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1. Insert your logo here A Recipe for Success: Maximized learning using unfolding cases

2. COI • There are no conflicts of interest to declare

3. Classroom Style simulation + “traditional simulation”+ an unfolding case= optimized experiential learning • Case study content comes to life (see:Effectiveness of Human Patient Simulator as a Classroom Teaching Strategy~ Deborah A Beyer MSN, RN) • Active learning and learner centered- engaging • Flexible • Fosters peer to peer feedback • Fosters self reflection • Encourages group problem solving • More robust- less time

4. Example • 12 students, 90 minutes including debrief • 3 students per group • 3 in room: • 1) Primary RN, • 2)Secondary RN • 3)Team leader, Reader, Recorder • 9 observing • Findings and observations • Suggestions • 15 minutes per group including report-(scenario time total=60mins) • Each group gives and gets report

5. Sample scenario 74 year old female diabeticright foot debub. • SET UP • This is what Group#1 will encounter: Patient VS 132/78 86 20 99.2 98% RA. Pt A & O x3. Pain 2/10. IV PRN angio. Dressing rt heel. Lungs clear. BS pos all 4 quads. Patient is propped on left side. Awaiting breakfast (or lunch). Three bruises on belly from Heparin. Pulses pos bilat. Feet cool. Good sensation. Lab Blood sugar back and high (294) – second group will cover. Healthy breakfast arrives as students prepare AM meds. Students will also turn and reposition patient (will they recheck all three stage 1 pressure areas-She has a reddened area on her iliac crest (2 inches in diameter) and on her left heel and her right elbow (1 inch) AND a new one on her left hip- (use bedsore pad). • ASSIGNMENT • Students will reposition her to her back for breakfast. complete focused assessment, record VS from monitor and give AM PO meds and Heparin. Will they complete a complete skin assessment? These students will report off.

6. Scene 2 • SET UP • This is what Group #2 will encounter: Patient VS 128/82 84 22 99.4 98% RA. Blood sugar will be 294. She also is slightly confused and says (about her breakfast tray) –“ it is really nice that they give us breakfast for supper sometimes like this, I used to do that at home with my kids when they were young”. Will they inquire more about the confusion? (She does not want them to think badly of her so she tries to cover up her confusion but poorly) Like “How many days until the next holiday?” I have to buy the birthday present etc etc. She keeps reorienting easily though. • ASSIGNMENT • Students will complete focused assessment, record VS from monitor and give insulin. They should also do more of a neuro assessment and check lung sounds. These students will report off.

7. Scene 3 • SET UP • This is what Group #3 will encounter: Bedpan is at bedside with 400 cc DARK yellow urine that smells of ammonia. Temp 99.8 other VS 126/84 90 24 0 98% RA. Pain is 9/10. Students will complete focused assessment and medicate for pain with Tylenol. She remains pleasantly confused. Knows where she is but not the day, month or year and won’t give her birthday, just says “I am too old now to even care about birthdays” – “You don’t have to do anything for my birthday” etc. If prompted with part of her Birthday- she will recall it eventually. Patient asks for bedpan again and says she has to “move her bowels”. Michelle will give it to her. • ASSIGNMENT • Students will complete focused assessment, record VS from monitor and give Tylenol for pain.Will students SBAR to MD about confusion and recognize foul smelling dark urine? These students will report off.

8. Scene 4 • SET UP • This is what Group #4 will encounter: VS 130/84 88 20 Temp 99.8 98% RA. Patient has bedpan under her with dark stool (a smidge of dark yellow urine) and frank blood on stool. Will students recheck VS especially BP and HR and look for other signs of bleeding- will they check her rectum for hemorrhoids OR inquire about a history of hemorrhoids? Stool is firm. She is NOT on a stool softener. • ASSIGNMENT • Students will complete focused assessment, encourage fluids, provide peri care and continue neuro assessment and assess for and inquire about bleeding elsewhere.

9. What the students said • What did I do well? 1)General and focused pain assessment.2)Called doctor to request PTT and occult blood stool test, Re-checked BP and blood sugar (call doctor to inform)3)Assed Pt’s pain, location, duration, etc.4)Wrap wound well, assess well wound care. • What will I do differently next time? 1)Gloves for injection and give info about meds given.2)Make sure to have all supplies out beside when preparing to administering med.3)Reposition patient when areas of non-blanchable areas are identified.4)Prop Foot Up to do dressing change. • Nursing diagnosis: 1)Impaired tissue integrity 2)Infection related to diabetes and PVD AEB ulcer in Right heel.3)Acute pain related to right heel decubitus, AEB the 9 out of 0/10 pain scale.4)Impaired tissue perfusion

10. Debrief= 30 minutes Debrief part 1 Debrief part 2 Group review Observations/feedback from room observers Case overview Connect to disease process, what we know about meds, treatments, symptoms etc. Reflective debriefs written from each group • immediate written: • What did we do well • What will we do differently next time • What did you NOT expect and what did you do about it • Name one nursing diagnosis/problem and all related interventions

11. Debrief= 30 minutes Debrief part 1 Debrief part 2 Group review Observations/feedback from room observers Case overview Connect to disease process, what we know about meds, treatments, symptoms etc. Reflective debriefs written from each group Tie it all together • immediate written: • What did we do well • What will we do differently next time • What did you NOT expect and what did you do about it • Name one nursing diagnosis/problem and all related interventions