105CHAPTER 11
Postoperative Care Following Appendectomy
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
This chapter incorporates students’ knowledge of postsurgical patients, emphasizing operative assessment, problem recognition, interprofessional collaboration, and patient education for the prevention of postoperative complications.
In 2003, our School of Nursing received its first high-fidelity human patient simulator (HPS) as a gift from an adult learner who was graduating and wanted to leave something of import to the lab. At the time, Dr. Mager was the Learning Resource Center director, so when the manikin arrived, she began experimenting to test its capabilities. She thought that using HPSs to simulate patient care was an innovative way to teach, but realized that the machinery was quite complex to run. Dr. Mager also knew that it would be a leap for the faculty to begin using this complex technology.
We began with small steps. Drs. Lange and Mager decided to create a very simple scenario about a patient in pain and run it in Dr. Lange’s medical–surgical course. Dr. Lange had attended workshops and demonstrations about how to conduct a simulated scenario and was willing to try out this new technology in her classroom. Together we designed a brief scenario about a patient who had an appendectomy and was in pain postoperatively. We created objectives and a checklist of desired student activities and set the date that the simulation would run live. We had no formal control room, cameras, or microphones at the time, so we ran the scenario in front of the classroom with four student volunteers while the other 60 students observed from their seats. Dr. Mager brought the manikin into the large auditorium on a stretcher and sat behind a rolling curtain running the controls. Dr. Lange introduced the simulation and facilitated the classroom discussion, while our faculty champion of simulation integration at the time, Dr. Suzanne Campbell, acted as the “on-call” health care provider. This allayed our anxiety about “going it alone” and broke the proverbial simulation ice. We have all come a very long way since that first scenario, but it was a starting point, and the scenario itself was rich and easy to run regardless of simulator fidelity level, amount of space available, or presence or lack of a control room.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
Once the School of Nursing began to use simulation as a teaching–learning strategy, it was clear that an expanded laboratory with a formal control room was needed. A generous donation provided the funding to create The Fairfield University Robin Kanarek Learning Resource Center in 2006, including a control room flanked by two simulation rooms with one-way mirrors. 106Ceiling-mounted cameras allowed simulations to be streamed live into two of the classrooms and recorded for debriefing. One room was designed so that it could be converted easily from an acute care patient room into an intensive care cubical by moving portable equipment in or out. Metal cabinets aligning one wall allowed for storage of various props and supplies used during simulations. Wall-mounted items included working oxygen/suction headwall unit, x-ray screen, hand sanitizer, sharps container/glove dispenser, and a flat-screen monitor to project images or lab values sent via the adjacent control room. Portable equipment housed in the room included high-fidelity simulator in a hospital bed, stretcher, intravenous (IV) pumps on poles, rolling vital signs station, linen cart, ventilator, EKG machine, wheelchair, and an overbed table.
One wall of the simulation room abutted the control room, where a handler controlled the HPS while watching the simulation through a double-sided mirror. Thus, although students could not see the control room, handlers could easily observe and record the simulation. Communication between the rooms was conducted via microphone, and the episode could be projected into nearby classrooms for viewing in real time, if desired. Once the control room was completed, Drs. Campbell, Lange, and Mager used streaming technology to demonstrate the use of simulation to faculty and staff during a business meeting. This, as well as the support of Drs. Mager and Campbell with planning scenarios and managing the control room, helped to accelerate faculty members’ willingness to incorporate this new technology into their courses.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Learning Objectives
We have added some complexity beyond the pain management and medication allergy to the following scenario so that it can be used with more experienced students, or simplified for the novice student. The primary objective of this scenario is to assess the prelicensure student’s ability to conduct a thorough postoperative assessment, recognize abnormal findings, and cluster cues to diagnose actual and potential problems. Elements of patient education, interprofessional collaboration and communication, infection control, and judgment in medication administration are incorporated.
Student Learning Activities
To achieve the objectives of this more complex scenario, students need to have mastered the content on postoperative care, medication administration, and physical assessment, including identifying abnormal laboratory results.
Learning activities include:
1. Completion of reading related to postoperative care and appendectomy procedures
2. Review of basic laboratory interpretation, medication administration procedures, and dosage calculation
3. Review of procedures for postoperative bedside physical assessment and patient safety
4. Review of steps to perform dressing changes, wound assessment, and drain care
D. INTRODUCTION OF SCENARIO
Setting the Scene
The setting for the scenario is the hospital room of a 59-year-old man who presented to the emergency department the previous afternoon with abdominal pain. He was diagnosed with appendicitis, and is 107now 12 hours postoperation following a ruptured appendix and open appendectomy. The students arrive on the surgical unit at 7 a.m. for their clinical rotation and receive a verbal report from the night nurse.
Technology Used
The “patient” can be a low-, mid-, or high-fidelity simulator. In this case, a high-fidelity HPS was used. The patient was lying in bed with an IV running, a name band and red allergy bracelet in place, and a dressing applied to the right lower quadrant of his abdomen. Moulage to simulate an infected wound, pus-like yellow drainage on the dressing, and props, such as a wig, makeup, glasses, and an over-bed table with tissues, a cup of water, an incentive spirometer and an emesis basin, can be added for realism. For low-fidelity simulation, a standardized patient or another student could act as the patient.
Objectives
1. Use communication skills to identify themselves and their role, affirm the patient’s identity
2. Perform a postoperative assessment on a patient in the acute care setting
3. Cluster cues to diagnose actual and potential patient problems (e.g., relate increased blood pressure [BP] and pulse to pain; recognize pain as a deterrent to coughing, deep breathing, and mobility; note increased temperature, pus-like drainage and elevated white cell count as indicators of infection)
4. Use clinical reasoning skills to decide on a course of action when discovering a potential medication error (allergy to a medication that is ordered)
5. Initiate interprofessional communication (with a physician or other health care provider) using appropriate communication skills
6. Provide patient education regarding prevention of potential postoperative complications
Description of Participants
Prelicensure student nurse in a medical–surgical course: Student preparation includes reading related materials: reviewing dosage calculations and basic laboratory value interpretation; practicing; medication administration, dressing changes, and drain care; and conducting a postoperative assessment. Students listen to the oral report and have electronic or written access to the medication record and laboratory results for electrolytes, blood urea nitrogen (BUN), glucose, and complete blood count (CBC). Faculty may wish to require that students wear uniforms and identification tags to mimic the clinical setting. It is expected that the students conduct a focused, postoperative assessment in a logical order, taking into account abnormal findings and/or patient-reported problems. Students must also assess the IV fluid rate, intake/output results, surgical site, recent and current vital signs, laboratory values, and the abdominal dressing. In addition, students are expected to incorporate appropriate postoperative patient education as they render care.
Adult patient in hospital room: A standardized patient with a script, or an HPS with preset vital signs and heart/lung/bowel sounds run by a handler may be used. The main script for this patient is to complain about terrible pain at the incision site (“9” out of 10) and to ask for pain medication.
On-call health care provider (physician, nurse practitioner): This role is designed to promote interprofessional communication, collaboration, and to encourage students to call a provider.
Faculty or staff running the scenario/handler: The handler may need to speak for the patient if using high- or mid-fidelity technology, and preset vital signs, lung and bowel sounds. If a standardized patient is being used instead, the faculty/staff member is there to observe and record whether and how the objectives are being met. In addition, notes may be kept that aid in debriefing later.
108E. RUNNING OF THE SCENARIO
Before the scenario, an HPS is prepared by setting various pertinent findings for a patient who is in postoperative day 1, is in pain and showing signs of a wound infection. Initial vital signs (BP: 144/94 mmHg, pulse [P]: 98 beats/minute, respiratory rate [RR]: 20 breaths/minute; temperature [T]: 100.9°F; pulse oximetry: 94%), lung sounds (slightly diminished bilaterally), and bowel sounds (hypoactive) are preset. Based on standard care following perforation and an appendectomy, a 3-inch wound with a Penrose drain is present on the right lower quadrant (Mason, 2014), covered by a dressing containing a small amount of yellow pus-like drainage (vanilla pudding). The perimeter of the wound looks red. A wristband with the patient’s name and a red bracelet indicating a morphine allergy are on the right wrist. An IV of 5% dextrose with normal saline (D5NS) is running into the left arm. Stethoscope, gloves, and a pulse oximeter are placed nearby. A medication record, intake/output flow sheet and laboratory results are available for students to review. When students approach the patient, he should be groaning and asking for pain medication. As students ask the patient questions and perform the assessment, the handler or standardized patient can answer. The scenario is designed to last approximately 15 minutes, not including the period of debriefing, which may take 30 to 40 minutes.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Postoperative care following appendectomy
Scenario Level
Prelicensure nursing students
Focus Area
Medical–surgical nursing course
Scenario Description
This scenario takes place at 7 a.m. in an acute care setting, in the room of a 59-year-old male who had an appendectomy following a perforated appendix the previous evening. Prelicensure students play the role of student nurses arriving at their clinical rotation, receiving morning report, and performing a postoperative patient assessment followed by any necessary interventions and patient education. Interprofessional communication is encouraged, and students are expected to use clinical reasoning skills to recognize problems and intervene appropriately. They are given the following information ahead of time:
Patient History
Patient: Mr. Joshua Rivera
Age: 59 years
Allergies: Morphine
Social history: Spanish is the preferred language for speaking, reading, and writing (speaks English).
Medical history: Hypertension, perforated appendix, 12 hours postop: appendectomy
109Health Assessment Results
Students must examine the patient to obtain the following results:
(Oriented to person, place, and time)
Vital signs: BP: 144/94 mmHg, P: 98 beats/minute, RR: 20 breaths/minute, T: 100.9°F; pulse oximetry: 94%
Pain: Patient moaning and rates pain as “9” out of 10
Skin: Pink, moist, no evidence of edema
Heart sounds: Normal but pulse slightly elevated (98); peripheral pulses present
Lung sounds: Slightly diminished bilaterally in lower lobes
Bowel sounds: Hypoactive, abdomen soft
Wound: Dressing in place to right lower quadrant, small amount of yellow pus-like drainage, Penrose drain inserted into 3-inch wound
IV site: D5NS running at 75 mL/hr; site intact in left arm, no redness or swelling present
Intake postoperatively: 1,180 (includes 120 mL of water and 60 mL Jello and 1,000 mL of IV fluid); output postoperatively: 650 mL urine via urinary catheter
Medication Record and Laboratory Results
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