Impaired Perfusion High Risk Obstetrical Simulation
Patient-Centered Care, Safety, Teamwork and Collaboration
Skills or Simulation Laboratories
Because of low patient census and the inability to ensure high risk obstetrical patient experiences, securing student clinical opportunities is difficult. Using the principles of a “flipped classroom”, an eight hour high risk obstetrical simulation clinical was developed for fourth semester, senior level nursing students. The content focused on the concept of impaired perfusion. This learning strategy allowed for student learning in a safe environment (where student could do no harm) while focusing on quality patient-centered care.
Pre-briefingPower point presentation (outlined the agenda, outcomes, and expectations). Outcomes included prioritization, critical thinking, becoming more comfortable in the clinical setting, being confident in one’s own nursing skills, and knowing when to ask for help from others in order to ensure patient safety. Discussion on the patient safety initiative TeamSTEPPS. The key principles of team structure, leadership, situation monitoring, mutual support, and communication were highlighted. The reasons for simulation clinical instead of clinical at the hospital were explained (see above). Power point continued with a review of obstetrical content presented in past semesters. The concept of perfusion as it relates to OB high risk situations were presented. Preeclampsia (how it effects the body systems and organs, assessment, management and treatment) and hypertension in pregnancy were explained. Risks for other disorders (HELLP syndrome and Eclampsia) and intrauterine resuscitation methods were discussed.
Group 1 independent paperworkCase studies of high risk OB situations--Drug use and domestic violence, preeclampsia, placental problems (abruption placentae and placenta previa, DIC and HELLP syndrome) Healthy people 2020 objectives (as they relate to the postpartum period) Fetal monitoring tracing
Group 2 Skills LaboratorySimulation--students assigned to a “patient” being prepped for a cesarean section. Start an IV, prime tubing, program a pump, secondary (piggyback) and insert a Foley catheter (problem solve with minimal assistance from the instructor). “Trouble shooting” with IV pumps, piggybacks, and tubing and Foley catheter insertion. Unfolding Case Study: 30 week primigravida patient, determine if symptoms were normal or abnormal for gestation. Identify abnormal vital signs, key lab values, important nursing interventions, and plan ahead for emergencies. Role play calling doctor using SBAR. Patient progressed from preeclampsia, HELLP syndrome, to eclampsia with a grand mal seizure. Demonstrate nursing care and interventions (seizure precautions and intrauterine resuscitation). Demonstration of assessing deep tendon reflexes and clonus.
Group 1 and 2 switched and the above was repeated.
Simulation“Noelle” 4 hours post-partum, “just did not feel very well and was a little lightheaded.” During the fundal assessment, the students discovered a large amount of blood on the chux pad. Student expectations: perform nursing interventions to assist with postpartum hemorrhage, implementation of hemorrhage management (calling doctor, IV start, medication administration, physical assessment, fundal massage). Instructor challenged students by asking critical thinking questions.
LaboratoryVaginal examinations using cervical models. Determination of dilatation at 1, 3, 5, 8, & 10 centimeters (baby in vertex, footling breech positions, and prolapsed cord presentations). Interventions discussed. Shoulder dystocia demonstrated using a mannequin, pelvic model and baby. Turtle sign, McRoberts maneuver, and suprapubic pressure were shown. Brachial plexus injury and the Zavanelli maneuver were discussed. Precipitous labor, precipitous delivery and nursing interventions were examined. Neonatal resuscitation was discussed. Principles such as initial assessment, oxygen administration, PPV, chest compressions and AGPAR scoring were demonstrated using a baby model. The Newborn resuscitation algorithm was shown and discussed in terms of routine vs. resuscitative care. Students demonstrated skills.
NCLEX ReviewNCLEX review was done using clickers and consisted of 14 questions involving high risk OB situations. After the review faculty clarified the reasoning for the correct answer.
DebriefingDebriefing was done as well as faculty shared personal experience and answered questions throughout each teaching session. A final debriefing was done with all students at the end of the day. Paperwork and fetal monitoring strips were reviewed.
Students completed a clinical journal discussing their impression of the clinical day, what they learned, and what they would change (if anything).
Students commented that this type of learning was beneficial to them, being able to call on their peers for help or advice instead of being put on the spot when they felt stressed. Students remarked that the clinical experience was helpful as many had not had the opportunity to practice the skills in the clinical setting.
Overall the feedback from the clinical journals, emails, and verbal comments from the students was positive. A few students did express the desire to have this simulation clinical along with a clinical day spent at the hospital.