Management of severe preeclampsia in the puerperium: development and scenario validation for clinical simulation

Silva, Samyla Carla Nóbrega; Alencar, Beatriz Rodrigues de; Viduedo, Alecssandra de Fátima Silva; Ribeiro, Laiane Medeiros; Ponce de Leon, Casandra Genoveva Rosales Martins; Schardosim, Juliana Machado

doi:10.1590/0034-7167-2020-0445

Samyla Carla Nóbrega Silva

Secretaria Estadual de Saúde do Distrito Federal, Programa de Residência Multiprofissional. Brasília, Distrito Federal, Brazil.

https://orcid.org/0000-0002-5485-7320

Beatriz Rodrigues de Alencar

Universidade de Brasília, Faculdade de Ceilândia. Brasília, Distrito Federal, Brazil.

https://orcid.org/0000-0003-0213-008X

Alecssandra de Fátima Silva Viduedo

Universidade de Brasília, Faculdade de Ceilândia. Brasília, Distrito Federal, Brazil.

https://orcid.org/0000-0002-3529-3814

Laiane Medeiros Ribeiro

Universidade de Brasília, Faculdade de Ceilândia. Brasília, Distrito Federal, Brazil.

https://orcid.org/0000-0002-5041-8283

Casandra Genoveva Rosales Martins Ponce de Leon

Universidade de Brasília, Faculdade de Ceilândia. Brasília, Distrito Federal, Brazil.

https://orcid.org/0000-0003-4378-9200

Juliana Machado Schardosim Corresponding author: Juliana Machado Schardosim. E-mail: jumachadoju@hotmail.com

Universidade de Brasília, Faculdade de Ceilândia. Brasília, Distrito Federal, Brazil.

https://orcid.org/0000-0003-2368-5834

Corresponding author: Juliana Machado Schardosim. E-mail: jumachadoju@hotmail.com

EDITOR IN CHIEF: Antonio José De Almeida Filho

ASSOCIATE EDITOR: Ana Fátima Fernandes

	n	%
Age (years)^* * Values expressed in mean ± standard deviation; §Values expressed in median and interquartile range.	27.25 ± 0.96
Academic background
Nursing degree	4	100
Graduate degrees
Specialization	2	50
Master's degree	2	50
Doctoral degree	0	00
Professional activity
Assistance	1	25
Professors	4	100
Graduate student	3	75
Time of experience (years)	4.75 ± 1.5
Experience with simulation
Professor	4	100
Researcher	2	50
Participation as a judge previously	3	75
Time of experience with simulation§	2.5 (2.0 - 3.75)
Publications in women's health	2	50
Publications on realistic simulation	1	25

Rated Items	Totally Inadequate		Inadequate, but can be redone		Adequate, with small adjustments		Totally adequate		CVI
Rated Items	n	%	n	%	n	%	n	%	CVI
Plausibility of the clinical case	-	-	-	-	-	-	4	100	1.0
Realism	-	-	-	-	1	25	3	75	1.0
Adherence to available scientific evidence	-	-	-	-	1	25	3	75	1.0
Complexity in relation to the level of knowledge and students' skills	-	-	-	-	-	-	4	100	1.0
Case description	-	-	-	-	2	50	2	50	1.0
Simulation objectives provided to students	-	-	-	-	2	50	2	50	1.0
Information provided to students prior to simulation	-	-	-	-	-	-	4	100	1.0
Data provided to students during9 simulation	-	-	-	-	-	-	4	100	1.0
Support provided to students during simulation	-	-	-	-	1	25	3	75	1.0
Learning objectives	-	-	-	-	-	-	4	100	1.0
Critical thinking promotion	-	-	-	-	1	25	3	75	1.0
Promoting the ability to prioritize nursing assessments and interventions	-	-	-	-	-	-	4	100	1.0
Promoting autonomous problem-solving	-	-	-	-	-	-	4	100	1.0
Simulator/actress parameters consistent with clinical case	-	-	-	-	-	-	4	100	1.0
Simulated environment	-	-	-	-	1	25	3	75	1.0
Materials and equipment available to students	-	-	-	-	1	25	3	75	1.0
Aspects assessed in debriefing	-	-	-	-	2	50	2	50	1.0
Reflection and analysis of actions in debriefing	-	-	-	-	1	25	3	75	1.0
Synthesis and feedback to students in debriefing	-	-	-	-	2	50	2	50	1.0
Mean CVI									1.0

Subject addressed: nurse's performance in the face of severe preeclampsia in the puerperium
Complexity: medium	Fidelity: high
Expected scenario execution time: up to 30 minutes
Number of students inserted in the scenario: 2 students
Simulated environment: hospital obstetric center
Learning objective: to assess students' knowledge about routine care in the face of gestational hypertension in the puerperium, as well as their attitude towards the puerperal woman and companion. Brief description of the clinical case: J.S.A., 36 years old, postpartum woman with newborn still in the obstetric center, 6 hours postpartum normal, accompanied by her husband. Second-in-law with 2 previous vaginal deliveries and no history of abortion. Gestational age: 38 weeks and 4 days, newborn adequate for gestational age. Puerperal women arrived at the hospital on the day of delivery with hypertensive crisis, being diagnosed with severe preeclampsia after the severity tests. She started magnesium sulfate hours before delivery and continues to sulfate, according to protocol. The last assessment of the parameters related to the infusion of the medication was made 4 hours ago. The baby has already been assessed by the nurse from the previous shift and by the pediatrician. Scripts: the scenario starts with the puerperal woman and her baby in the obstetric center. The nurse of the previous shift begins the shift and delivers the patient's medical records to students. Nurse: good morning, this is Janaína, is 36 years old, is her second baby. Now it's okay, but she's had severe preeclampsia and she's sulfating. The baby was born well and has already been assessed by me and the pediatrician, the puerperium is going well so far. She's already had a bath. Good call for you. Students are expected to observe the puerperal woman's medical records in order to better understand their clinical picture. Check the medication you're running and talk to the couple about everything that happened, and then assess the postpartum. If students talk about pregnancy, the puerperal woman will answer: Puerperal woman: in pregnancy, my pressure has changed since 7 months and I took the medicine right. Then, on the day of delivery, I came here feeling very ill, I thought it was because of the pain, but my blood pressure was too high and they said it was preeclampsia. After they started this medication in the vein, I got better. They just didn't tell me how long I'm going to have to stay here with this serum. If students talk about how the patient feels in the puerperium: Puerperal woman: I'm feeling good, the pressure is still not very normal, but it has already improved a lot. I've showered and felt good, I eat. The baby breastfeeds well and sleeps well. If students talk about breastfeeding history: Puerperal woman: I had a little difficulty in the first few days, but I managed to breastfeed my daughter until 2 years. Mamou only in the chest up to 6 months. Students are expected to take a full physical examination in the postpartum period, noting: Hypocorated, anicteric and acyanotic skin and mucous membranes. Venous access in salinized right upper limb and access in left upper limb infusing magnesium sulfate with 5% glucose serum in 100ml/h infusion pump. Flaccid breasts, protracted nipples, with colostrum output to expression. Flaccid abdomen, painless on palpation, Pinard safety globe at the height of the umbilical scar. Perineum intact, red lochias in physiological quantity. Diuresis in a collection bag of the long-delayed bladder probe (200ml), had been emptied for 4 hours. She hasn't evacuated after childbirth yet. Swollen lower limbs 3+/4+, no signs of thrombosis (Homans, Brancroft and Flag negative). Vital signs: Blood Pressure: 14 0mmHg, Heart Rate: 89bpm, Respiratory Rate:19irpm, Axillary Temperature: 36.5ºC. Because students have 4 hours of the last assessment of the effects of the medication, students are expected to check blood pressure, respiratory rate, diuresis and patellar reflexes. If they assess and do not explain the reason for assessment, the companion may ask: Companion: why does anyone review all this again from time to time? Is it because of her pressure? If they take a physical examination and test the newborn's reflexes, everything will be within normal limits. Because it is a mannequin, the professor will answer what is necessary. Students will receive the medical records of puerperal woman where there will be the evolutions of labor, delivery and immediate postpartum and the medical prescription according to the protocol of management of severe preeclampsia in the puerperium. Moreover, the professor should prepare a sheet containing the vital signs of the puerperal woman compatible with the described scenario. If students do not explain to the couple about the evolution of gestational hypertension in the puerperium and the therapeutic plan, they may question students. Below are some speech suggestions: Companion: and how long will she stay here? The family is very curious to visit and meet the baby. Several mothers who have won baby after her have already gone to rooming-in. Puerperal woman: why am I with this probe? It doesn't hurt, but it bothers me, can we take it off? Puerperal woman: when will my pressure normalize? How do I know if I've had high blood pressure forever or if it's really going to pass?
Materials required for simulated environment assembly: - Furniture and decoration: items of hospital furniture such as stretcher with sheets, procedure table, table with medical-hospital materials to simulate nursing station, telephone, screen, contaminant garbage and common garbage, small staircase, common acrylic cradle, serum support, posters (topics such as labor and breastfeeding) and identification of the patient in bed, as other materials that can be added. - Medical-hospital materials: sphygmomanometer, stethoscope, axillary thermometer, reflex test hammering, personal protective equipment (gloves, caps and masks), cotton, 70% alcohol, aluminum trays, syringes, needles and jelcos of various sizes and calibers, cutting-hole disposal box, infusion pump, simple serum equipment and for infusion pump, multi-way, 500ml saline 0.9% vial and 500ml glucose serum vial 0.5%, distilled water, medication ampoules (simulating magnesium sulfate; and other medications commonly used in the obstetric center), micropore/adhesive and garrote. - Medical records and other documents: pregnant woman's booklet with information about prenatal care, obstetric center care form, medical and nursing evolutions of labor, medical prescriptions and vital signs control sheet. Simulators/mannequins, costumes and makeup of the actors: - Simulators/mannequins: newborn simulator and silicone breast model for physical examination - Costume: puerperal woman (hospital sweater, legging and leather-colored blouse, perineal lining and postpartum absorbent with scenographic blood or red paint), companion (common clothing of choice of the actor, avoid shorts), nurse (surgical clothing, closed shoe, cap and identification badge) - Makeup: the case does not require specific makeup, it is only suggested that the puerperal woman be made up with a little dark circles and pallor to give appearance of tiredness.

	Skills and knowledge expected from students	NP
Behavior	They presented themselves to the puerperal woman and companion.
	They welcomed the puerperal woman and companion.
	They explained each procedure before starting.
	They provided a privacy environment for the patient and companion (use of screen, curtains or private room).
	They presented effective communication with the other professionals of the scenario.
	They presented work organization (choice of leader, division of tasks as a team).
Knowledge and clinical reasoning	They remembered to research a history of pressure change in pregnancy and other alterations related to gestational hypertension.
	They demonstrated knowledge about the evolution of gestational hypertension in the puerperium.
	Demonstrated knowledge about the MgSO administration protocol4 in the puerperium	.
	They demonstrated knowledge about the test results.
	They demonstrated knowledge about actions to avoid stimulus and raise pressure.
Technical skills	They performed hand washing/antisepsis before direct contact with the pregnant woman.
	Performed all procedures with correct use of personal protective equipment.
	They verified complete vital signs (heart rate, respiratory rate, axillary temperature, blood pressure).
	They underwent cephalocaudal physical examination.
	They performed gynecological assessment (breast examination, palpation of pinard safety globe, perineal inspection, lochia assessment).
	The lower limbs were assessed (edema and other alterations).
	The parameters related to magnesium sulfate impregnation (respiratory rate, diuresis volume, patellar reflex) were assessed.
Guidelines	They guided on the evolution of gestational hypertension in the puerperium and care for pressure control.
Guidelines	They guided on routine puerperal care (feeding, water intake, uterine involution, perineal hygiene, breastfeeding and return to the Basic Health Unit).

[1] Corresponding author: Juliana Machado Schardosim. E-mail: jumachadoju@hotmail.com

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Management of severe preeclampsia in the puerperium: development and scenario validation for clinical simulation

Manejo de la preeclampsia severa en el puerperio: validación de escenarios para simulación clínica

ABSTRACT

Objective:

Method:

Results:

Conclusion: