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StudentSimulation Preparation: GI/ Sepsis

Student Learning Objectives:

1.

Focused post-op assessment

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2.

Assess and care for colostomy

3. Assess for signs and symptoms of sepsis

4

. Educate patient on colostomy care.

Preparation for scenario:

Read Pearson Module 10.C – Inflammation

Nursing Skills: 4, 4.18 and 4.1

9

GI/ Sepsis Student Worksheet

I. Data Collection

History of Present Problem:

Justine Walsh, is a 45 year old female diagnosed with Crohn’s Disease. Patient admitted through the Emergency Department with abdominal pain and hematochezia for 2 weeks. S/p hemicolectomy with a colostomy. Transferred to the medical/surgical unit for continued care and education. PMH of Crohn’s Disease and anxiety.

Personal/Social History:

Married with two young children. No history of smoking, alcohol or drug use.

Clinical Significance:

RELEVANT Data from Present Problem:

Clinical Significance:

RELEVANT Data from Social History:

1.
2.

PMH:

Home Meds:

Pharm. Classification:

Expected Outcome:

Pantoprazole (Protonix)

Lorazepam (Ativan)

 1.
2.

Current VS:

WILDA Pain Assessment (5th VS):

T: (oral) 99oF

Words:

sore

P: (regular) 88

Intensity:

4/10

R: (regular) 20

Location:

At incision site

BP:142/88

Duration:

surgery

O2 sat: 99% on RA

Aggravate:

Alleviate:

Nothing

medication

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT VS Data:

Current Assessment:

GENERAL APPEARANCE:

Resting in bed, appears in no acute distress

RESP:

Nonlabored respiratory effort. Diminished breathe sounds bilateral LL.

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation (x4)

GI:

Abdomen soft, no bowel sounds audible per auscultation in all four quadrants. Abdomen tender to touch. Colostomy stoma beefy red.. Abdominal incision DSD intact, no drainage noted.

GU:

Foley Catheter draining urine clear/yellow

SKIN:

Abdominal incision, 14 staples, DSD C/D/I. Colostomy stoma protruding and beefy red.

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT Assessment Data:

Expected Outcome:

Nursing Interventions:

Rationale:

Medical Management: Rationale for Treatment & Expected Outcomes

Rationale:

Expected Outcome:

Care Provider Orders:

1. OOB to chair x30 min. BID

2. NPO

3. NGT to low continuous suction

4. Accu check q6hr

5. Foley catheter

6. Strict I&O

7. DSD dressing change daily and prn to keep dry

8. Assess stoma qshift

9. PICC line care

PRIORITY Setting: Which Orders Do You Implement First and Why?

Rationale:

Order of Priority:

Medication Dosage Calculation:

Medication/Dose:

Mechanism of Action:

Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

PPN standard at

12

5ml/hr

Morphine 2mg IVP prn q4 hours for moderate pain

Cefazolin (Ancef) 2gm IVPB q12hours

Lab Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

Complete Blood Count (CBC:)

Current:

High/Low/WNL?

WBC (4.5–11.0 mm 3)

11.8

Hgb (12–16 g/dL)

 12

Platelets (150-450 x103/µl)

245

Neutrophil % (42–72)

43

Band forms (3–5%)

 4

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT Lab(s):

Current:

High/Low/WNL?

Basic Metabolic Panel (BMP:)

Sodium (135–145 mEq/L)

136

Potassium (3.5–5.0 mEq/L)

3.6

Chloride (95–105 mEq/L)

96

Glucose (70–110 mg/dL)

106

Calcium (8.4–10.2 mg/dL)

8.5

BUN (7–25 mg/dl)

 9

Creatinine (0.6–1.2 mg/dL)

0.8

RELEVANT Lab(s):

Clinical Significance:

Situation:

Background:

Assessment:

Recommendation:

Depression/Overdose with Psychosis

UNFOLDING Reasoning

Jenna Taylor, 18 years old

Primary Concept

Mood and Affect

Interrelated Concepts (In order of emphasis)

1. Safety

2. Psychosis

3. Clinical Judgment

4. Communication

5. Collaboration

Depression/Overdose with Psychosis History of Present Problem:

Jenna Taylor is an 18-year-old woman who is brought to the emergency department by ambulance after she admitted to her mother that she had taken a “handful” of dextroamphetamine/amphetamine (Adderall) this morning. Mom noted that there are 20 tablets missing. Jenna admits that she has been hearing voices telling her that she is worthless and would be better off dead. She denies visual hallucinations.

As the primary nurse explores these comments further, Jenna states, “The devil is in the place! I can feel it! The voices are telling me that I am going to hell forever.” Jenna appears fearful, anxious and does not maintain eye contact. When she briefly glances and looks your way, she appears to be looking through you.

Personal/Social History:

She was hospitalized three weeks ago for depression and suicidal ideation and was discharged ten days ago. Jenna lives with her mother. Her parents were divorced 12 years ago. She graduated from high school, has few close friends, and has no current plans for her future.

What data from the histories is RELEVANT and has clinical significance to the nurse?

Clinical Significance:

RELEVANT Data from Present Problem:

Clinical Significance:

RELEVANT Data from Social History:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect.)

PMH:

Home Meds:

Pharm. Classification:

Expected Outcome:


Attention deficit hyperactivity disorder (ADHD) Depression with psychosis Anxiety

1. Dextroamphetamine/amphetamine XR

20 mg PO daily

2. Clonazepam

0.5

mg PO BID

3. Bupropion HCL SR 100 mg PO BID

One disease process often influences the development of other illnesses. Based on your knowledge of

pathophysiology, (if applicable), which disease likely developed FIRST, then initiated a “domino effect” in Jenna’s life?

· Circle the PMH problem that likely started FIRST.

· Underline at PMH problem(s) FOLLOWED as domino(s).

Patient Care Begins:

Current VS:

WILDA Pain Assessment (5th VS):

T: 99.2 F (37.3 C) oral

Words:

Denies

P: 92 (regular)

Intensity:

R: 20 (regular)

Location:

BP: 118/70

Duration:

O2 sat: 98% RA

Aggravate: Alleviate:

What VS data is RELEVANT and must be recognized as clinically significant by the nurse?

Clinical Significance:

RELEVANT VS Data:

Current Assessment:

GENERAL

APPEARANCE:

Appears comfortable, no acute distress

RESP:

Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC:

Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert and oriented to person, place, time, and situation (x4), flat affect

GI:

Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU:

Voiding without difficulty, urine clear/yellow

SKIN:

Skin integrity intact

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?

Clinical Significance:

APPEARANCE:

RELEVANT Assessment Data:

Mental Status Examination (MSE):

Dressed in casual clothes, no make-up; no body odor; appears tired and appears stated age; cooperative during interview

MOTOR BEHAVIOR:

Psychomotor agitation, restless

SPEECH:

Speech is rapid, pressured

MOOD/AFFECT:

Appears anxious/fearful

THOUGHT PROCESS:

Illogical and not linear (thoughts do NOT make sense and are disorganized

THOUGHT CONTENT:

Evidence of psychotic thinking and loss of contact with reality. States, “The devil is in the place! I can feel it! The voices are telling me that I am going to hell forever.” Hearing voices telling her that she is worthless and would be better off dead.

PERCEPTION:

Auditory hallucinations present

INSIGHT/JUDGMENT:

Does not have insight, judgment is impaired

COGNITION:

Alert and Oriented x3, has difficulty concentrating

INTERACTIONS:

Has been isolating from friends and family over the last two days

SUICIDAL/HOMICIDAL:

Denies homicidal thoughts, is currently suicidal, and acted on this ideation by taking overdose of medication.

What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

Clinical Significance:

RELEVANT Assessment Data:

Lab Results:

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Complete Blood Count (CBC:)

Current:

High/Low/WNL?

WBC (4.5–11.0 mm 3)

5.2

Hgb (12–16 g/dL)

14.2

Platelets (150-450 x103/µl)

229

Neutrophil % (42–72)

58

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Clinical Significance:

RELEVANT Lab(s):

Current:

High/Low/WNL?

Basic Metabolic Panel (BMP:)

Sodium (135–145 mEq/L)

140

Potassium (3.5–5.0 mEq/L)

3.6

Glucose (70–110 mg/dL)

125

Creatinine (0.6–1.2 mg/dL)

0.5

RELEVANT Lab(s):

Clinical Significance:

Current:

High/Low/WNL?

0.00

RELEVANT Lab(s):

Clinical Significance:

Current:

Misc. Labs:

Acetaminophen

0.00

Salicylate

Urine pregnancy

Neg

Urine Drug Screen:

Opiates

Benzodiazepines

THC

Amphetamines

Cocaine

RELEVANT Lab(s):

Clinical Significance:

Clinical Reasoning Begins…

1.
What is the primary problem that your patient is most likely presenting with?

2.
What is the underlying cause/pathophysiology of this concern?

Collaborative Care: Medical Management

Expected Outcome:

Care Provider Orders:

Rationale:

Acetaminophen level

Salicylate level

Complete blood count

(CBC)

Basic metabolic panel

(BMP)

Urine drug screen

Urine pregnancy

Establish peripheral IV

Diazepam 5 mg IV PRN for seizure activity

1:1 watch

Check for items of harm

Cardiac monitor

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders:

Rationale:

Order of Priority:

Establish peripheral IV

1:1 watch

Check for items of harm

Cardiac monitor

Collaborative Care: Nursing

3.
What nursing priority(s) will guide your plan of care?

(if more than one-list in order of PRIORITY)

4.
What interventions will you initiate based on this priority?

Rationale:

Expected Outcome:

Nursing Interventions:

5.
What body system(s) will you most thoroughly assess based on the primary/priority concern?

6.
What is the worst possible/most likely complication to anticipate?

7.
What nursing assessments will identify this complication EARLY if it develops?

8.
What nursing interventions will you initiate if this complication develops?

9.
What psychosocial needs will this patient and/or family likely have that will need to be addressed?

10.
How can the nurse address these psychosocial needs?

Evaluation: Two hours later…

Jenna has become more restless with increased pacing in room. She cries out loudly in a shriek. As the nurse enters the room, Jenna is sitting on the bed and states fearfully, “I told you the devil is in this place! Please help me!” She suddenly becomes unresponsive, her body becomes rigid and she begins to have rhythmic tonic/clonic movements of her entire body.

Current VS:

T: 99.2 F (37.3 C) oral

Words:

Denies

P: 92 (regular)

Intensity:

R: 20 (regular)

Location:

BP: 118/70

Duration:

O2 sat: 98% RA

Aggravate: Alleviate:

Current Assessment:

RESP:

CARDIAC:

NEURO:

GI:

Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU:

SKIN:

Skin integrity intact

Most Recent:

Current WILDA:

T: 99.8 F (37.6 C) oral

P: 140 (regular)

R: 24

BP: 158/90

O2 sat: unable to obtain

GENERAL
APPEARANCE:

Rigid body posture

Loud, snoring respirations, oral secretions bubbling out of mouth

Pale, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

Unresponsive, tonic/clonic movements lasted 60 seconds and have now stopped, lethargic, not responsive to verbal commands

n/a

1.
What clinical data is RELEVANT that must be recognized as clinically significant?

Clinical Significance:

RELEVANT Assessment Data:

Clinical Significance:

RELEVANT VS Data:

2.
Has the status improved or not as expected to this point?

3.
Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

4.
Based on your current evaluation, what are your nursing priorities and plan of care?

Jenna is going to be admitted to intensive care for close assessment and monitoring. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will care for this patient:

Situation:

Name/age:

BRIEF summary of primary problem:

Background:

Primary problem/diagnosis:

RELEVANT past medical history:

Assessment:

Most recent vital signs:

RELEVANT body system nursing assessment data:

RELEVANT lab values:

How have you advanced the plan of care?

Patient response:

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation:

Suggestions to advance the plan of care:

.

Education Priorities/Discharge Planning

1.
What will be the most important discharge/education priorities you will reinforce with her medical condition to prevent future readmission with the same problem?

2.
What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

Caring and the “Art” of Nursing

1.
What is the patient likely experiencing/feeling right now in this situation?

2.
What can you do to engage with this patient’s experience, and show that she matters to you as a person?

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.

1.
What did I learn from this scenario?

2.
How can I use what has been learned from this scenario to improve patient care in the future?

© 2016 Keith Rischer/www.KeithRN.com

© 2016 Keith Rischer/www.KeithRN.com
© 2016 Keith Rischer/www.KeithRN.com

Medical/Surgical Simulation: Cancer

 

Student Learning Objectives:

      SLO’s 1-8

9

10. Provide education specific to patients with Cancer.

11. Implement interventions for a patient on neutropenic precautions.

I

 

 

Preparation for scenario:

Pearson – Cellular Regulation

Module 16.M

Module 2 and 2C

 

Cancer Simulation Student Worksheet

I. Data Collection

History of Present Problem: Julie Hammel, a 58 year old female, has just undergone chemotherapy and radiation therapy for stage II Breast Cancer, currently on Tamoxofen.

Patient presents to her oncologist’s office with lymphedema, was admitted to the hospital for monitoring.

PMH: Gravida 2; Para 2;  full term uncomplicated vaginal deliveries.  Breast Cancer with right mastectomy. No known allergies.

Personal/Social History: Married for 28 years. Has two adult children. Works as a dental hygienist part time.

 

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

Clinical Significance:

RELEVANT Data from Present Problem:

Clinical Significance:

– Stage II Breast Cancer

– Right Mastectomy

– Lymphedema

–

Tamoxifen

RELEVANT Data from Social History:

 

II. Patient Care Begins:

 

Current VS:  

T: (oral)  99.0

P:  (regular) 84

R: (regular) 14

BP:114/64

O2 sat:97% on RA

Pain:0/10
 

 

 

 

 

 

 

 

 

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

 

RELEVANT  VS Data:

 

 

 

Current Assessment:

GENERAL APPEARANCE:

Resting comfortably, appears in no acute distress

RESP:

Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation (x4)

GI:

Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU:

Voiding without difficulty, urine clear/yellow

SKIN:

Unremarkable except for slight erythema in right upper extremity due to external radiation. RUE edema.

Skin intact.

 

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT  Assessment Data:

Unremarkable.

Patient needs to be prepared for limited contact with visitors and health care personnel for neutropenic precautions.

Needs teaching about importance of neutropenia and lymphedema.

 

What interventions will you initiate based on this priority?

Nursing Interventions:

Rationale:

Foley output

 

Limit Visitors

 
 

Monitor Skin

 

Neurtropenic Precautions

Risk of stroke with Tamoxifen

Medical Management: Rationale for Treatment & Expected Outcomes

Rationale:

 

Care Provider Orders:

Expected Outcome:

 

Monitor neutrophils, temp and affected site (right arm)

 

Monitor skin

Limit Visitors

Monitor for signs and symptoms of stroke

I &O’s

 

 

Medication Dosage Calculation:

 

Medication/Dose:

 

Mechanism of Action:

Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

Ondansetron (Zofran) 4mg IV Push prn q4 hours nausea

 

Tamoxifen
 

Lab Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

 

 

Complete Blood Count (CBC:)

Current:

High/Low/WNL?

WBC (4.5–11.0mm 3)

2.3

Hgb (12–16g/dL)

13

Platelets (150-450 x103/µl)

140

 

 

 

 

 

Current:

High/Low/WNL?

Manual Diff:

Range:

Neutrophil

16

40-80

Band Neutrophils

12

0-5%

Lymphocyte

54

 20-50%

Monocyte

19

 2-12%

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT Lab(s):

 

 

Situation:

Background:

Assessment:

Recommendation:

StudentSimulation Preparation:

Ischemic & Hemorrhagic Stroke

Student Learning Objectives:

SLO 1-8

9. Perform appropriate neurological assessment.

10. Implement seizure precautions.

1

1.

Prioritize care for increased intracranial pressure.

1

2.

Utilize a communication board.

Patient information: Julie Wilson, a

4

8-year-old female, brought into ER by husband after she collapsed at home. Patient presented confused, complaining of a severe headache and blurred vision. Diagnosed with ischemic stroke and treated with rTPA in the ICU. Is currently being treated on the med/surg floor status post CVA.

Preparation for scenario:

Completion of Student Worksheet (bring with you to sim lab)

Pearson: Perfusion:

Read Pearson Module 1

6.

J & 16. M – (PVD & Stroke)

Nursing Skills:

· Care of a patient with Hemianopsia: Food Tray

· Complete Neuro Check

Skills Set Up:

· Hemianopsia glasses, thickener, Food tray with food

I. Data Collection

History of Present Problem:

Julie Wilson, a 48-year-old female, brought into ER by husband after she collapsed at home this am. Initially was slightly confused. Complaining of severe right temporal lobe headache and blurred vision. Husband reports that she was complaining of headaches and blurred vision that “came & went quickly” over the past 3-4 weeks.

CT w/o contrast

of right temporal lobe positive for ischemia. Treated in ICU with rTPA. Residual left sided weakness noted. Patient transferred to med/surg floor to begin rehabilitation and for blood pressure stabilization. Patient noted with edema of bilateral lower extremity upon assessment by the med-surg nurse.

PMH:

HTN

, Diabetes – type II, hypercholesterolemia, ½ ppd smoker and peripheral vascular disease (PVD).

Personal/Social History:

Married for 20 years. Has 3 children who are grown and on their own. Patient works in human resources at a local supermarket. Exercises a couple times a week.

What data from the histories is important & RELEVANT; therefore, it has clinical significance to the nurse?

Clinical Significance:

RELEVANT Data from Present Problem:

Clinical Significance:

RELEVANT Data from Social History:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect.)

PMH:

Home Meds:

Pharm. Classification:

Expected Outcome:

HTN

Peripheral vascular disease (PVD)

Metoprolol (Lopressor) 50mg daily

Metformin 500mg daily

Cilostazol (Pletal)

II. Patient Care:

n/a

n/a

n/a

Most Recent VS:

WILDA Pain Assessment (5th VS):

T: (oral) 99o F

Words:

No Pain

P: 102

Intensity:

n/a

R:

22

Location:

BP:

174

/104

Duration:

O2 sat:

96

% on RA

Aggravate:

Alleviate:

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT VS Data:

Current Assessment:

GENERAL APPEARANCE:

Resting in bed, visibly upset about diagnosis and lifestyle changes.

RESP:

Breath sounds clear with equal aeration bilaterally

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation (x4), neuro check: eyes open to speech, inappropriate words, abnormal flexion, severe weakness left arm and severe weakness left leg

GI:

Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. BM this shift

GU:

Foley catheter with c/y/u

SKIN:

Erythema on buttocks and bilateral lower extremity with edema.

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT Assessment Data:

Expected Outcome:

Nursing Interventions:

Rationale:

Neuro checks

Monitor VS

Reinforce

PT/OT

recommendations

Evaluate anxiety

Turn and Repo q2

Educate about assistive devices (i/e- communication board)

Medical Management: Rationale for Treatment & Expected Outcomes

Rationale:

Expected Outcome:

Care Provider Orders:

Labetalol 10mg IVP for systolic BP >160

Seizure precautions

Speech therapy

PT/OT

Neuro Checks q4hours

Continuous oxygen sat monitoring.

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders:

Rationale:

Order of Priority:

1.
2.

3.

4.

5.

6.

Medication Dosage Calculation:

Medication/Dose:

Mechanism of Action:

Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

Labatelol 10mg IVP prn, every 2 hours for systolic BP >160

Acetaminophen (Tylenol) 650mg PO, prn every 4 hours for temp> 101.4oF

Radiology Reports:

What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

Clinical Significance:

RELEVANT Results:

CT w/o contrast

Lab Results:

Complete Blood Count (CBC:)

Current:

High/Low/

WNL

?

WBC (4.5–1

1.0

mm 3)

4.6

Hgb (12–16 g/dL)

13

Platelets (

15

0-450 x103/µl)

155

Neutrophil % (42–72)

44

Band forms (3–5%)

 4

Clinical Significance:

RELEVANT Lab(s):

TREND: Improve/Worsening/Stable:

Current:

High/Low/WNL?

22

Basic Metabolic Panel (BMP:)

Sodium (135–145 mEq/L)

138

Potassium (3.5–5.0 mEq/L)

3.8

Chloride (95–105 mEq/L)

 96

CO2 (Bicarb) (21–31 mmol/L)

 22

Anion Gap (AG) (7–16 mEq/l)

 15

Glucose (70–110 mg/dL)

 174

Calcium (8.4–10.2 mg/dL)

8.6

BUN (7–25 mg/dl)

Creatinine (0.6–1.2 mg/dL)

 1.0
RELEVANT Lab(s):

Clinical Significance:

Current:

High/Low/WNL?

Misc. Labs:

Magnesium (1.6–2.0 mEq/L)

1.8

Coags:

Prothrombin Time (9.5 – 11.6 seconds)

10.8

INR (0.7 – 1.8)

0.82

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

WNL

Revised from

http://www.ksbn.org/education/Scenario/SimulationScenarioLibrary.htm

Situation:

Background:

Assessment:

Recommendation:

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