363CHAPTER 31
Diabetes Management: Nurse Practitioners
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Nurse practitioner (NP) instructors are finding it increasingly challenging to evaluate students in the clinical area because of an increase in nursing school enrollment, nursing faculty shortage, and difficulty in evaluating students in the clinical setting because of the Health Insurance Portability and Accountability Act’s (HIPAA) privacy rules. Although the need for clinical evaluations is not eliminated, nursing instructors can use simulation to evaluate student’s clinical performance in a safe learning environment using standardized clinical scenarios. Faculty can schedule an evaluation of a large number of students in one central location versus traveling to different clinical sites. Simulation has been found to improve knowledge, skills, and attitudes in undergraduate students; however, more research is needed to evaluate the benefits of simulation for NP students (Rutherford-Hemming, Nye, & Coram, 2016).
Simulation-based pedagogy has been implemented in the Common Health Problems of Adults and Older Adults course as a method of teaching/learning to prepare NP students for their first clinical rotation. This course is designed to enable students to develop the necessary knowledge base and problem- solving skills for practice as an NP in the management of common health problems such as hypertension and diabetes. The goal of the diabetes management scenario is to allow students an opportunity to complete a comprehensive patient encounter in the context of a modified objective structured clinical examination (OSCE) format. A group of three to four students rotate through five stations that represent each component of a patient encounter. These stations include patient history taking, physical examination, ordering of a diagnostic test, development of a diagnosis and treatment plan, and discussion of treatment plan with the patient. Each group is allowed 15 minutes at each station and instructors provide feedback during the simulation. This formative simulation experience enhances assessment, critical thinking, teamwork, and communication skills.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
New York University (NYU) Meyers College of Nursing’s Clinical Simulation Learning Center (CSLC) is designed to simulate the hospital and outpatient environment for both undergraduate and graduate students. Our cutting-edge simulation center is larger than 10,000 square feet and consists of 21 simulation rooms to simulate medical–surgical rooms, outpatient examination rooms, and the home environment—all with video-recording capability. Each week, more than 364100 simulation sessions are conducted at the CSLC for more than 1,200 undergraduate BS and graduate MS students. The CSLC allows students to enhance their clinical skills and nursing knowledge in a safe learning environment.
The CSLC is currently equipped with close to 30 human patient simulators (HPS), including SimMan 3G, Birthing Noelle, mid fidelity HPSs, and five pediatric HPSs. In addition to the HPSs, the CSLC has a database of more than 20 diverse standardized patients (SPs) that are used for almost all graduate simulations and selected undergraduate simulation sessions.
The scenario can take place in either a simulation room or an OSCE room. The rooms contain either a bed or examination table, laptop for charting, a medical and diagnostic headwall. The role of the patient can be represented by a faculty member or an SP.
C. SPECIFIC OBJECTIVE FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The Common Health Problems of Adults and Older Adults course enables students to use their knowledge base and clinical skills to manage simulated patients in the simulation center, as well as real patients in their assigned clinical placement. The scenario was designed for all NP students who are scheduled to begin their first clinical rotation. All students enrolled in the course have completed pathophysiology and advance health assessment courses.
Student Learning Activities
1. Review diabetes management.
2. Complete a history on a patient with diabetes mellitus, type 2.
3. Perform a complete physical assessment.
4. Order appropriate diagnostic test.
5. Develop a comprehensive plan of care based on findings.
D. INTRODUCTION OF SCENARIO
Setting the Scene
The setting is an outpatient primary care clinic. The patient is seated in a chair in the NP’s office. The medical assistant has taken the patient’s vital signs and has written them on the assessment form.
Technology Used
A medium- or high-fidelity HPS or SP can be used for this scenario. The HPS is wearing a patient gown, a female wig, and female genitalia are applied. The vital signs are programmed as follows: heart rate (HR): 84 beats/minute, respiratory rate (RR): 14 breaths/minute, and blood pressure (BP): 144/84 mmHg, temperature: 98.7°F. If using an SP, a programmable BP cuff and thermometer can be used.
Objectives
1. Obtain a patient history based on patient’s chief concern
2. Perform a focused physical assessment based on patient presentation
3. Order appropriate diagnostic test based on history and physical examination
4. Develop a diagnosis based on clinical findings
5. Create a treatment plan based on evidence-based practice
6. Demonstrate effective techniques in providing patient education
365Description of Participants
Mrs. Roberta Johnson is a 62-year-old African American female who presents to the clinic because she is feeling “tired” and thinks she has a “bladder infection” because of an increase in urination. She is a regular patient at the clinic and was last seen by another primary care NP 5 months earlier for her annual physical checkup. She has a history of hypertension and diet-controlled type 2 diabetes mellitus. Her last hemoglobin A1c (HbA1c) was done 5 months ago and was 6.8%.
E. RUNNING THE SCENARIO
The students are divided into groups of three to four and assigned times to begin the scenario. The students rotate through each of the five stations starting with station 1: history taking, station 2: physical examination, station 3: diagnostic test ordering and interpretation of results, station 4: diagnosis and development of treatment plan, and station 5: review treatment plan with the patient. Each group is staggered 15 minutes apart to allow each group 15 minutes to complete each station. All five stations are clearly labeled. Each group is given a one-page subjective objective assessment plan (SOAP) format form to be used for charting the patient encounter. An instructor or SP plays the role of the patient and is seated across from the four students at the first station. The second station has an HPS or SP seated on an examination table. At this station the students are expected to complete a focused assessment. A programmable BP cuff, thermometer, and stethoscope are used for the SP. If an HPS is used, an instructor is at the station to provide assessment findings that cannot be elicited by the HPS. At station 3 an instructor or staff member is seated across from the students and provides lab reports requested by the group. The person at station 3 is assigned to be the time keeper and resets the timer every 15 minutes. The fourth and fifth stations are located in the second room. At station 4, students complete the treatment plan as a group using available resources such as Epocrates Essential, Cochrane Reviews, or UpToDate. At the fifth station the students discuss the treatment plan with the patient (instructor), who has returned to the clinic 3 days later for results.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Diabetes Management
Scenario Level
This scenario is used as a formative evaluation of graduate students in the clinical course titled Common Health Problems of Adults and Older Adults. Students must complete 30 hours of lecture followed by 120 clinical hours.
Focus Area
NP students
Scenario Description
Patient: Roberta Johnson
Age: 62 years
Allergies: No known drug allergies
Race: African American woman
Height: 5 feet, 4 inches. Weight: 175 pounds
Reason for visit: The patient presents to her primary care provider stating that she has been “very tired” the past month and thinks she has a “bladder infection” because of her frequent urination.
Past medical history: Patient has a history of diabetes mellitus type 2 for the past 2 years that has been controlled with diet. She did not receive a blood glucose monitoring machine at the time of diagnosis. She has a history of hypertension for the past 10 years.
Medications: Lisinopril 20 mg PO (per os) daily and hydrochlorothiazide 25 mg PO daily.
Surgical history: Has not had any surgeries.
Social history: Married, has two adult children. She is a retired Post Office worker. She denies alcohol, drug use, or cigarette use.
Physical assessment:
HR: 84 beats/minute, RR: 14 breaths/minute, temperature (T): 98.7°F, BP: 144/84 mmHg
Head, ears, eyes, nose and throat (HEENT): Unremarkable, normal fundus examination
Respiratory: Lungs clear bilaterally
Cardiovascular: Normal rate and rhythm; no murmurs
Integument: Clean, dry, and intact
Abdomen: Bowel sounds present; all 4 quadrants; soft, no masses or bruits
Extremities: Pulses 2+, no edema or abnormalities noted, no loss of sensation during monofilament test
Scenario Objectives
1. Students obtain a focused patient history. The focused patient history should include questions about current symptoms, review of past medical history, blood glucose monitoring, current medications, level of exercise, and diet. Students should ask the patient whether she has any signs and symptoms of a urinary tract infection (UTI) and/or hypothyroidism.
2. Perform a physical assessment based on patient presentation and history. The focused physical examination should include examination of the heart, lungs, extremities, and eyes.
3. Order appropriate test based on clinical findings and patient history. The group should order a complete blood count (CBC), comprehensive metabolic panel, lipid panel, urine dipstick, urinalysis, HbA1c, EKG, and microalbumin test.
4. Analyze laboratory results and identify abnormal findings (McKulloch, 2015).
5. Develop an appropriate diagnosis and an appropriate treatment plan based on evidence-based practice. The group should order Metformin 500 mg by mouth daily with meals (McKulloch, 2015). Provide education on lifestyle changes, including blood glucose monitoring, diet, and exercise.
This scenario also allows graduate students the opportunity to practice essential skills as outlined by the American Association of Colleges of Nursing (AACN); Essentials of Master’s Education in Nursing (AACN, 2011).
Essential I: Background for Practice from Sciences and Humanities, Objectives 1, 5
Essential V: Informatics and Healthcare Technologies, Objective 5
Essentials VIII: Clinical Prevention and Population Health for Improving Health, Objective 5
Essential IX: Master’s Level Nursing Practice, Objectives 1, 2, 7, 12, 13
Setting the Scene
Equipment Needed
The HPS or SP seated on examination table, video recording equipment (optional), BP cuff, timer, stethoscope, a hard copy of lab results for each group, picture of normal fundus of eye (if using HPS), and 10-gauge nylon monofilament. The scenario requires five stations that are spaced far enough 367apart to avoid noise distraction among the groups. The patient history station requires a chair for the patient and four additional chairs circled in front of the patient. The physical examination station is an examination table where the SP or instructor is seated. The monofilament, ophthalmoscope, and a picture of a normal retinal fundus examination are located beside the HPS. The diagnostic test station has a seat for the person distributing lab results, folders containing copies of lab results, and four chairs for the students. The diagnosis and treatment plan station can be in a separate room that contains chairs, a desk, and a computer with Internet connection. The fifth station has chairs for the patient and each student.
Resources Needed
Computer access for Epocrates Plus, UpToDate, and Cochrane Reviews
Simulator Level
SP or medium- or high-fidelity HPS; SP or instructor is needed at the stations for history taking and physical examination.
Participants Needed
A minimum of four people are needed for this scenario. An instructor or SP is needed to play the role of the patient at the history-taking station. Each “patient” is provided with a script of standardized responses to history questions. An SP or instructor is needed at station 2 for the physical examination. If an HPS is used, the instructor must provide students with assessment findings that the HPS cannot elicit such as sensation from the monofilament test. A third person (can be nonfaculty person) is needed at the diagnostic test station to distribute test results based on the labs ordered by the group. Lastly, an instructor is needed at the fifth station to play the role of the patient returning to the clinic for results and a treatment plan.
Scenario Implementation
Initial Settings for HPS
• HPS is seated on the examination table with a patient gown, a female wig, and female genitalia.
• Bedside table has a picture of a normal fundal examination of eyes and 10-gauge nylon monofilament.
• BP cuff and stethoscope are at HPS bedside.
• HPS vital signs programmed as follows: HR: 84 beats/minute, RR: 14 breaths/minute, temperature: 98.7°F, BP: 144/84 mmHg
Resources Needed
• Lab reports: CBC (all values within normal limits)
• Complete metabolic panel: fasting glucose level 254 mg/dL (all other values within normal limits)
• Lipid panel: (all values within normal limits)
• Urine dipstick: +2 glucose
• Urinalysis: +2 glucose
• HbA1c: 7.8%
• 12-lead EKG: normal sinus rhythm
• Microalbumin: 11.8 µg/mL
• SOAP format form with vital signs written on the form
368Required Student Assessments and Actions
Station 1: History
___Introduce self to patient
___Ask patient’s purpose of visit
___Elicits information on concerns
___Obtains patient’s medical history
___Obtains surgical history
___Obtains medication history
___Obtains information on family history
___Asks patient about social history, including alcohol, cigarette use, and drug use
___Asks patient about current diet
___Asks patient about level of exercise
Station 2: Physical Examination
___Auscultates heart sounds
___Auscultates lung sounds
___Examines lower extremities
___Performs a monofilament test
___Performs a retinal examination
Station 3: Diagnostic Test
___Orders CBC, comprehensive metabolic panel, HbA1c, microalbumin, lipid panel, urinalysis, EKG, and thyroid-stimulating hormone (TSH)
Station 4: Diagnosis Development of Treatment Plan
___Analyzes lab work for abnormalities
___Develops treatment plan as a group based on evidence-based practice
Station 5: Discussion of Treatment Plan With Patient
___Explains the results of laboratory results with patient
___Discusses the need to start metformin
___Explains proper use and side effects of medication
___Discusses proper diet with patient
___Encourages weight loss
___Encourages patient to exercise
___Discusses the need for blood glucose monitoring at least once a day
___Orders education on blood glucose monitor by RN
___Explores patient’s questions/concerns
___Asks patient to repeat treatment plan
Instructor Interventions
The SP or instructors at stations 1, 2, and 5 will be allowed to provide feedback during the last 5 minutes of the rotation. If a key element of the history or physical examination was missed, the SP/instructor can cue the students in order to make sure that they have key necessary information needed to develop a treatment plan. Students are not allowed to discuss the simulation with other groups and are not allowed to repeat stations.
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