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Home > Simulations > Simulation 9: El Salvador

Scenario #9: El Salavador, Juan Dominguez

Learner Group: PT, Nurse

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 language barriers that could influence patient compliance and plan for care
  3. Identify and understand cultural barriers that could influence patient compliance and plan for care
  4. Nurse and PT jointly determine Plan of Care with patient

Performance measures

1 B PT to decide upon translation services
2 C PT to explain purpose of assessment
3 T PT to perform mobility assessment to determine rehab status
4 T Nurse to perform routine vitals and dressing check
5 B Nurse to respond to patient's request for a female nurse.
6 B Nurse and PT to discuss with patient and spouse about rehabilitation/ D/C options

Skills/tasks/procedures

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

Imbedded challenges

  1. PT to determine translation services

    Nurse need to manage patient's request for a female nurse

  2. Discussion of how educate patient and family about D/C rehab options
  3. Education and brokering with patient to agree upon D/C rehab recommendations
  4. Possibilities of accessing female nurse or using female PT for patient care

    Involvement of social work

  5. 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 being visited by a PT at the hospital, to be assessed for discharge, following a (L) BKA 5 days ago. Patient was originally admitted 10 days ago with osteomyelitis and gangrene of the (L) foot and underwent a supramalleolar amputation of the (L) foot 10 days ago . A patient evaluation has been ordered for mobility, transfers and strengthening to prepare for D/C.

Learner roles

  1. PT
  2. Male Nurse

Confederate roles and scripting

Role Tone Timing of participation Lines / comments
Wife Concerned Sitting in room at bedside Translates to the patient

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, patient was admitted to the hospital and underwent an supramalleolear amputation to the (L) foot 10 days ago. Five days after the surgery patient developed a secondary infection into his tibia and then underwent a (L) BKA 5 days ago. patient now needs to be assessed for discharge.

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: 13th of the month.

(PT will enter first, give 5 minutes to get patient sitting at edge of bed, then send in Nurse)

"Your patient, Mr. Dominguez speaks primarily spanish, his wife is with him and is bilingual. Your patient has just been informed that his boss will let him return to work when he is ready. His co-workers do not come and visit him and do not accept that he wants to return to work quickly instead of resting at home. This has put Mr. Dominguez in a sad mood."

Patient: "You are assigned to Mr. Dominguez's case, you are to evaluate him for bed mobility, get him sitting on the edge of the bed and prepare for standing. His team needs to make a decision if he is able to be discharged to home or go for rehab, it would be best for him to go for rehab but the family seems to want to take him home"

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

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) fBKA 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 Medicine/Surgery Floor
Equipment

Hospital bed

Commode at bedside and Urinal

IV antibiotics

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 Wife Script

0-5 minutes

HR: 70 bpm

RR: 13 bpm

BP: 128/72

Temperature: 99

SpO2: 98%

Auscultation sounds

  • RRR
  • Clear bilaterally
  • Active X 4 quads

Manikin Vocals

Mental status: alert, oriented x 3

Tone: Calm

Manikin Voice: ¿quién eres? qué es lo que quieres?

  • PT enters, introduces self, explains purpose of visit
  • PT to decide upon translation services
  • If PT decides to call for official translator services, they will be denied due to staffing shortage in the hospital
  • PT to ask patient to perform bed mobility and assist to sit at edge of bed

"Who are you?"

"He doesn't understand or speak much English, he speaks Spanish"

"I can translate for my husband, what does he need to do"

"he hasn't even sat up yet on his own since this surgery"

"you need to let him go home"

5-10 minutes

HR: 96 bpm

RR: 20-22 bpm

BP: 140/86

Temperature: 99

SpO2: 98%

trend over       minutes

Auscultation sounds

  • No change
  • No change
  • No change

Manikin Vocals

Mental Status:

Tone: very agitated

Manikin Voice:

quiero ir a casa

tengo que volver al trabajo

  • Nurse enters room, introduces self and describes purpose
  • Nurse attempts to take vitals or works with PT on doing so
  • PT explains the benefits of going for inpatient rehab
  • PT/ Nurse attempt to be involved in the conversation with patient and wife
  • PT/Nurse tries to explain that the patient can go back to work but the hospital cannot keep me any longer but he can go to a rehab center

"my husband wants to go back to work immediately, he does not want to go to rehab"

"he cannot get to therapy, there no buses and I have to take the car to work and the children are in school"

"he does not want to go to another hospital he wants to go home and go back to work"

WIFE to Patient:

Yelling: "you should just go home and not work-you are lucky to be alive"

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 Were patients desires adequately addressed? What are some solutions?
Understand clinical presentation

What signs and symptoms with this patient following a recent amputation?

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 about rehab potential? 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?