Deteriorating Patient



Case Summary Robert Caron is a 57-year-old male who was admitted to the medical unit with shortness of breath, mild chest pain that increases with deep breaths, and a mild fever.  He had an ECG in the Emergency Department that shows sinus tachycardia.  Lab values: Creatine Kinase (MB) and cardiac troponin were within normal limits.  He had a nasopharyngeal swab for COVID-19, results pending.  He is currently receiving oxygen, 2L nasal prongs.

Target Learner:  Intermediate and Senior Nursing Student & New Graduate Nurses

Keywords: Oxygenation, Conscious Proning, Nebulizer

 Learning Outcomes


Learning Outcomes

  1. Conducts a focused respiratory assessment when an individual exhibits respiratory symptoms to prioritize the next steps in care.

  2. Communicates relevant priority information to the healthcare team to enhance patient outcomes.

  3. Anticipate modifications required for the care of a patient suspected of COVID-19 based on best practice guidelines.

  4. Determines appropriate PPE for the current clinical situation to ensure personal safety and adherence to principles of control and prevention.

  5. Communicates therapeutically with the patient in an urgent situation to decrease anxiety and promote collaboration with care.

  6. Perform critical interventions in response to assessment findings to prevent further deterioration in clinical status.
Self Assessment Rubric

Self-Assessment Rubric

  The use of this customized learning outcomes rubric, based on self-regulated learning (SRL) theory, allows student self-assessment of the game content and targeted learning outcomes.  Each rubric also describes competency indicators which levelled from the novice to competent learner. Below each learning outcome, users can provide additional comments/reflections/rationale to support scoring. The self-assessments rubric can be used to:
  1. Assess success on preparation for the simulation
  2. Assess performance during the simulation
  3. Guide the post-simulation debriefing in order to identification remedial learning requirements.
Further, the rubric can be used by the simulation facilitator for evaluation purposes or by examining the difference between instructor assessment scores and students’ self-assessment of the understanding of course criteria.
For the Respiratory Deterioration Learning Outcome Assessment Rubric (word document) – click here

For the Respiratory Deterioration Learning Outcome Assessment Rubric (pdf) – click here
Game Link

English Game LinkClick here  
  1. The game works best using Google Chrome or Firefox.  The game does not have full functionality when using your cell phone.
  2. You will be shown a video of an interaction between a nurse and a patient, their family and/or other medical staff.
  3. Following each video, you will be asked to select the most appropriate response.
  4. Please note that sound is required to fully understand the interactions within the video.
  5. It is preferred you use Google Chrome or Firefox to maintain optimal audio/visual output.
  6. The game will take approximately 20-30 minutes to complete.
  7. You may complete the virtual simulation game as many times as you like.
Virtual Debrief

The Can-Sim Virtual Simulation Games are an online resource that can be used as either presimulation preparation, stand-alone games, or as a teaching resource in or outside of the classroom.  According to The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Simulation Practice (2016), debriefing is a critical aspect of the simulation experience. Debriefing after simulation provides the opportunity for self-assessment and peer evaluation by giving feedback to others. Therefore, it is important that after any simulation, a debriefing should take place. Options for debriefing a virtual simulation game debriefing include:

  1. Embedded feedback debrief: CAN-Sim Virtual Simulation Games (VSG) are designed to provide the player with immediate feedback to selected responses in the form of an Embedded Debrief.  Aligned with the game’s learning outcomes, the player is required to answer a series of multiple-choice clinical decisions key points during the game.  Upon selecting a response, the player will be shown a video clip portraying the outcome of their chosen response with a written rationale on why their decision was either correct or incorrect. Correct responses will advance the game to the next video and corresponding decision point.

  2. Self-debrief: Use the provided game-specific Learning Outcomes Assessment Rubric to reflect on perceived self-competence specific to game learning outcomes. It is recommended that completion of the Learning Outcomes Assessment Rubric should be done before and after playing the virtual simulation game.  Using the Learning Outcomes Assessment Rubric, reflect on areas of perceived competence and areas needing further improvement.  We have provided suggested reading resources to support further learning.

  3. In-person debrief: This form of debriefing involves a traditional face-to-face debrief with a facilitator. This debrief can be performed in the classroom or lab setting.

  4. Synchronous online debrief: This involves an online debrief immediately following gameplay guided by a simulation facilitator using a video-conference software (ie. Zoom, Adobe Connect). Similar to an In-person Debrief, the synchronous online debrief uses an online platform.

  5. Asynchronous online debrief – This asynchronous involves a debrief using a discussion board platform where participants post responses to reflective debriefing questions. Other participants and facilitators then respond to reflective postings.
Reflective Questions

Reflective Questions

  1. Interventions such as nebulized medications can quickly improve the respiratory status of a patient in respiratory distress.  As they are aerosol-generating procedures, they increase the risk of transmission of airborne particles.  This procedure is supported as long as enhanced personal protective equipment (PPE) is used.  What are your thoughts on this practice?

  2. Wearing PPE inhibits the therapeutic nurse-patient relationship.  What activities could you do to personalize the relationship?

  3. The use of face-masks limits communication (both verbal and non-verbal) between the nurse and the patient.  What are some actions/activities that could enhance communication while wearing PPE?

  4. What are some of the challenges of wearing enhanced PPE?  How would you respond to these challenges?

  5. The patient has significant problems using the metered-dose inhaler appropriately.  How should the nurse best respond to this issue?




Dieckmann, P., Torgeirsen, K., Qvindesland, S. A., Thomas, L., Bushell, V., & Langli Ersdal, H. (2020). The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK. Advances in Simulation5, 1-10.

Gattinoni, L., Chiumello, D., Caironi, P., Busana, M., Romitti, F., Brazzi, L., & Camporota, L. (2020). COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Medicine, 46, 1099-1102

Holland, S., & dos Reis, C. (2020).  Conscious prone positioning of COVID-19 patients.  For document, click here

Jiang, L. G., LeBaron, J., Bodnar, D., Caputo, N. D., Chang, B. P., Chiricolo, G., … & Sharma, M. (2020). Conscious proning: An introduction of a proning protocol for non‐intubated, awake, hypoxic Emergency Department COVID‐19 patients. Academic Emergency Medicine.

Marini, J. J., & Gattinoni, L. (2020). Management of COVID-19 respiratory distress. Jama, 323(22), 2329-2330

World Health Organization (2020).  Clinical management of COVID-19.  Interim guidance.  For document, click here


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