387CHAPTER 33
Abdominal Pain in a Woman of Childbearing Age: A Trauma-Informed Care Approach
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
In a typical gynecology setting, a common chief concern is lower abdominal discomfort. As the advanced practice nurse obtains the history of present illness (HPI) and assesses a woman with this concern, the patient will often point to her pelvic area as the source of discomfort. In fact, pelvic pain is one of the chief concerns that women’s health practitioners will manage (Hacker, Gambone, & Hobel, 2016). Many possible etiologies for pelvic pain exist; therefore, a simulation-based scenario with this chief concern allows students to use strong analytic skills to work toward making a diagnosis. The possible life-threatening diagnoses of appendicitis, ectopic pregnancy, and pelvic inflammatory disease (PID) are often first to be ruled out (Kruszka & Kruszka, 2010). Other common causes of pelvic pain in a woman of reproductive age include adnexal torsion or ovarian cyst (intact or ruptured; Kruszka & Kruszka, 2010). All of these diagnoses are usually at the forefront of a student’s thought process as potential etiologies for pelvic pain. However, in our experience, it is also important for students to work through combining both physical assessment and HPI skills to arrive at the etiology of undiagnosed pregnancy in preterm labor as a cause of abdominal pain in a reproductive-aged woman, which this scenario portrays. This diagnosis requires the advanced practice nurse to think outside of the box; display accurate physical assessment skills; and complete a thorough history, with particular attention to the woman’s gynecologic, menstrual, and obstetric histories. About one half of all pregnancies in the United States are unintended; therefore, ruling out pregnancy in reproductively aged women is essential (Hacker et al., 2016).
A preterm birth is a birth occurring before 37 completed weeks (37 weeks, 0 days) gestation (American College of Obstetrics and Gynecology [ACOG], 2016). The burden to families and society at large from the fetal outcomes of prematurity and from the cost of preterm births is important to note. The March of Dimes Foundation (2015) reported that the preterm birth rate in the United States was 9.6% in 2015 and that African American women disproportionately experience preterm birth. Further, preterm birth costs over $26 billion in health care spending each year (Behrman & Butler, 2006). Low socioeconomic status, previous preterm birth, urinary tract infections, bacterial vaginosis, smoking, multifetal pregnancy, and lack of prenatal care are all associated with preterm birth (Kiran, Ajay, Neena, & Geetanjaly, 2010). Recent research found that maternal binge drinking also contributes significantly to preterm birth and low birth weight and differs across socioeconomic groups (Truong, Reifsnider, Mayorga, & Spitler, 2013). ACOG’s (2016) most recent practice bulletin, No. 171, on the management of preterm labor, is an excellent resource for faculty and students alike when debriefing this case.
388This scenario has been enhanced for use with family nurse practitioner (FNP) master’s and doctor of nursing practice (DNP) students. Before this simulation, students learn how to conduct gynecological examinations on task trainers and perform their first pelvic and breast examinations on teaching-model patients as part of their health assessment class. The task-trainer activities are introduced in the beginning of the semester, but the hands-on learning culminates with simulation-based patient scenarios at the end of the semester, once the content has all been taught consistently with the International Nursing Association for Clinical Simulation and Learning (INACSL) best practice standards, specifically, Standard IX: Participant Evaluation (Lioce et al., 2015).
This abdominal pain scenario is based on a real patient situation and represents one of the most common presentations of female patients of childbearing age—pelvic or abdominal pain. For FNP students, the diagnostic skills necessary to differentiate appendicitis from ectopic pregnancy or PID are critical to patient safety, given some of these presentations are life threatening. The twist in this scenario is that the patient has an unknown pregnancy and is in preterm labor. It takes a careful identification of patient risk factors (e.g., African American race, irregular menstrual history, previous preterm birth), review of systems (ROS), HPI, and assessment for the FNP student to arrive at the proper diagnosis and treatment.
Since the development of this scenario, which is expected to take place in a clinic or emergency department (ED), many other scenarios were developed and used during the course of the FNP program. For the Adult Health II course, which includes a women’s health component, the students have a simulated gynecologic annual well-woman visit, as well as primary care simulations with standardized patients in which they see multiple patients during one simulation environment to mimic a real clinical practice day. Students have 15 minutes per patient to gather the history; assess, diagnose, and order labs treat, and prescribe before moving on to the next patient. Overall, students have been incredibly enthusiastic about the experiences they have gained with the use of simulation at the Fairfield University Marion Peckham Egan School of Nursing and Health Sciences graduate program.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
Currently, the abdominal pain scenario is run in the acute-care setting using a high-fidelity human patient simulator (HPS), but it can easily be adapted to a gynecology or primary care office-based setting. The current setup for the simulation involves a control room with mirrored glass looking into the simulation room. Typically, to run this scenario one or two faculty are needed, one to be the voice of the patient and one to manage the vital signs (VS) and laboratory values. The faculty members running the simulation are able to talk to the students in the simulation room via a microphone into the room, a microphone from the high-fidelity HPS, and a telephone. The telephone communication allows the faculty to call with results as a doctor, certified nurse midwife (CNM), or laboratory technician, or for students to call another health care provider, the lab, the operating room, and so on. An electronic health record system is also available for use by the students in the simulation room. The simulation room also has the capacity to video-record the scenario with student permission for later viewing and evaluation.
In addition, if this scenario is run as a flipped-classroom experience, for the students in the classroom who are active observers, the scenario can be projected live via a 360-degree camera into one of two classrooms (with seating capacity for 35 and 120+ students, respectively). This setup allows the students in the classroom to work through the diagnosis as well and to recognize the strengths and areas for improvement of their classmates’ patient assessment skills. Finally, the students participating in the scenario can return to their classmates, who watched the simulation for a debriefing (INACSL Standard VI) with the entire class (Decker et al., 2013).
389C. SPECIFIC OBJECTIVES OF SIMULATION USE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The primary objective of this scenario is to assess the student’s ability to use a trauma-informed care approach to conduct a thorough examination and assessment of a childbearing-age woman with abdominal pain, to recognize abnormal findings, and to determine a plan of action to enhance patient safety and emotional stability. This scenario was initially designed as a flipped-classroom, advanced-level simulation for third-year BSN students. This was a high-level simulation for BSN students and is leveled more approximately for the master’s and DNP FNP students we currently run it with during Adult Health II. These students have completed health assessment, pathophysiology, pharmacology, and Adult Health I. In their health assessment course, they have all performed their first pelvic and breast examinations on teaching-model patients. This simulation allows for students to think broadly, use physical assessment skills, and understand the importance of a detailed HPI to arrive at the diagnosis.
Student Learning Activities
• Perform an assessment of a reproductive-aged woman with abdominal pain.
• Review and practice obtaining the chief concern, ROS, and HPI (with particular attention to obstetric, gynecologic, and menstrual history).
• Educate patients regarding potential tests, considerations, and findings.
• Provide trauma-informed care.
D. INTRODUCTION OF SCENARIO
Setting the Scene
The setting can be either acute care or primary care, depending on the student needs.
When this simulation is run with undergraduate students, an ED setting at a hospital of a tertiary-level institution at change of shift is appropriate. In this setting, the students receive a report from the night nurse and are told a CNM is available on call.
For FNP students, either the ED setting listed previously (with a report from the nurse practitioner who worked over night) or a primary care setting may be appropriate. In a primary care setting (private practice or clinic), the patient would present for an episodic visit on the FNP’s schedule for today.
Technology Used
The medium-fidelity HPS is a female (wig and female genitalia in place), running manually, with the following initial VS: blood pressure (BP), 116/76 mmHg (up to 186/110 mmHg); O2 sat, 86% (up to 94%); pulse (P), 88 beats/minute; respiratory rate (RR), 20 breaths/minute; temperature (T), 98.1°F/36.72°C; and pain level 10/10, but these do not show on the monitor, and the pulse oximeter is not in place. The patient is in mild distress and is anxious. She has an obese abdomen. She does not have an intravenous (IV) line in place. She is wearing a panti-liner that has light vaginal bleeding on it (water and red food coloring can be used). A wristband identifies the patient as “Ms. Mary Small.” Stethoscopes, gloves, O2, nasal cannula, and a pulse oximeter are placed nearby for student use, as well as an IV start tray and tubing and IV fluids (choices of 1,000 mL D5NS [potassium chloride in 5% dextrose and sodium chloride injection], Ringer’s, or normal saline [NS]). Routine and as-needed (PRN) medications are available: Dilaudid 1 to 2 mg IV push PRN for pain q (every) 4 hours.
390Objectives
1. Describe the assessment of a reproductive-age woman with abdominal pain
2. Obtain a history to determine the potential causes of abdominal pain
3. Examine menstrual history to determine chance of pregnancy
4. Perform an accurate assessment of a reproductive-age woman with abdominal pain
5. Educate patient regarding her status and your findings
6. Incorporate and provide emotional support and trauma-informed care to the woman throughout
Description of Participants
Ms. Mary Small: 23-year-old African American woman. She is 5 feet, 2 inches and weighs 200 pounds. Her obstetric history includes gravida 1, term 0, preterm 1, abortions 0, living 1. Her son was born vaginally at 34 weeks, 2 days gestation and is now 2 years old and healthy. She reports her menstrual history as “very irregular menses” and is unsure of her last menstrual period (LMP). She reports she “only has a few menses a year.” She has a history of sexual assault as a child and reports “a very difficult time” with vaginal examinations. Patient states that only her CNM, Sarah Jones, has checked her and everything was “fine” at her annual examination last year.
E. RUNNING OF THE SCENARIO
Students enter the simulation room and are given the aforementioned patient history. In addition, they are told by either the nurse or nurse practitioner giving report that the patient is experiencing intermittent abdominal pain with scant vaginal bleeding and is requesting pain medication.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Abdominal Pain in a Woman of Childbearing Age
Scenario Level
Designed as an in-class, advanced-level simulation for BSN students and graduate nursing FNP students. For use in Nursing 314: Maternal and Newborn Nursing, a specialty clinical course in obstetrics for second-semester third-year or first-semester fourth-year baccalaureate students, and Nursing 643: Adult Health II, a clinical course for graduate FNP students.
Focus Area
ED nursing, gynecology, obstetrics, midwifery
Scenario Description
Patient: Mary Small (M. S.) Age: 23 years
Race: African American Gender: Female
Date of birth: 4/23 Height: 5 feet, 2 inches Weight: 200 pounds
Allergies: No known drug allergies (NKDA)
Past medical history (PMHx): Obesity
Past surgical history (PSHx): Appendectomy at age 7 years
Exhibit 33.1 Medication Record
Patient: Ms. Mary Small | DOB: 4/23/1994 |
Notes: none |
|
Medication list: none | Time given: |
PRN List: Dilaudid 1–2 mg IV push PRN for pain q 4 hr | Time given: not administered |
Allergy: NKDA | Medical provider: Sarah Jones, CNM |
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