discussion of how to proceed with patient care
  3. Education and brokering with patient to proceed with care
  4. Possibilities of accessing female nurse or using female PT for patient care
  5. Contacting MD regarding temperature increase
  6. Deciding course of action to proceed with care respecting patient cultural considerations
    remove cultural barriers

Synopsis of scenario

Patient is a 64 year old El Salvador male. Patient was admitted 5 days ago for osteomyelitis and gangrene of the (L) foot. Patient underwent a supramalleolar amputation of the (L) foot 1 day ago. A PT evaluation has been ordered for mobility, transfers and strengthening to prepare for D/C to home.

Learner roles

  1. Male Nurse
  2. Female PT

Confederate roles and scripting

Role Tone Timing of participation Lines / Comments
None

Patient information

Juan Dominguez

Name: Juan Dominguez
Age: 64
Weight: 195 lbs
Height: 5'6"
Gender: Male
Religion: Christian
Support: Wife, 4 children

Past medical history

20 year history of Type II diabetes, fair control with Lantus, Novolog. Patient is noncompliant with diet recommendations. Peripheral vascular disease. Hypertension controlled with Metoprolol. Patient has chronic ulcerations of feet complicated by PVD and DM.

History of present illness

Patient had an ulcer on the left heel and ball of the foot that has not responded to treatment. The ulcer became infected and resulted in osteomyelitis of the calcaneous and 1st metatarsal. To contain the infection, an amputation to the (L) foot was performed (transcalcaneous). Patient did well with surgery and now needs to learn to ambulate with assistive device and prosthetic.

Social history

Patient works on a farm picking crops. He lives with his wife and 2 of his children in a 2 story home close to the farm (he is able to walk to work, the family does not own a car).

Report to participants

Today's date: 3rd of the month.

Nurse will enter first, give 5 minutes and then send in PT

Nurse (Male): "You are on duty for Mr. Dominguez's care. You are scheduled to check his vitals and his surgical wound every hour"

PT (Female): "You are assigned to Mr. Dominguez's case, you are to evaluate him for mobility, ambulation and education on stump care and use of an assistive device until he is ready for a prosthesis"

Technician staging

Staged for learners Available for learners to use

Manikin

Gender: Male

Clothing: hospital gown

Position: Supine

Male

Hospital gown

Laying in bed; sitting up in bed with HOB at 65 degrees,

head up (multiple pillows)

Recent (L) foot amputation is dressed and is elevated on a pillow. (R) LE is donned with a compression stocking. Patient is hooked up to IV antibiotics, pain medication pump and an EKG monitor

Walker at bedside
Environment Hospital Room, Acute Med/Surg Floor
Equipment

Hospital bed

Commode at bedside and Urinal

IV anitbiotics

Pain medication pump

EKG monitor

Oximeter

Glucometer - results 170 m/dL

O2 sat= 97%

Medications
Labs Blood Sugar- 170 m/dL
Xrays
Other Diagnostics
Chart Records

Progression of events

Manikin Actions Performance Measures Patient Script

0-5 minutes

HR: 70 bpm
RR: 13 bpm
BP: 128/72
Temperature: 102
SpO2:

Auscultation sounds

  • RRR
  • Clear bilaterally
  • Active X 4 quads

Manikin Vocals

Mental status: alert, oriented x 3

Tone: patient becomes anxious about having a male nurse

Other: Patient speaks very limited English, speaks mostly Spanish

  • Male Nurse enters to check vitals, introduces self and explains purpose
  • Nurse begins to check vitals and check residual stump
  • Nurse explains that he is trying to help and that Males can also be nurses

"Who are you?"

"What are you doing?"

"You are not a nurse? Females are nurses!"

"I don't feel well "

"I want a female for a nurse"

5-10 minutes

HR: 96 bpm
RR: 20-22 bpm
BP: 140/86
Temperature: 104
SpO2: trend over       minutes

Auscultation sounds

  • No change
  • No change
  • No change

Manikin Vocals

Mental Status:

Tone: slightly agitated

Script:

Other:

  • Female PT enters room and explains purpose to help him get up and out of bed
  • Nurse and PT decide whom should proceed to take vitals
  • Nurse, PT detect increased temperature and discuss course of action and possible infection

"Who are you? Are you a nurse? can't you take my vitals"

"I don't want to get out of bed I am feeling hot and sweaty and my leg hurts"

Integrated debriefing guide

Threads Performance Measures Debriefing Prompt
Opening

Give us a quick summary of what happened.

What went well?

What didn't go so well?

Recognize a concern during patient interaction

What was concerning about this case?

Please explain.

Understand cultural implications

What cultural influences may have been present in this case?

How were they addressed? How should they be addressed?

Team Communication How was the communication between the nurse and PT regarding the patient's desire to have a female nurse? Was his request adequately addressed? What are some solutions?
Understand clinical presentation

What signs and symptoms would you expect for this type of patient with a recent amputation?

What signs and symptoms were present?

How did the patient describe his/her symptoms?

What other presentations can produce similar symptoms?

Identify contributing factors

What risk factors were present?

What is important about this patient's history?

Assessment

What specific assessments are important to consider with this type of patient?

Whom was to provide them?

Documentation

What is important to document?

Whom documents what?

Decision Making Prioritization

What information was necessary to make a decision? What cultural considerations need to be explored?

How were decisions made?

What resources could be accessed?

Communication

When is it helpful to contact a referring provider?

What additional information do you need to proceed with this case?

What are some ways we could improve on sharing information?

Situational Awareness Cultural Considerations

What are strategies for keeping the big picture in view?

What are strategies to be a cultural broker in this scenario?

Leadership

When was there a clear leader?

How were the roles delegated?

How could the workload be divided up differently?

Professional Behavior To patient, and team of nurse/PT

How were we coming across?

What was the team performance like?

Was the patient included in the team conversations?

What are some strategies for managing difficult interactions?

Closing

What would we do differently next time?

Any other questions or comments?