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PEARS Simulation

Section 1: Demographics
Case Title: Respiratory Distress in the Pediatric Patient

Case Description & Diagnosis: The nurse enters the patient room to find the child in
mild respiratory distress. He then progresses to severe respiratory distress. The nurse
must then follow the PEARS algorithm to treat the patient. The patient has an upper
airway obstruction (blockage of the large airway - upper trachea) from the endotracheal
tube.

Author(s): Molly Gleason RN, BSN

Date(s) of Development: May, 2018

Target Audience: PEARS students

Section 2: Curricular Information


Prerequisite Knowledge and Skills:
Required Knowledge Background
● Parts 1-6 in the PEARS Provider Manual
● Review Respiratory assessment in Kyle, Pediatric book
Required Background Skills
● Pediatric Assessment
● Emergency Airway Management (PEARS)

Learning Objectives:
● Recognize a seriously ill or injured child using a systematic approach
● Begin to stabilize a child in respiratory distress
● Practice effective team interaction
● Define the "initial impression"
● Explain how to utilize a systematic approach algorithm
● Discuss the evaluate, identify, intervene sequence
● List 5 elements in evaluation of breathing
● Identify signs and symptoms of and interventions for upper airway obstruction,
● Recognize signs of and describe interventions for mild and severe respiratory
distress
● Recognize signs of inadequate oxygenation and inadequate ventilation
References used:
● American Heart Association PEARS Provider Manual

Section 3: Preparation
1. Simulator
a. “Timmy” manikin
2. Machines
a. Pediatric crash cart
b. Patient monitor
c. Pediatric nebulizer
3. Supplies
a. Pulse-ox monitor
b. Stethoscope
c. IV with NaCl (running at 125 cc/hour)
d. Empty Azithromycin secondary bag
e. IV pump
f. Epinephrine for nebulizer
g. Pediatric non-rebreather O2 mask
h. Pediatric nasal cannula
i. Pediatric ambu-bag
j. Steri-strips on right lower abdomen (appendectomy)

4. Supporting Materials:
a. Labs
i. Hgb 4.0
ii. Hct 37
iii. WBC 21.1
b. Handouts
i. Patient chart
ii. PEARS algorithm

Standardized Actors/Roles:
1. Timmy- 7 year old male
2. Mother- 35 year old female who is anxious about her son’s condition but is
understanding and trusts the medical team and their decisions

Time Duration

Set-up 30 minutes
Preparation for
15 minutes
students
Simulation 30 minutes
Debrief 30 minutes
Section 4: Simulation Exercise

Information for Participant


Case Stem to be read to participants:
● Your patient, Timmy, is a 7 year old male pediatric patient who underwent an
emergency appendectomy this morning and is in the PACU. His incision is closed
with sutures and steri-strips. He was given Azithromycin prophylactically. His
vitals have been stable and he was extubated 60 minutes ago. His pain is under
control. He is tired but awake. He has NaCl running at 125 cc per hour. His
mother just stepped out to make a phone call. Patient has no past medical history.
He weighs 23 kilograms.

Information for Facilitator/Simulator Operator Only

Initial presentation: Timmy underwent an emergency appendectomy. He was extubated


60 minutes ago. Timmy is now laying in the bed with a tachycardia, pallor, hoarseness,
and anxiety.

How the Scenario unfolds: The students must perform an assessment and as the
assessment is taking place Timmy’s respirations increase, he has nasal flaring and
retractions. He starts to drool and his lung sounds show decreased air movement. If the
students do not take action, he starts to have a slow respiratory rate, grunting,
bradycardia, mottling and cyanosis, and a decreased level of consciousness

Critical Action Items: Early detection of respiratory distress, give O2, determine the
cause of respiratory distress

Actual course of events and outcomes (for real patient cases): Timmy’s airway is
narrowed due to tissue injury from the endotracheal tube.

Simulation Events Table


Step Participant action/ Patient Status Monitor Display
Trigger (Simulator response) (Vital Signs)
& Operator Prompts
1 Nurses performing Simulator voice: Rhythm: NSR
baseline assessment Answering nurse’s B/P: 95/60
● Initial questions appropriately P: 95
impression (with a hoarse voice) R: 24
● Evaluate - T: 99.1 F
identify - O2 sat: 95%
intervene
2 Nurses identifying Simulator voice: Rhythm: NSR
mild respiratory Anxious and agitated B/P: 95/60
distress P: 105
● Activate R: 26
emergency T: 99. F
response O2 sat: 93%

3 Nurses performing Simulator voice: Rhythm: NSR


initial interventions Anxious and agitated B/P: 95/60
● Position child P: 105
(for comfort, R: 26
open airway) T: 99. F
● Do not O2 sat: 93%
suction
● Do not
agitate the
child
● O2 via nasal
cannula
4 Nurses identifying Simulator voice: No Rhythm: NSR
severe respiratory longer speaking B/P: 95/60
distress P: 120
● Activate R: 32
emergency T: 99. F
response O2 sat: 89%

5 Nurses performing Simulator voice: No Rhythm: NSR


further interventions longer speaking B/P: 95/60
● Epinephrine P: 120
nebulizer to R: 30
reduce the T: 99. F
swelling of O2 sat: 89%
the airway
● Bag-mask
ventilation
with oxygen
(1 breath
every 3-5
seconds)
● Can lead to
endotracheal
re-intubation
6 Nurses re-assessing Simulator voice: Weak Rhythm: NSR
but audible B/P: 95/60
P: 95
R: 24
T: 99. F
O2 sat: 95%

Section 5: Debriefing & Evaluation


Debriefing

Reactions

1. What was the sequence of events?

2. How did you feel about the simulation?

Understanding (advocacy/inquiry)

1. What were you thinking when Timmy’s condition worsened?

2. It looked to me that ____________?

3. I felt that you ____________?

4. I saw you do/use ____________?

5. Has this happened in your experience?, if so how was it addressed?

6. Now that you have completed this simulation, how will this (if any)

change your practice?

Summary

1. What did you do well?

2. What could you have done better/differently?

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