375CHAPTER 32
Assessment and Differential Diagnosis of the Patient Presenting With Chest Pain
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
The use of simulation in nurse anesthesia training has been an integral part of the educational process for many years. Low-fidelity simulators and static manikins have been utilized to teach basic psychomotor skills and critical decision making with much success. However, with the addition of high-fidelity simulation, nurse anesthesia education has moved to an entirely new level through the incorporation of a simulation-based pedagogy into the nurse anesthesia curriculum. High-fidelity simulation scenarios are used in the student’s clinical orientation and throughout all five clinical practicums in order to facilitate the progression from novice to competent anesthesia care provider. Students are given the opportunity to use increasingly complex critical decision-making skills in the anesthetic management of their patients. In addition, students are introduced to situations that are rarely encountered in the clinical setting, but in which expertise is essential for safe practice. Students are therefore able to “experience” rare and complex clinical situations before entering into practice so that the first time they care for these types of patients is not in a crisis situation. The following scenario demonstrates the use of simulation in increasingly complex situations and will be applicable to senior-level undergraduate and entry-level advanced practice students (master’s and doctoral preparation).
This chapter focuses on the assessment, differential diagnosis, and initial management of the patient who presents to the emergency department (ED) with complaints of crushing substernal chest pain. The student is required to conduct a rapid history and physical; develop an initial diagnosis; initiate lifesaving therapy; and use effective communication techniques with the patient, family, and members of the interdisciplinary health care team in order to successfully meet the objectives of the scenario. The scenario can be modified for use in the primary care, intensive care, medical–surgical, or the perioperative setting as required to meet the specific needs of the students.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The Fairfield University Egan School of Nursing and Health Sciences (SON) will be moving into a new building and state-of-the-art simulation center on the Fairfield University campus in the fall of 2017. This facility embraces the simulation-based pedagogy adopted by the SON and has been designed to 376foster the development of psychomotor, cognitive, and affective clinical skills in the students enrolled in all programs. It will be equipped with two fully functional operating rooms, as well as critical care, acute care, and primary care facilities to facilitate simulation across programs. Simulation space is also available to mirror other hospital environments such as a preoperative holding area or postanesthesia care unit (PACU) in order to run scenarios in other locations where anesthesia care providers are required to manage patients. Control rooms are adjacent to the simulation rooms and are designed to allow separation of the facilitators from the students participating in the scenarios to increase fidelity. The control rooms are equipped with and capable of recording and transmitting to adjacent classrooms in real-time running scenarios in order to facilitate effective debriefing.
In addition to the high-fidelity simulation rooms, independent skills labs have been incorporated to house the low-fidelity simulators and static trainers, which can also be used to supplement learning within the high-fidelity simulation environment. A stand-alone 20-bed graduate health assessment lab with integrated audiovisual capabilities for recording and debriefing is also available for use. Faculty have the ability to use recorded sessions for both formative and summative evaluation of student performance within the health care setting.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The overarching objectives of this scenario are threefold and are consistent with both the program essentials for undergraduate, graduate, and doctoral education as delineated by the American Association of Colleges of Nursing (AACN; 2006, 2008, 2011). This scenario will enhance the student’s ability to do the following:
1. Collaborate with peers, patients, health care professionals, and other members of the health care team in the assessment, planning, implementation, and evaluation of health care.
2. Use critical thinking skills and current scientific evidence in clinical decision making.
3. Prioritize patient care to optimize outcomes.
4. Communicate effectively in order to provide appropriate patient-centered care.
This scenario is designed for undergraduate nursing students who have completed their basic medical–surgical experience and are participating in transitional experiences in critical care settings during their senior year. It can also be used at the graduate level as part of the advanced-practice nursing curriculum in the advanced health assessment or advanced physiology and pathophysiology courses in both master’s and doctoral entry-into-practice programs.
This scenario addresses the following Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008):
Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety, Objectives 1, 2, 5 to 8
Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes, Objectives 2 to 6
Essential VII: Clinical Prevention and Population Health, Objective 9
Essential VIII: Professionalism and Professional Values, Objectives 1 and 2
Essential IX: Baccalaureate Generalist Nursing Practice, Objectives 4, 12, and 14
This scenario addresses the following Essentials of Master’s Education in Nursing (AACN, 2011):
Essential I: Background for Practice From Sciences and Humanities, Objectives 1 and 2
Essential II: Organizational and Systems Leadership, Objectives 1 and 2
Essential III: Quality Improvement and Safety, Objective 1
Eseential IV: Translating and Integrating Scholarship Into Practice, Objectives 1, 2, and 5
Essential VII: Interprofessional Collaboration for Improving Patient and Population Outcomes, Objectives 3, 4, and 6
Essential IX: Master’s-Level Nursing Practice, Objectives 3 and 11.
This scenario addresses the following Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006):
Essential I: Scientific Underpinnings for Practice, Objectives 1 and 2
Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking, Objectives 1 and 2
Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes, Objectives 1 to 3
Essential VIII: Advanced Nursing Practice, Objectives 1 to 4
D. INTRODUCTION OF SCENARIO
Setting the Scene
This scenario takes place in the ED. The patient has just walked into the waiting room with her husband and tells the nurse at the triage desk that she has had crushing substernal chest pain that has been radiating to her back for the past 2 hours and it has not been relieved by rest. She was out for dinner with her husband at their favorite local Italian restaurant before the onset of symptoms. She states that she feels “terrible.” Her husband is very anxious and insistent that something be done for his wife immediately. The patient is placed in a room with a monitored bed, where the ED nurse (student) who will be caring for her is waiting.
Technology Used
In order to run this scenario, a high-fidelity human patient simulator (HPS) is required to allow the student to visualize hemodynamic and EKG changes that will be implemented as part of the scenario. If one is not available, an actor can be substituted, but the instructors will need to be creative with displaying hemodynamic changes. In addition, a training program for simulated patients would need to be developed to ensure that appropriate patient characteristics and actions are displayed during the scenario. Access to patient records, either in electronic or paper format, will also be necessary as they allow for greater fidelity. Audiotaped recordings of the common sounds in the ED should be incorporated into the scenario to simulate the noisy and hectic emergency environment. Finally, video-recording equipment will be required to tape the scenario so that it can be evaluated and discussed during debriefing sessions. The facilitator should make sure that consent for videotaping is obtained from all participants.
Objectives
At the completion of this scenario, the student will be able to do the following:
1. Discuss the differential diagnosis of “life-threatening” chest pain, including alternative diagnoses, such as noncardiac (gastroesophageal reflux disease) and vascular causes
2. Conduct an immediate targeted physical assessment and health history
3. Initiate intravenous fluid therapy
4. Discuss the initial treatment of acute coronary syndrome (ACS), including the drugs, dosages, and adjuvant treatment modalities
5. Apply the advanced cardiac life support (ACLS) ACS algorithm
6. Interpret common laboratory and diagnostic tests used in the differential diagnosis of ACS, including cardiac enzymes, troponin levels, and the EKG.
7. Develop skills as a team leader, patient advocate, and effective communicator.
This scenario addresses the following National Council Licensure Examination for Registered Nurses (RN®) test plan categories and subcategories (National Council of State Boards of Nursing [NCSBN], 2015):
Safe and effective care environment: Management of care (case management, collaboration with interdisciplinary team, consultation, establishing priorities, ethical practice, resource management), Safety and infection control (handling hazardous and infectious equipment, safe use of equipment, standard precautions), Health promotion and maintenance: (techniques of physical assessment), Psychosocial integrity: (crisis intervention cultural diversity, family dynamics, situational role changes, support systems, therapeutic communication); Physiological integrity: Pharmacological and parenteral therapies (dosage calculations, expected effects/outcomes, medication administration, parenteral/intravenous therapies, pharmacological agents/actions), Reduction of risk potential (diagnostic tests, laboratory values, potential for alterations in body system, therapeutic procedures), Physiological adaptation (alterations in body systems, hemodynamics, medical emergencies, pathophysiology).
Description of Participants
A total of five or six participants will be required to run this scenario. If the scenario is run with undergraduate students, then the student to be evaluated will take the role of the ED nurse assessing the patient. This student will also be assigned the role of team leader and will be required to delegate tasks and coordinate interdisciplinary discussion and activities. An assessment form may be given to the student to help guide the scenario, if deemed appropriate by the instructors. If the scenario is being run with graduate students, then the student evaluated will take on the role of an advanced practice registered nurse (APRN) and an additional participant will be required to take on the role of ED nurse. The graduate student will serve as the team leader, as outlined earlier.
An additional student or actor can take on the role of the nursing technician (or the equivalent). This individual is included to carry out tasks as directed by the team leader, such as sending blood to the lab, obtaining equipment, or assisting with procedures. The purpose is to assess the student’s ability to delegate and work as a member of the health care team.
An actor (or student) will be needed to serve as the patient’s husband. This individual should be provided with a short script so that he can effectively portray the anxious husband. This individual should not offer any information about the patient unless specifically asked. The husband is included to facilitate communication and activation of support systems.
Example of Husband’s Script
The scene: Mr. Hart brings his wife, Mrs. Hart, to the ED with complaints of crushing substernal chest pain that radiates to her back and has lasted more than an hour. The couple was out for dinner at their favorite local Italian restaurant before the onset of the symptom, and they consumed a very heavy meal. Mr. Hart is extremely anxious and is demanding that his wife be seen immediately. He is yelling at the nurses and ancillary staff and is being disruptive to other patients in the waiting room.
Suggested dialogue:
a. If Mr. Hart’s needs are not addressed:
i. “My wife needs help, and I want it now!”
ii. “Somebody do something now, or I’ll take her inside myself!”
iii. “Don’t tell me to calm down! You don’t have any idea how I feel right now.”
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