A Simulation: Post-Op Care for a Pediatric Patient With Hidden Evidence of Abuse

An original simulation case was developed for junior and senior level pediatric nursing students at a mid-Atlantic state university. The simulation is run once per semester for each team of 4 students enrolled in the undergraduate nursing pediatric clinical course. They are assigned roles as the primary pediatric nurse, the secondary or float nurse, the medications nurse, and the documenter/team leader. The simulation is 20 minutes in length and develops as it progresses depending on what the students do.

The students are given an introduction to the simulated patient and an orientation to the room and the equipment prior to the start of the simulation. The students are given a hand-off report from PACU, last vital signs, written orders from the physician/surgeon (none have been initiated), a patient history, and previous x-ray reports, all on the EHR. The students enter the patient’s room after reviewing the chart and the clock begins. There is no instructor in the room. The simulation is being viewed by the instructor and the camera/mannequin operator and is recorded for later review in debriefing by the team and instructor. During the simulation the team is able to interact by phone with the operator/instructor as they are in the roles of charge nurse, unit secretary, physician, pharmacy, lab and respiratory technicians, and social work. The simulation offers many interdisciplinary interactions and reinforces collaboration. The students are told to complete and/or initiate others to complete as many of the physician orders as possible and to deliver appropriate post-op care to the patient.

As the simulation unfolds, the student doing the assessment discovers bruises of differing levels of healing, an infected injury, a history that doesn’t match the injury, a history of old healed fractures, an absent mother, a questionable report on the mother’s earlier exit, and a possible developmental delay. When questioned about the injury the patient keeps repeating “My mother said I…” and if asked what he thinks or remembers, he responds “I don’t remember..." Will the students connect the dots and identify physical child abuse? And, will the students take appropriate legally mandated action?

Even if they miss the abuse diagnosis and/or fail to take action, the simulation is loaded with other learning opportunities. There is a medication allergy, an incomplete order, a stat order, 2 medication safe dose calculations, a medication volume calculation, an assessment to do, vital signs to take, an incorrect IV rate, an IVP medication that must be diluted, and a low grade fever. There is a fresh cast (still wet?) to be moved, assessed, and elevated. There are lots of phone calls to make to members of other disciplines with proper identification and title usage, patient’s room number, use of SBARR or not, taking and repeating back of verbal orders & verbal reports. Priority setting and critical thinking are required frequently.

The documenter records the events during the simulation and then leads the team discussion after exiting the patient room to identify what the team did right and what needed improvement. The team watches the recording and then critiques themselves and shares their list with their instructor. Following their critique the instructor expands on their self-critique, reviews the physician orders with correct actions & priorities, the correct actions to be taken based on the new unexpected findings and the required deviation from the normal post-op care. The clinical ends with a discussion of child abuse and the role of the healthcare provider.