Natalie Hall Simulation Scenario

Learning Objectives:
PATIENT CENTERED CARE:
Complete focused or head to toe assessment
Identify changes in patient condition and reassess as necessary.
Consider developmental level of patient.
Include family in treatment plan
TEAMWORK AND COLLABORATION:
Communicate using SBAR format
SAFETY:
Implement 6 rights for safe administration of medications.

Follow along with this written scenario, respond to the questions/answer prompts that are
within. During class you will participate in a pre-briefing and then a debriefing on this
patient and your experience in completing this simulation. You will need to reference this
worksheet in order to participate in the debriefing. This debriefing will allow you to discuss
the scenario, ask questions and prepare you to complete a care plan on Natalie Hall. The
questions/prompts you will respond to have an asterisk, are in all capital letters, bolded,
and italicized.

REPORT:

The current time is 2pm. You are working in the ED. You are caring for Natalie Hall, a 4-
month-old brought in by her mom for increasing irritability and crying for 3 days. The baby has
no past medical history. She is a 4-month-old female delivered at full term via uncomplicated
vaginal delivery. Mom, Samantha Hall, is a G1P1 and she is currently breastfeeding Natalie. Her
birth weight: 7.5 lbs.; current weight 12 lbs. Natalie’s mom brought her into ER stating, “Natalie
hasn’t been sleeping and is constantly crying”. She expressed that the child has been irritable for
3 days. She has also been congested with a runny nose and low-grade fever. Natalie is late on
vaccines. She did receive Vitamin K and Hepatitis B at birth but nothing since then. I did do
nasal swabs to rule out Rapid RSV & influenza. A CBC and Chem panel were sent but we’re
waiting to hear back from lab with results. The physician is writing orders for her, so I haven’t
done much yet. He should be done by the time we are finished. I triaged Natalie and brought her
back to the room. She does have a saline lock 24 gauge IV in her right-hand. Dr. Jacobs is the
ED doc and is available through the operator. Mom is at the bedside.

DESCRIBE YOUR NURSING ACTIONS AND CARE AFTER RECEIVING REPORT &
WHEN ENTERING THE ROOM
Do an assessment on the child, head to toe preferably since it is my first time seeing the
patient. Check patency of IV. Build a rapport with family. Any other queations.

INITIAL ASSESSMENT
NEURO: Infant is awake and fussy. Responds to touch. Not interested her pacifier.

HEENT: Anterior fontanel open, sunken, posterior fontanel closed. Clear nasal drainage. Mucus
membranes dry. Sclera clear, dry. Normocephalic.

RESP: Bilateral breath sounds clear throughout lung fields, equal. Chest expansion equal.

CARDIAC: Rate regular, no murmurs present, S1 & S2 noted. Bilateral Brachial & Pedal pulses
+2. Capillary refill 2 sec.

SKIN: Color normal to ethnicity, warm and dry, tenting noted.

ABDOMEN: Round, soft, no distension with + BS x 4 quadrants. No tenderness with palpation.

Diaper dry keep an eye on output, no stool.

MUSCULOSKELTAL: Moves all extremities equally x4 with stimulation.

IV: 24g IV in right hand. Dressing dry and intact. No redness, drainage, edema noted.

VITAL SIGNS: T- 101.9 axillary, BP: 71/40 in the low averages keep an eye, Pulse: 165, RR:
65, SpO2: 98%

While you are completing Natalie’s assessment her mother says, “I’m so tired. I babysit my
sister’s kids during the day too. I’m not getting any rest; Natalie is so fussy when I try to nurse
her, I’m not sure how well she is eating.” - “The Doctor told me Natalie was going to be tested
for the flu, do I need to tell my sister to take her kids to get tested too?” “Can they come visit?
Natalie really likes her cousins.”

2. INDICATE ANY ADDITIONAL ASSESSMENT INFORMATION YOU WOULD LIKE

TO HAVE, SUBJECTIVE OR OBJECTIVE.

 Ask parent if child has reached any of the following Hitting milestones:
o Rolls over from front to back
o Sits with support
o Bears weight when standing on a hard surface
o Holds a rattle or other baby toys
o Holds up head and chest
o Pushes up to elbows when laying on stomach
o Reaches for objects with one hand
o Coordinates seeing and movement—spotting something they want, then reaching for it
o Follows objects moving from side to side with eyes
o Brings hands to mouth
 Vitals
 Weight
 Assess respiratory status, auscultate lungs for adventitious
  I&O

Natalie’s mother tells you that she would prefer her daughter not be catheterized saying “isn’t
there something else we could do, maybe she will pee if she eats more.” “Can I try to feed her?”

You decide to ask Natalie’s mother about her intake and output. She responds, “I try to breast
feed her every 2-3 hours, but she has been so fussy, she doesn’t seem interested in eating much”.
“It’s been awhile since she’s had a wet diaper, she’s been pretty dry, maybe 3 or 4 wet diapers
the past 2 days”.

3. ARE THERE ANY ADDITIONAL FOLLOW-UP QUESTIONS YOU HAVE FOR

NATALIE’S MOTHER?

Try to calm the mother down but ask more about the length of time the child has been “pretty dry” what
does she mean by its been awhile.

4. INDICATE YOUR RESPONSE TO NATALIE’S MOTHER’S CONCERNS (describe).

About the concern for influenza or RSV swabs I would explain to her that right now the main priority is
her 4 month old and that once they go home she can talk to her sister about getting her children checked.
If the mother doesn’t want her kid being catheterized well we can try tto explain that the best choice is
straight cath but if she’s still not convinced in certain situations, a sterile bag can be placed around a baby’s
diaper area to collect a urine sample.

5. PRIORITIZE YOUR SIGNIFICANT ASSESSMENT FINDINGS

1. Fluid volume deficit related to decreased fluid intake.
2. Hyperthermia related to dehydration
3. Ineffective Infant Feeding Pattern related to parent stating child isn’t interested in eating much

6. PRIORITIZE YOUR PRIORITY NURSING ACTIONS AFTER CONCLUDING YOUR

ASSESSMENT.

1. Encourage oral fluid intake.

2. Call doctor give report
3. Give antipyretic medications as prescribed. Antipyretic medications lower body temperature
4. Smaller, more frequent meals. It can also involve switching feeding methods from breast to
bottle.

7. WHAT IS THE RATIONAL FOR OBTAINING A URINE CULTURE, CBC, CMP, AND
RSV AND INFLUENZA NASAL SWABS?

The reason we need so many lab tests is because the child already has a high fever and we need
to figure out where the infection is and how this illness’ sypmtoms are affecting your child.
8. WHAT SHOULD YOU KNOW ABOUT PATIENT CARE RELATED TO THE NASAL
SWABS?
Remember that the nasal swab could be a nasopharynx swab so its not just the nares, the anatomy of the
child, and remember to always label your swabs.

9. DESCRIBE ALL YOUR ACTIONS RELATED TO THE ADMINISTRATION OF THE

TYLENOL.
I would call the physician and recommend to change the oral administration of the Tylenol to a rectal
administration, due to the child not allowing to be fed anything also not wanting the pacifier.

10. HOW DO YOU SAFELY ADMINISTER AN ORAL MEDICATION TO AN INFANT?

WHAT IS A POTENTIAL RISK WHILE ADMINISTERING AN ORAL MEDICAION TO
AN INFANT OR YOUNG CHILD?

Before administering oral medications, the nurse assesses the child’s gag reflex and ability to
swallow. The specific form of oral medication used should be tailored to the child’s
developmental level and ability to successfully take a particular form. An assessment of the way
the child takes medications at home will help determine the best form to us.

When preparing to administer an elixir or a suspension, the nurse first ensures that the correct
dose is drawn for administration. Physicians’ orders often specify the dosage in milligrams (mg),
not milliliters (mL), for liquid medications. It is important to calculate the mL dose properly on
the basis of the number of mg per mL for the available liquid medication.

The method for administering oral medications differs according to the child’s age and
developmental level. Infants usually receive elixir or suspension forms that are administered
using an empty nipple or oral syringe. First, the infant is placed in an upright or semi-upright
position, similar to the position used for feeding. The nurse opens the infant’s mouth by applying
gentle pressure to the chin or cheeks. If using a nipple, the nipple is placed in the infant’s mouth
and the medication added to the empty nipple when the baby begins to suck. If using an oral
syringe, the syringe is gently placed in the infant’s mouth along the side of the cheek, and the
nurse pushes the medication in slowly as the infant sucks

A potential risk is if the amount of medication is too high the child may overdose so always
check the dose. Another big issue is the child’s risk of aspiration.

11. INDICATE YOUR RESPONSE TO NATALIE’S MOTHER (describe).

Give your baby the medicine Hold your baby the same way you do when you nurse or feed her. Put the
syringe into your baby's mouth and gently squirt a small amount of the medicine between his tongue and
the side of her mouth. This helps her swallow it easily.
 12. YOU ANTICIPATE BEING WITH ANOTHER PATIENT FOR A WHILE, CAN YOU
DELEGATE NATALIE’S NEXT CHECK TO A CNA? JUSTIFY YOUR RESPONSE.

Labs have returned and are below.

LABORATORY NAME: NATALIE HALL

NORTHERN ILLINOIS UNIVERSITY SCHOOL
DOB: 08/01/XX
OF NURSING MRN#: 1574778
SIMULATION CENTER

1240 NORMAL ROAD

DEKALB, ILLINOIS 60115
Date/Time Lab Test Result Alert Range
Today CBC
WBC 14,000 5000 - 19,500 /mm3
RBC 5.2 H 2.7 - 4.5 million cells/cc
HGB 15.4 H 9.0 - 14.1%
HCT 47 42-52 %
MCV 89 74-108 fl
MCH 29 25-35 pg/cell
MCHC 32 28-36 g/dl
RDW 12.5 11.5-14.5%
Platelets 350,000 150,000-450,000 /µL

Date/Time Lab Test Result Alert Range

Today CMP
Na 128 H 130-140 mEq/L
Cl 102 96-106 mEq/l
K 5.6 H 3.5-5.0 mEq/L
Ca 9 9.0-10.5 mg/dL
CO2 15 18-27 mEq/l
Phosphorus 6.0 4.2- 9.0 mg/dL
BUN 20 H 4-15 mg/dL
Creatinine 1.2 H 0.3- .7 mg/dL
Anion gap 10 8-16 mEq/l
Glucose 80 70-110 mg/dL
Albumin 4.5 3.8-5.4 g/dL
Alkaline phosphatase 250 82/383 IU/L
ALT 20 4-36 units/L
 AST 18 0-35 units/L
Total Bilirubin 1.0 0.3-1.0 mg/dL
Total Protein 5.2 4.7-6.7 g/dL
Date/Time Lab Test Result Alert Range
Today RSV Negative
Influenza A Positive
Influenza B Negative

SECOND ASSESSMENT “30 MINUTES” AFTER TYLENOL:

Natalie continues to fuss and cry with stimulation, mom is putting on a new diaper when you
arrive. Overall her physical assessment has not changed, although you notice that seems less
responsive, so you take her VS and obtain those listed below. Natalie mom turns to you and say,
“Still dry. Do you know what the flu test was?”

Influenza A

VITAL SIGNS: T- 102.2 axillary, BP: 63/35, Pulse: 180, RR: 68, SpO2: 95%

13. PRIORITIZE YOUR ASSESSMENT DATA AND NURSING ACTIONS

1. Fluid volume deficit related to decreased fluid intake. High K, creatinine, BUN, RBC, BP lower than
average. Less responsive, still dry diaper.
2. Hyperthermia related to infuenza, and possible dehydration. 102.2 temp, positive unuenza A
3. Ineffective Infant Feeding Pattern related to parent stating child isn’t interested in eating much

14. PROVIDE AN SBAR TO THE PHYSICIAN

The physician responds to your SBAR to begin a fluid bolus of .9NS 20mL/kg over 30 minutes,
then run at 1 ½ x maintenance. He will be in shortly to see the patient.

15. CALCULATE THE FLUID BOLUS

220 mL/hr

16. DESCRIBE THE STEPS TO SETTING UP A FLUID BOLUS (OR CAN DISCUSS).
ASSESSMENT 3#
When you walk into Natalie’s room the mom is distraught and tearful. She states “What is
wrong with Natalie? She won’t even try to eat and she’s not even crying anymore! She won’t
even open her eyes, but I don’t think she is sleeping, she doesn’t look right”

Natalie opens her eyes to vigorous stimulation; no cry, pallor noted, cool to touch.

VITAL SIGNS: Temp: 102.2, BP: 51/25, Pulse: 191, RR: 71, SpO2: 94%

17. EXPLAIN WHAT YOU THINK (PATHOPHYSIOLOGY-WISE) IS OCCURING WITH

NATALIE AND WHAT ADDITIONAL ASSESSMENT PIECES DO YOU NEED?

It is manifested by two or more of the SIRS (Systemic Inflammatory Response Syndrome)

criteria as a consequence of documented or presumed infection.

 Extremes of age. Elderly people and infants are more prone to septic shock because
of their weak immune system.
 Malnourishment. Malnourishment can lower the body’s defenses, making it
susceptible to the invasion of pathogens.
SIRS with a suspected source of infection is termed sepsis. Confirmation of infection with
positive cultures is therefore not mandatory, at least in the early stages. Sepsis with one or more
end-organ failure is called severe sepsis and with hemodynamic instability in spite of
intravascular volume repletion is called septic shock.  Together they represent a physiologic
continuum with progressively worsening balance between pro and anti-inflammatory responses
of the body

Heart Rate (bpm)¹

Systolic
Age Respiratory Leukocyte
Blood
Group Rate² Count³
Bradycardi Pressure⁴
Tachycardia
a

0 days – >180 <100 >50 >34 <59

1 week
 Heart Rate (bpm)¹
Systolic
Age Respiratory Leukocyte
Blood
Group Rate² Count³
Bradycardi Pressure⁴
Tachycardia
a

1 week – >180 <100 >40 >19.5 or <5 <69

1 month

1 month >180 <90 >34 >17.5 or <5 <75

– 1 year

2-5 >140 NA >22 >15.5 or <6 <74

years

6 - 12 >130 NA >18 >13.5 or <83

years <4.5

13 - <18 >110 NA >14 >11 or <4.5 <90

years
18. WHAT CHANGES IN HER ASSESSMENT WOULD YOU ANTICIPATE IF HER
CONDITION IS PROGRESSING?

PALS has a chart of steps if she were too progressivily get worse, but definetly call a code blue or RR.
19. PROVIDE AND DETAIL ONE EXAMPLE OF HOW YOU IMPLENTED THE
NURSING PROCESS (adpie) AS YOU WALKED THROUGH THIS PATIENT SCENARIO?

Upon assessment I was able to gather up that the child was dehydrated due to sunken fontanels, the
mother stating she “tries to feed her baby but child refuses”, fever of 101, BP at the low threshold, dry
diaper and high RR.
This led to the nursing diagnosis of at first of:
1. Impaired gas exchange related to possible viral pneumonia.
2. Fluid volume deficit related to decreased fluid intake.
3. Hyperthermia related to dehydration
Which after the second assessment and lab tests changed to:
1. Fluid volume deficit related to decreased fluid intake. High K, creatinine, BUN, RBC, BP lower than
average. Less responsive, still dry diaper.

2. Hyperthermia related to infuenza, and possible dehydration. 102.2 temp, positive unuenza A

3. Ineffective Infant Feeding Pattern related to parent stating child isn’t interested in eating much
Patient is normovolemic as evidenced by systolic BP greater than or equal to 75 mm HG (or
patient’s baseline), absence of orthostasis, HR 100 to 190 beats/min, respirations 30-53 per min,
urine output greater than 30 mL/hr and normal skin turgor.

Patient will display hemodynamic stability.

Patient will verbalize understanding of the disease process.

Patient will achieve timely wound healing.

1. Encourage oral fluid intake.  Continue breast-feeding or bottle-feeding your infant as

you would normally.
2. Administer IV fluids, such as isotonic crystalloids (D5W normal saline [NS],
lactated ringer’s [LR] and colloids (albumin, fresh frozen plasma), as indicated.
Fluid therapy is most effective early in the course of severe sepsis because as the
condition worsens, there is greater dysfunction at the cellular level. Large volumes of
fluid may be required to overcome relative hypovolemia or peripheral vasodilation, and
 replaced losses from increased capillary permeability (e.g., sequestration of fluid in the
peritoneal cavity) and increased insensible sources such as fever and diaphoresis.
3. Monitor trends in blood pressure (BP), especially noting progressive hypotension
and widening pulse pressure. Hypotension develops as circulating microorganisms
stimulate release and activation of chemical and hormonal substances. These endotoxins
initially cause peripheral vasodilation, decreased systemic vascular resistance (SVR), and
relative hypovolemia. As shock progress, the cardiac output becomes severely depressed
due to major alterations in contractility, preload, and/or afterload, thus producing
profound hypotension.
4. Hematocrit and red blood cell count. Evaluates changes in hydration/blood viscosity.
5. Blood urea nitrogen and creatinine. The BUN/Cr ratio could indicate dehydration or
renal dysfunction and failure.
6. Provide supplemental oxygen. Supplemental oxygen improves cellular
oxygenation.
7. Inotropic agents and vasopressors, such as norepinephrine (Levophed), dopamine
(Intropin), and vasopressin (Pitressin). Inotropic agents and vasopressors may be
needed to improve organ perfusion and to maintain blood pressure during and after fluid
treatment.

20. HOW DOES NATALIE’S DEVELOPMENTAL LEVEL INFLUENCE YOUR CARE?

21. IDENTIFY ANY POTENTIAL QUALITY IMPROVEMENT ISSUES YOU MAY HAVE
ENCOUNTERED DURING THIS SCENARIO THAT MAY NEED TO BE INVESTIGATED
FOR AN INTERVENTION.

I would ask for more data to help stop the potential Shock.

22. IDENTIFY THREE NURSING DIAGNOSIS LISTING APPROPRIATE SUBJECTIVE

AND OBJECTIVE INFORMATION