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Scenario File: Eating Disorder

Discipline: Psych MH Student Level: interm./advanced

Expected Simulation Run Time: 10 min. Guided Reflection Time: 20 min.

Admission Date: Today’s Date:Brief Description:Name: Joyce Gender: Female Age: 27 Race: Asian American Weight: 130 lbs Height: 5’.5” cmReligion: Buddhist Major Support: Boyfriend of 3 years-Austin Phone: Allergies: cephalosporins Immunizations: Up to dateAttending Physician/Team: :Nurse/nurse practitioner:Past Medical History:J is a 27 year old IT professional with fulltime job. She lives alone in a condo in downtown Silver Spring which she purchased 1 year ago. J started disordered eating in high school, at first to control her weight, and then the behavior became a form of coping with stress especially with academic and interpersonal concerns. She sought therapy for bulimia while in college, and was helped by short-term cognitive behavior therapy. She did not engage in binging and purging for over 2 years after college, but in the past year as occupational and relationship stress increased, she relapsed into the binging and purging several times a month.History of Present illness:Boyfriend found her passed out in bathroom of her apartment; toilet bowl was splattered with blood stained vomit.He called 911 when J appearedPsychomotor Skills Required Prior to SimulationObservation of patients body language, facial expressions, synchrony between verbal and non verbal behavior.Cognitive Activities Required Prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]Nursing Diagnosis: Collaborative Problems:

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.

disoriented and continued to heave and complain of upper GI distress.

Joyce reports symptoms as follows:

· Intense feelings of anxiety over work stress

· Leaves work at lunchtime (her condo is about 3 blocks from her office) to binge/purge.

· Frequent work absences/tardiness.

· Cancels plans with boyfriend and friends due to fatigue and fear she will have urge to binge and will not be able to get away.

· Poor concentration, negative ruminations, cognitive distortions

· Frequent episodes of gastric reflux at night and 2-3 hours after a binge/purge episode.

· Severe ulcers of mouth and gums

· Vegetative symptoms: changes in sleeping, eating problems increase with more frequent bulimic episodes-having trouble consuming food that must be chewed thoroughly before swallowing, e.g. breads, vegetables, fruits, meats, nuts.

Social History:

J is a college graduate with a MS degree in computer science from University of Maryland.

J has several girlfriends she has met since graduate school and working. She socializes with these friends 2-3 times/ month. She is an avid runner, and is in training for the Marine Corps Marathon in October.

At work J was named project manager for a new account. She must shuttle between Boston and DC at least once monthly. She may be away from home for 7-10 days working on the project. It is a good assignment which will likely improve her

position in the company, but the responsibility adds significantly to her level of stress. While on travel, occurrences of bulimia have increased to daily episodes.Family:Family lives in S. Korea. One sister, age 32, lives in the US, but resides in Southern California with her husband and two children. Parents visit annually in the spring. J is concerned about father’s recent diagnosis with colon cancer. She fears he will not do well after surgery and radiation. J feels guilty that she is so far away from family and is not available to help. Her mother has always confided in J about her worries and sometimes relies on J to help her deal with financial and marital concerns. J sends her mother several hundred dollars monthly to keep the family budget balanced.J has been dating Austin for 3 years. They met in graduate school. Austin is Asian- African American and J is concerned her parents will not accept him. J spends many weekends and holidays with A’s family who treat her as a member of their family. J also feels guilty that she gets along better with A’s mother than her own.A has proposed to J. He does not know about her bulimia.Primary Medical Diagnosis:Bulimia Nervosa; Severe ulcerations of the mouth, gums and throat.Surgeries/Procedures & Dates: N/A

Simulation Learning Objectives

1. Apply the nursing process to initiate care of the patient with bulimia nervosa and patient’s family.

2. Assess the pt with bulimia, including information obtained through communication.

3. Determine (plan) the nursing care for the patient based on assessment findings.

4. Implement the appropriate care in a safe manner.

5. Evaluate the care provided.

6. Identify the primary nursing diagnosis and/or collaborative problems.

7. Document the assessments, patient changes, and interventions completed.

8. Demonstrate therapeutic communications in care of the patient and family.

Scenario Specific Objectives

1. Identify physical and psychosocial characteristics of patient with bulimia nervosa.

2. Describe the difference between a patient with anorexia nervosa, binge eating disorder and bulimia nervosa.

3. List 2 short term and 2 long term objectives for this client.

4. Discuss nursing role for working with clients with eating disorders.

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.

Program / Curriculum Specific Objectives

1. Provide professional and ethical care to patients.

2. Practice selected critical thinking skills.

3. Implement therapeutic communication techniques when caring for patients

4. Provide for the nutritional needs of patients with selected alterations in health.

5. Apply knowledge of psychosocial development of children, adolescents, and adult experiencing alterations in mental health.

Fidelity (choose all that apply to this simulation)

Setting/Environment· ER· Med Surg· Peds· ICU· OR / PACU· Women’s Center· Behavioral Health· Home Health· Pre-Hospital· Other Simulator/Manikin/s Needed: Props:Equipment Attached to Manikin:°IV tubing with primary line fluids running at cc/hr· Secondary IV line running at _ cc/hr· IV pump· Foley catheter cc output· PCA pump running· IVPB with running at cc/hro 02· Monitor attached· ID band· OtherEquipment Available in Room· Bedpan/Urinal· Foley kit· Straight Cath Kit· Incentive Spirometry· Fluids· IV start kit· IV tubing· IVPB Tubing· IV Pump· Feeding Pump· Pressure BagMedications and Fluids· Oral Meds· IV Fluids· IVPB· IV Push· IM / Subcut / Intradermal· Other Diagnostics Available· X-rays (Images)· Labs· 12-Lead EKG· OtherDocumentation Forms· Admit Orders· Physician Orders· Flow sheet· Medication Administration Record· Kardex· Graphic Record· Shift Assessment· Triage Forms· Code Record· Anesthesia / PACU Record· Standing (Protocol) Orders· Transfer Orders· Other

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.

· 02 delivery device· Crash cart with airway devices and emergency medications· Defibrillator/Pacer· Suction· Other – dynamapRecommended Mode for Simulation (i.e. manual, programmed, etc.)Requires standardized patient or high fidelity mannequin that cries
Roles/Guidelines for Roles· Primary Nurse· Secondary Nurse· Clinical Instructor· Family Member #1· Family Member #2· Observer· Physician / Advanced Practice Nurse· Respiratory Therapy· Anesthesia· Pharmacy· Lab· Imaging· Social Services· Clergy· Unlicensed Assistive Personnel· Code Team· OtherImportant Information Related to RolesStudent Information Needed Prior to Scenario· Has been oriented to simulator· Understands guidelines/expectations for scenario· Has accomplished all pre- simulation requirements· All participants understand their assigned roles· Has been given time frame expectationso OtherReport Students Will Receive Before SimulationTime: (real time)Report from EMT“We have Joyce W. date of birth 10/16/83 who was brought from her home, where we were called by her friend who found her unconscious in her bathroom.We found her on the floor, groggy but oriented, no apparent injuries. Initial vitals were BP 80/40, heart rate 108 andweak, respirations 22 and shallow. We put a 22 in her right antecubital and

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.

Significant Lab ValuesPhysician Ordersstarted saline wide open. Looked like she’s been vomiting a lot – undigested food mostly. Could’ve been some bright red blood too, but hard to tell. We transported her via stretcher, and now she’s alert, oriented x3, moving all extremities and says she’s allergic to keflex. Vitals at (5 minutes ago) were 100/60, 98 and 18. She’s had a liter in but no more vomiting. Questions? OK – later.”

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario: (site source, author, year, and page)

1. Videbeck, S. (2008) Psychiatric mental health nursing, Ch 18.

2. Wolfe, B. (2008) Issues of body weight and eating behavior in psychiatric and mental health nursing practice. Journal of the American Psychiatric Nurses Association , vol. 13: pp. 343 – 344.

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.

2007 NCLEX-RN© Test Plan Categories and Subcategories

Choose all areas included in the simulation

Safe and Effective Care Environment

Management of Care

· Advance Directives ● Establishing Priorities

· Advocacy ● Ethical Practice

· Case Management ● Informed Consent

· Client Rights ● Information Technology

· Collaboration with Interdisciplinary Team ● Legal Rights and Responsibilities

· Concepts of Management ● Performance Improvement


· Confidentiality / Information Security ● Referrals

· Consultation ● Resource Management

· Continuity of Care ● Staff Education

· Delegation ● Supervision

Safety and Infection Control

· Accident Prevention ● Medical and Surgical Asepsis

· Disaster Planning ● Reporting of Incident/Event/

· Emergency Response Plan Irregular Occurrence/Variance

· Ergonomic Response Plan ● Security Plan

· Error Prevention ● Standard /Transmission-Based

· Handling Hazardous and Infectious Materials Other Precautions

· Home Safety ● Use of Restraints/Safety Devices

· Injury Prevention ● Safe Use of Equipment

Health Promotion and Maintenance

· Aging Process ● Health Promotion Programs

· Ante/Intra/Postpartum and Newborn Care ● Health Screening

· Developmental Stages and Transitions ● High Risk Behaviors

· Disease Prevention ● Human Sexuality

· Expected Body Image Changes ● Immunizations

· Family Planning ● Lifestyle Choices

· Family Systems ● Principles of Teaching/Learning

Growth and Development ● Self-Care

· Health and Wellness ● Techniques of Physical Assessment

Psychosocial Integrity

· Abuse/Neglect ● Psychopathology

· Behavioral Interventions ● Religious and Spiritual Influences

· Chemical and Other Dependencieson Health

· Coping Mechanisms ● Sensory/Perceptual Alterations

· Crisis Intervention ● Situational Role Changes

· Cultural Diversity ● Stress Management

· End of Life Care ● Support Systems

· Family Dynamics ● Therapeutic Communications

· Grief and Loss ● Therapeutic Environment

· Mental Health Concepts ● Unexpected Body Image Changes

Physiologic Integrity

Basic Care and Comfort

· Assistive Devices ● Nutrition and Oral Hydration

· Complementary and Alternative Therapies ● Palliative/Comfort Care

· Elimination ● Personal Hygiene

· Mobility/Immobility ● Rest and Sleep

· Non-Pharmacological Comfort Interventions

Pharmacological and Parenteral Therapies

· Adverse Effects/Contraindications ● Parenteral/Intravenous Therapies

· Blood and Blood Products ● Pharmacological Agents/Actions

· Central Venous Access Devices ● Pharmacological Interactions

· Dosage Calculation ● Pharmacological Pain Management

· Expected Effects/Outcomes ● Total Parenteral Nutrition

· Medication Administration

Reduction of Risk Potential

· Diagnostic Tests ● Potential for Complications from

· Lab Values Surgical Procedures and Health

· Monitoring Conscious Sedation Alterations

· Potential for Alterations in Body Systems ● System Specific Assessments

· Potential for Complications of Diagnostic ● Therapeutic Procedures Tests/Treatments/Procedures ● Vital Signs

Physiologic Adaptation

· Alterations in Body Systems ● Medical Emergencies

· Fluid and Electrolyte Imbalances ● Pathophysiology

· Hemodynamics ● Radiation Therapy

· Illness Management ● Unexpected Response to Therapies

· Infectious Diseases

Scenario Progression Outline

Timing(approximate)Manikin ActionsExpected Interventions NurseMay Use the Following Cues
First 5 minutesSitting up at side of bed.Clutching abdomen, has worried look on face.“ I passed out in the bathroom. I guess I ate something that didn’t agree with my stomach and I vomited several times.”Introduces self, asks J what has occurred.Takes vitals, assessment including oral musocaRole member providing cue: BoyfriendCue: Pacing nervously near bedside. Worried expression.
Next 5-10minutesRelaxes slightly.Begins to cry“I have trouble with food and eating.”RN asks client about presenting complaint and history.“Has anything like this happened before that caused you to get sick from eating?”Role member providing cue: Boyfriend

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.

“It never has been this bad before. I get anxious and then start to binge eat to cope with the stress. I usually stop when I feel full and go in the bathroom and throw up. This time when I was throwing up I saw blood and got more anxious. I guess I overdid it and next thing I knew I was on the floor, then my boyfriend came in.” She relates current bulimic behavior and concerns about family, especially father.“Yes. I started doing it just occasionally in college, but lately because of all that’s going on I do it two or three times a week.It’s getting out of hand.”“In college I was in therapy. It was helpful because I learned to use other ways to cope with stress. I also got serious about exercise to control my weight.But lately I go backinto the binging and started to freak out, but“Go on”“You have been binging on food and vomiting to cope with stress-is that correct?”“Have you seen a therapist or been treated for this eating disorder?”Cue:Surprised to hear about binge/purging. “I had no idea!How long has this been happening?”“Why didn’t you tell me about this?
couldn’t stop it.”“I didn’t want to tell you. I’m so embarrassed about it. It’s sick!”“OK-thanks.”“Ok. Well you are in the ER to get stabilized and we will discuss options for follow up treatment. I’ll report this to the MD and we’ll be back in a few minutes to start an IV and talk about thenext steps.”I could help you deal with the stuff that’s going on.”
Role member providing cue:
Final 15-20 minutes“Is that bad?”Returns to pt room with IV materials.“Your blood work shows that you have some electrolyte imbalance from dehydration.We are going to start an IV solution to restore your potassium and sodium.”Cue: Listens with interest to the plan.
“I didn’t know I was causing all of that to happen.”“When you vomit excessively you not only get rid of whatever food is in your stomach, but water and electrolytes that keep your muscles and heart working.”
“That would be great”“Let’s begin to plan for your discharge. I’m going to provide you with names of therapists who use the cognitive therapy approach you said was helpful to you while you were in college.”
“I really enjoy the running and working out. I’m training for a marathon, but I usually run with a group of people and we meet only at certain times. I belong to a gym that offers yoga and pilates which I like also.”“I see what you are saying. In the past, when I was in therapy, I wrote down my feelings-just poured it all out in a journal.That was helpful because sometimes I’d see a solution to what was bothering me.”Ok“I’ve already been such a bother, I don’t want to lay this on you.”“But when you leave here, the stress that has contributed to you binging and purging to cope is not going away. Let’s talk about some ways to manage stress that is more effective.What have you done in the past that has been helpful?”“Those are all good measures. But I think you need to have something more accessible for the times at work or home when you feel overwhelmed and bring on the urge to binge/purge. ““Ok. Let’s add that to the plan. You have a journal to write in?When you feel stressed at work or anytime spend a few minutes getting down your thoughts and feelings on paper.”“I’d also suggest one or two people to call or text to let them know you are anxious.”“You can call me, Babe. I’ll pick up and be there for you.”“I’m here and will help in anyway I can.”
“My college roommate and I are still close. She knows all about what I went through. I know she would understand.”“I’ll follow up. I really need to get this under control. Too much is at stake.”“How about another friend or relative?”“Ok. That’s good. So when you feel stressed you will either start writing in your journal and/or call Austin or your old roommate.Here is a list of a few therapists to call to schedule an appointment. Here is my card. When you have made an appointment, call or email me to let me know how it went. If you don’t have any luck with these therapists, I’ll provide you with additional resources.“I’ll do as much as I can to help Joyce follow the plan. Thanks.”

Debriefing / Guided Reflection Questions for this Simulation

(Remember to identify important concepts or curricular threads that are specific to your program)

1. How did you feel throughout the simulation experience?

2. Describe the objectives you were able to achieve?

3. Which ones were you unable to achieve (if any)?

4. Did you have the knowledge and skills to meet objectives?

5. Were you satisfied with your ability to work through the simulation?

6. To Observer: Could the nurses have handled any aspects of the simulation differently?

7. If you were able to do this again, how could you have handled the situation differently?

8. What did the group do well?

9. What did the team feel was the primary nursing diagnosis and/or collaborative problems?

10. What were the key assessments and interventions?

11. Is there anything else you would like to discuss?

Scenario File: Eating Disorder

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This scenario was created using the scenario template downloaded from http://sirc.nln.org with permission from the NLN and Laerdal Medical.