|Learning OutcomesAt the completion of the obstetric telehealth simulation, the learner will be able to:|
Communicate effectively with client and peers utilizing audio-visual technologies.
Interpret pertinent risk factors and findings.
Formulate a plan of care based upon assessment findings.
|Background: Client C.D.DOB: 4/17/2000
Client is 10 days postpartum: Client called the office and has left a voice message that she is experiencing pain in her right breast. She is also having difficulties with breastfeeding and feeling a bit defeated. She is requesting a telehealth service.
Surgical History: 2 vaginal deliveries (2019, 2020); wisdom teeth extraction (2018)
G2P2: 4/9/2019: vaginal delivery: 35 weeks, epidural, birth weight 2359 grams (5.2 lbs.);4/17/2020:vaginal delivery: 39 weeks; vacuum assisted, epidural, birth weight 4445 grams (9.8 lbs.).|
|Teaching Materials: Postpartum Depression (PPD) Edinburg Postnatal Depression Scale Calculation Tool, health record, Telehealth Triage Nurses Notes/Documentation form|
|Didactic Content: Mastitis, Postpartum Hemorrhage (PPH), Postpartum Depression|
|Pre-BriefingAddress any technology issues. Describe telehealth triage simulation process, expectations, and learning outcomes. Review the clients background information and health record. Orientate to the simulation lab. Each student nurse was encouraged to speak and interact as the primary nurse. There is only one role. Students can reach out to the instructor with the use of the CHAT videoconferencing feature. Review didactic topics related to postpartum telehealth.|
|Didactic Topics:||Didactic Discussion Content:|
|SCHOLAR Triage(see Telehealth Triage Documentation Form)||SCHOLAR acronym to gather subjective data and document findings=Symptoms, Characteristics, History: Onset and duration, Location, Aggravating or Associated Factors, Relieving Factors. Collecting subjective data/review of systems and a general survey/objective data that can be assessed during a telehealth video conference.|
|Telehealth Privacy and Confidentiality Issues||Consent Form
“Non-public facing” videoconference technology
Nurses note/Documentation Form/Date/Time/Findings|
|Effective Communication||Identify self. Use of empathetic statements: “Tell me more”, “I understand”, “What happened next”, “I'm sorry you aren't feeling well.” Active listening. Utilizing SBAR communication.|
|Mastitis, PPH, PPD||Didactic review and question and answer period with students. Risks and signs and symptoms. Nursing interventions.|
|Telehealth Script: Live Patient and Anticipated Student Nurse Responses|
|Client Response:||Student Nurse Response:|
Introduce themselves and inquire about the voice message requesting a telehealth service.|
|Client: Yes, I did. Thank you for calling me back!I've been trying to breastfeed this baby; I didn't try to breastfeed the first baby because she was so little and born early. But I thought since this baby was bigger, I would try to breastfeed him. I got help in the hospital, but they told me I had an improper latch and I ended up getting some blisters on my nipples. It was very uncomfortable initially. Now, the pain I've been having seems to be worsening. PAUSE(allow time for students to analyze and respond)||Student Nurse:
Empathetic Response: “I'm sorry you aren't feeling well.”
-Mastitis: Should evaluate for mastitis based on symptoms reported. Should ask about temperature? Describe the pain? Is it localized to one area?|
|Client: I started noticing that not only is it painful but its tender too.||Student Nurse: Mastitis-Should evaluate for mastitis based on symptoms reported. Should ask about temperature? Describe the pain? Is it localized to one area? Asks questions related to the symptoms (attributes of a symptom) redness, discharge, pain scale, fever, chills, etc…|
|Client: I see what looks like red streaks and I can barely breastfeed without crying and he's crying all the time because he's hungry||Student Nurse: Mastitis-Should evaluate for mastitis based on symptoms reported. Should ask about temperature? Describe the pain? Is it localized to one area?|
|Client: At first, I was just so cold and felt so bad, like my body hurt all over, even my bones hurt, I felt like I had a fever. I don't really have a way of taking my temperature, but I am shivering all the time and my skin feels hot.||Student Nurse: I will report these findings to the healthcare provider. You potentially have an infection of the breast. In the meantime, you might try cold compresses to help with the pain.
Students may also inquire if the Ibuprofen PRN listed on the health record has been helping with the pain.|
|Client: I'm tired and I just need help.||Student Nurse: PPD-Should recognize that client appears disheveled, mentions crying a lot, and feeling defeated. Should ask about feelings? Potentially use EPDS tool for questioning? Ask if having thoughts of harming self or others.|
|Client: And, I googled that breastfeeding helped my uterus to contract and would helpmy bleeding be less but it seems to just have increased and is getting heavier and heavier.PAUSE(allow time for students to analyze and respond)||Student Nurse: PPH-Should inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, color, etc.…?Describe how much of the pad is saturated.|
|Client: I don't know if it's because he's not nursing well and he's spitting up all the time. I just don't know. I think I remember at delivery they were worried about the afterbirth taking so long but they told me it would be ok.||Student Nurse: Should inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, etc.…?
Tell me more about the spitting. How is baby? How much spitting? How many wet diapers changed? How many bowel movements/loose?|
|Client: Not only is my breast hurting but I am feeling weak and light headed and I don't' know if it's the fever or what. I'm even kind of worried I might have COVID. Would that make me feel weak and my heart race? I feel like the baby is fine they said she just has a little reflux.||Student Nurse: PPH: Should inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, etc.…?COVID-Have you traveled outside of the country? Have you been exposed to anyone with a known positive case?|
|Client: I didn't pay a lot of attention to the bleeding at first because they told me when I left the hospital that it would increase because I would be moving around more but I seem to be filling up a pad a lot more.
No, I have not been out of the country or around anyone who has tested positive.||Student Nurse: PPH: Should again inquire about the bleeding. Ask questions such as how heavy is the bleeding, how often are you changing pads, etc.…?
COVID: answered negative questions, should understand that client is most likely symptomatic from the blood loss.|
|Client: Sometimes 2 to 3 times an hour.
PAUSE (allow time for students to analyze information and respond)
Bright red. Sometimes large clots. Well you know it just hurts so bad and I'm tired and I feel so weird, I have called my mother, my sister, and my friend over to take care of the baby because I just can't deal right now.||Student Nurse: Student should recommend having someone bring the client in to the hospital for evaluation since she is also symptomatic. Suggest calling emergency services to transport if no one is available to bring her in and recommend no driving. Students should recognize this is an excessive amount of bleeding.|
|Client: As students are offering recommendations and telling the client what they are going to report to the physician, the client passes out.||Student Nurse: should know to call 911/Emergency Services|
|*Once the student states to call 911/Emergency services, the simulation is complete.|
|DebriefingBegin the debriefing with the following statements: “Let's begin by focusing on what happened throughout your conversation with the client without judging our performance.” The instructor will continue the conversation by stating, “What happened next?” Once the instructor has engaged students in reflecting upon the telehealth triage simulation experience, he/she will transition to a deep-dive analysis and reflection period.|
|Analysis of Communication||This telehealth triage experience was designed for students to have an opportunity to demonstrate effective communication. How did you respond to the client? What questions did you ask? What additional questions could you ask? Would you rephrase any of your questions? Which ones and why? Why did you respond in this way? What challenges did you face related to communicating through videoconferencing? Are there additional people with whom you communicated (peers? Instructor?) What other professionals might be helpful to you in this case? What empathetic statements were provided? What could you have said and when? When talking with patients in the hospital, how could you show empathy? What would you say and why? Examples include: Tell me more, I understand, what happened next, I'm sorry you aren't feeling well.|
|Analysis of Risks and Signs and Symptoms||This simulation experience was also designed to provide students with an opportunity to interpret postnatal risk factors. What statements did the client make that concerned you the most? Why? What actions did you take in response to the client's statements? Why? What were the risk factors? What were you thinking about as the patient shared her s/s? What risk factors/signs/symptoms were missed? How did you interpret pertinent risk factors and findings related to PPH, mastitis, and PPD? What additional information or resources do you need? What would you do differently? Why? What was the most significant or priority concern? Why?|
|Analysis of Nursing Interventions and Plan of Care||In this clinical experience student nurses were to formulate a plan of care based upon assessment findings. What was your plan of care for the client? What additional information did you need? What would you do differently? Why? How could you use this information when caring for patients in the hospital or another setting? Discuss how they felt when the client passed out. What information might be needed for the nurse to report to emergency services (i.e. address, history, etc.…) Who should be contacted and why? How did they respond to the client? How did they feel? Why did they feel this way?|
|Simulation Documentation and Evaluation of Simulation Experience||Each student completes the telehealth documentation form and submits to their clinical supervisor. Students are given the link to complete a simulation evaluation.|