399CHAPTER 34
Primary Care Patients With Gastrointestinal Problems: Graduate Program Advanced Physiology and Pathophysiology
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
This three-credit course is mandatory for all graduates of accredited master’s programs in nursing. It is commonly referred to as one of the “three Ps” (physical assessment, physiology and pathophysiology, and pharmacology). The course combines theory and case study analyses across the life span and in all health care delivery settings. It is a prerequisite for any of the specialty track courses for nurse practitioners (NPs), midwives, and nurse anesthetists.
The course focuses on the physiological processes central to biophysical and psychopathologic alterations of function across the life span. Analysis of physiologic responses and implications of the genome model to illness are included. Interpretation of laboratory data for patient management of acute and chronic disease is discussed. Students analyze case studies of hospitalized and primary care patient scenarios.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
This simulation experience can be made to fit any type of community health center clinic, hospital emergency department (ED), private practice, long-term subacute facility, or even the home setting. It is important that there are enough students and/or faculty to take the NP, family member(s), and physician roles so there can be a collaborative discussion as well as health teaching with the family members. Using the primary care clinic area of the Learning Resource Center at the Fairfield University School of Nursing makes it easy to carry out the scenarios because an examination table, four primary care curtained-off “rooms,” electronic documentation, and mobile vital signs (VS) devices are already set up. The high-fidelity human patient simulator (HPS) is handled by the teaching assistant, who is able to run the controls and software. This handler has already been apprised by the faculty of the appropriate settings for the HPS.
400C. SPECIFIC OBJECTIVES OF SIMULATION USAGE WITHIN ADVANCED PHYSIOLOGY AND PATHOPHYSIOLOGY
General Learning Objectives
The overall objectives are for students to gain increased knowledge, pathophysiology rationale for signs and symptoms, clinical reasoning, and some basic clinical skills for a primary care patient. The goals for this complex scenario are for students to be successful in identifying three differential diagnoses and the pathophysiology rationale for each diagnosis.
Student Learning Activities
Students need to be knowledgeable about the risk factors for colon cancer, signs and symptoms, and the pathophysiology of adenocarcinomas. Students need to review the pathophysiology of colon cancer and physiology of the intestines and be able to successfully accomplish the simulation goals.
D. INTRODUCTION OF SCENARIO
Setting the Scene
The following is the scene for students working with this beginning advanced-practice patient with gastrointestinal (GI) complaints:
Background: Mr. Luiz is a 73-year-old Hispanic U.S. citizen from Puerto Rico, who has been one of your patients for the last 3 years. His English is good, although he often speaks quickly in Spanish. He generally comes to the clinic on a bus with his wife. His chief complaint today is abdominal tenderness and distention and a change in bowel habits. He presents with fatigue, anorexia, and blood in his stool, which he says has been going on at least 3 months.
He has been your patient at the Bridgeley Community Health Center and has been in good health. He was adopted and has no known family history and no known drug allergies. In Puerto Rico, he never had much health care and definitely no prevention. His last visit was approximately 1 year ago for his annual physical examination, which was within normal limits. He has a history of benign prostate hyperplasia (BPH) and takes no over-the-counter (OTC) medication. He takes no prescription drugs and does not have any history of street drug or ethanol use. He has Medicare with some supplemental insurance.
Technology Used
Settings for HPS
Settings will remain the same throughout the scenario:
• Pulse oximetry ranging from 92% to 94% over 5 minutes
• Pulse increased from baseline of 70 beats/minute from last visit to 84 beats/minute
• Blood pressure (BP) increased from baseline of last visit of 120/70 mmHg to 150/80 mmHg
• Respiratory rate (RR) ranging from 18 to 24 breaths/minute
• Patient complains of chills and slight sweating, temperature = 100°F
• Patient exhibits no shortness of breath at rest, has tenderness over maxillary and facial sinuses, nasal secretions of thick yellow mucus, nasal congestion hence a nasal voice, nonproductive cough, and postnasal drip
• Lungs are clear
• No pretibial swelling palpated or other signs of heart failure
401Objectives
After completing the scenario simulation exercise the students will be able to:
1. Demonstrate knowledge of obtaining patient history
2. Demonstrate cultural awareness in caring for patient and family
3. Demonstrate appropriate communication with patient/family
4. Demonstrate timely and effective assessment of patient’s signs and symptoms
5. Identify the three differential diagnoses given this patient’s presentation and history
6. Describe the pathology of colon cancer
Description of Participant Roles
Student NP: One student is the NP assigned to work with this patient
Mr. Luiz: A high-fidelity HPS programmed with gastrointestinal (GI) symptoms spoken by the teaching assistant or faculty member
Physician: One student role-plays the physician who is called for a consultation
Mrs. Luiz: One student role-plays the wife
Observer: One student is assigned to document the entire scenario in order to share with the class
Teaching assistant/faculty member: Runs the simulator from the control room
E. RUNNING OF THE SCENARIO
Students have read the required reading on GI disease, had class with discussion regarding this same topic, and have completed the study guide questions regarding GI problems. The students have already had a class on neoplasia earlier in this course. All of the students have also had an opportunity to practice in the Learning Resource Center if they desire. Some students may have already had the advanced assessment course and thus will be familiar with working with the monitor and examination table.
The equipment set up on a bedside table consists of a stethoscope, oximeter, intravenous (IV) and blood-drawing equipment, gloves, K-Y lubricating jelly, guaiac cards, and an anoscope. The patient is sitting up on the examination table at a 60º angle and does not seem to be in pain.
The scenario is planned for 15 minutes and the students have practiced themselves and had an actual run-through of the scenario before presenting it to their classmates independent of the faculty.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Primary Care Patient With Gastrointestinal Problems
Scenario Level
Graduate nursing students in a graduate nursing program studying advanced practice
Focus Area
Pathophysiology, diagnosis workup
402Scenario Description
Students participate in this scenario for experience in obtaining data from the patient and family, records, and patient assessment in order to work up the patient’s diagnosis of colon cancer and to identify the etiology of the signs and symptoms obtained (the three differential diagnoses are early-stage colon cancer, benign polyps, and late-stage colon cancer with systemic lymphatic spread and liver metastasis). The scenario takes place in a simulated primary care clinic.
Patient history: Mr. Luiz’s chief complaint today is abdominal tenderness and distention and a change in bowel habits. He presents with fatigue, anorexia, and blood in his stool, which he says has been going on at least 3 months. His last visit was approximately 1 year ago for his annual physical examination, which was within normal limits. He has a history of BPH only and takes no OTC or prescription medication.
Health assessment results: Skin assessment shows poor skin turgor and dry oral mucous membranes. Abdominal assessment reveals increased bowel sounds, abdominal distention with wide abdominal girth, mild tenderness with palpation but only mild tenderness over liver with percussion and palpation, enlarged liver span, no splenomegaly. Rectal examination shows loose stool palpated with some discomfort and overt blood noted. No other significant findings.
Medication record: No medications.
SCENARIO OBJECTIVES
Objectives Based on Master of Science in Nursing Essentials
The American Association of Colleges of Nursing (2011) has created nine master’s-level Essentials that are used as a guide to developing curriculum for graduate nursing programs. The Essentials addressed in this simulation by objective are:
Essential I: Background for Practice From Sciences and Humanities
Essential III: Quality Improvement and Safety
Essential IV: Translating and Integrating Scholarship Into Practice
Essential V: Informatics and Health Care Technologies
Essential VIII: Clinical Prevention and Population Health for Improving Health
Essential IX: Master’s-Level Nursing Practice
Setting the Scene
Equipment Needed
HPS to be the patient, primary care unit in the simulated geriatric clinic, BP cuff and stethoscope, oximeter, alcohol wipes, gloves, anoscope, IV and blood-drawing equipment, and electronic record
Resources Needed
Pathophysiology textbook, patient record, participant’s script
Simulator Level
Mid- to high-fidelity HPS
Participant Roles
Student NPs to play NP, physician, and wife role; an HPS, and a person to run and/or observe the scenario. We have recently been using undergraduate students majoring in theater to play the various roles—including the patient—and this has been extremely successful (Fletcher, Justice, & Rohrig, 2015).
403NP Script
NP: Hello, Mr. Luiz. How are you feeling?
Mr. L: Not so good, I’m having “fullness in my stomach,” no appetite, feel really tired and have no energy. I have been sleeping almost every day approximately 14 hours, and the rest of the time I am going to the bathroom.
Mrs. L: He also has been bleeding down there and leaves a “very stinky” smell in the bathroom.
Mr. L: The bleeding is worse now.
NP: When did you notice the bleeding? [NP tests for hydration and finds poor skin turgor, dry oral mucous membranes, within normal limits (WNL) level of consciousness, no confusion].
Mr. L: It started approximately 3 months ago and I thought it would go away, like a hemorrhoid or something.
Mrs. L: I told him to come see you as soon as he saw the blood. It is a very bad sign, isn’t it?
NP: Well, I need to examine you, so can you step out for a minute Mrs. L?
Mr. L: I have to go about eight times a day and it is loose now, with blood every time.
NP: [While doing exam]: Do you have any abdominal pain? Have you ever had a test where they look with a tube through your rectum into your bowels—this is called a colonoscopy?
Mr. L: No, not really; it just is tender when you are touching it just about everywhere, no tests like that were ever done.
NP: [Abdominal assessment reveals increased bowel sounds, abdominal distention with wide abdominal girth, mild tenderness with palpation but only mild tenderness over liver with percussion and palpation, enlarged liver span, no splenomegaly.] Can you please turn over so I can do a rectal exam? [Loose stool palpated with some discomfort and overt blood noted.]
NP: Let me recheck your blood pressure—it is about the same as when the tech took it: 90/60 mmHg, pulse is 119 beats/minute, respiratory rate is 18 breaths/minute, temperature is 98.8°F, and your weight is 20 pounds less than at your last visit 1 year ago. I am going to have you lie down and start an IV and ask your wife to come back in. [Asks tech to call ambulance.]
Mrs. L: So, what is wrong? It is cancer, isn’t it? I knew he had cancer—he smells like cancer. What is happening, Paul? You look so white in your face.
NP: I am going to admit you to Barry Hospital now and start an IV since you are dizzy and seem to be dehydrated from all the rectal bleeding.
Mr. L: I think I should not go by bus—I feel so dizzy. And my wife does not drive.
Mrs. L: We are going by ambulance, aren’t we?
NP: Yes, and I want you to call someone to come down and be with you … why don’t you do that now while I draw some bloods and get the IV in.
(NP starts an IV normal saline [NS] @ 150/hr in right antecubital vein [AC]. Blood drawn and sent stat [immediately] to Barry Hospital lab for chemical profile, complete blood count [CBC] with differential, amylase, lipase, transanimases. Writes up short summary for Mr. L’s case and arranges transfer to ED via ambulance.)
The next day, the NP gets a report showing multiple tumors in the ascending and descending bowel approximately 3 to 1.5 cm, so Mr. Luiz is scheduled for surgery.
The following day, the surgical report indicates complete large bowel removal and rectum with ileostomy, liver metastasis.
Scenario Implementation
Initial Settings for HPS/Equipment
If the clinical laboratory does not have a primary care clinic area, one can develop a one-patient unit with an examination table. Two other ways to teach this material would be to have the faculty give a demonstration in class of the simulation or show a digital video recording (DVR) of the simulation performed by other students to the entire class. If possible a box of gloves; anoscope; IV and blood-drawing equipment module; and a mobile BP, temperature, oximeter, otoscope, and ophthalmoscope setup could be available.
404Expected Student Assessments and Actions
This advanced pathophysiology course may be the first course a master’s student takes at the graduate level. More than likely, at least half of the students in the class have probably had simulation experience as an undergraduate or continuing-education student or from their employer. Students may feel more comfortable having some hands-on experience in simulation working with a high-fidelity simulator (HFS) than just having lecture and discussion classes for this course. Introducing the patient to working up a diagnosis should assist the student in seeing the importance of having a strong pathophysiology base. Ebbert and Connors (2004) found that graduate students perceived simulation learning as a realistic, challenging, and positive experience that greatly influenced their education. Students will have had multiple case study analyses in the course, so participating in a few simulations toward the middle to end of the course develops their confidence. Students involved in the actual simulation should assist in creating a script. Next, they should have a rehearsal with the faculty member, who should assist them in polishing the script. After the designated time, they should accomplish the scenario objectives, be able to self-critique their performance, receive constructive feedback from the class, and identify their strengths and weak areas.
Instructor Interventions
The faculty member needs to develop the objectives for the learning experience and share the case with the students. The background information given, along with the objectives for the student learning, is then molded into a script. It is up to the students to practice and perfect the scenario and then obtain feedback from the faculty member. More practice is suggested until the students feel comfortable and confident to perform the script independently for the 15-minute time frame in front of their classmates. The faculty member needs to keep the students to the time frame by holding up cards notifying them of the time still left. The debriefing session is held with the whole class and the faculty member leads the discussion, being sure to evaluate the students’ performance and answer questions that may come up. Based on the objectives for this scenario, the following evaluative criteria need to be measured.
Evaluative Criteria
___Reviews patient’s chief complaint and VS
___Begins diagnostic reasoning
___Checks electronic record for most recent lab reports and finds they are from 1 year ago
___Begins plan for next 10 minutes with priorities
___Performs hand hygiene
___Introduces self to patient/wife
___Communicates clearly with patient/wife
___Demonstrates professional dress/behavior
___Assesses patient’s status regarding hydration level given low BP
___Interprets VS and poor turgor
___Performs a focal assessment regarding GI and cardiovascular (CV) systems, does rectal examination
___Asks pertinent questions about the last few months with regard to the signs and symptoms obtained, determines this patient probably has colorectal cancer at a late stage
___Puts in IV and starts fluid resuscitation, explaining to patient and wife that Mr. Luiz needs to be brought to the ED to have a colonoscopy
___Has medical technologist stay with patient and redo VS and obtain blood specimens (CBC with differential, chem profile with blood sent to hospital lab so reports will be ready once patient is worked up at hospital)
___Tells tech to call ambulance and notify ED of patient’s status and expected arrival time
___Explains information to patient/wife, tells wife to call friend or family member to meet them there
___Documents on electronic record for health care workers at hospital (has appropriate differentials along with all supporting data).
405G. DEBRIEFING GUIDELINES
Issues to Consider
Students need to receive immediate feedback after each simulated scenario. As long as the scenario was developed using sound objectives, the students are prepared and studied diligently, and there were measurable evaluative criteria, debriefing is very matter of fact. Generally, it is a good idea to ask the participants to give their own self-evaluation using the recorder’s notes so they can stay organized.
Student Questions
Next, it is important to obtain the classmates’ feedback. Be sure that the classmates are aware they need to prepare for this scenario just like they were going to be participating in it. In this way they can be more a part of the evaluation process. Once the students realize they are going to be called on either by the faculty member or the scenario participants for feedback, or asked a question regarding the case, they will prepare thoroughly.
Classroom Questions
Some questions that may assist the discussion among the class in getting started are listed as follows:
1. What focal assessments were done, and why?
2. What were your differentials besides colon cancer?
3. What were your rationales for your differentials?
4. Describe the pathophysiology of Mr. Luiz’s problem.
5. What were your rationales for ordering the labs, and what do you think the lab results were?
Senior students generally have no difficulty discussing and sharing their ideas in the debriefing session. The faculty member should limit the time for the debriefing to no more than 30 minutes and, if students are not asking appropriate questions, should steer the discussion toward the evaluative criteria.
H. SUGGESTIONS/KEY FEATURES TO REPLICATE OR IMPROVE
This scenario is focused on gaining experience with analyzing patients’ differential diagnoses and explaining the etiology for each diagnosis. In identifying patient signs and symptoms to determine three differential diagnoses, the students gain much confidence in their reasoning skills. Also, the case provides some application of assessment skills for students to collect data regarding this patient’s GI complaints.
I. RECOMMENDATIONS FOR FURTHER USE
Ultimately, each pathophysiology class may include a similar simulation of a diagnostic workup. Future cases could be modeled after this one but with a chief complaint of a specific system. Currently, the students develop individual case studies depicting diagnostic reasoning for the development of three differential diagnoses. Small groups of students could pick one case to use as a simulation and receive a group grade for this. More complex cases could be developed in sequential courses whereby the students who worked a specific simulation, such as that of Mr. Luiz in advanced physiology and pathophysiology, encounter him again in their first specialty 406track course and add a follow-up of how the patient did postoperatively and the management needed for his care. It is imperative during debriefing that faculty and the involved students have a chance to review their simulation immediately after performing the simulation. In my experience, I have found this to greatly assist the students who were in the simulation to participate fully in the general debriefing with the rest of the class.
Graduate students seem to enjoy simulation (Chikotas, 2008; Harris, Shoemaker, Johnson, Tompkins-Dobbs, & Domian, 2016). The general consensus is that most students feel it is important to practice and bridges the gap between theory and clinical practice. Even though this advanced pathophysiology course is one of the seven core graduate courses that everyone must take, all graduate students, from NPs to nurse anesthetists, rank this course as extremely important. Being able to practice diagnostic reasoning, critical thinking, and working up differential diagnoses are skills that come with knowledge and practice. Therefore, simulation pedagogy allows the student to get a glimpse of what this pedagogy is and, at our institution, allows them the opportunity to practice in a simulated primary care clinic. After getting acclimated to the HFS, students can book time in the simulated clinic to practice their skills as well as time management and interviewing. In fact, students can arrange time to videotape and self-critique their performances. Administrators need to allow funding for necessary resources so these invaluable experiences can happen. Student learning outcomes, as well as their self-perceived confidence in adapting to their new advanced practice role, should improve.
J. HOW SIMULATION-BASED PEDAGOGY HAS CONTRIBUTED TO IMPROVED STUDENT OUTCOMES
Graduate students, with little to much clinical experience as an RN, have shared with the faculty that they enjoy and gain much knowledge and clinical competency from the use of simulation in the NP courses. For example, students in the advanced pathophysiology course have improved their laboratory scores on quizzes and examinations since doing simulation in this course. Most of the students request more simulations, even if they are just group simulations in class. Their rationale is that the process of analyzing the cases, that is (a) identifying three differentials for each patient, (b) describing pertinent pathophysiology for each differential, and (c) discussing specific genetics for each differential assists them in remembering the content they are learning. Preliminary evaluation of student’s knowledge retention of this content in the family NP track courses points to improved learning outcomes and less time needed to be spent reviewing laboratory values for the majority of diagnoses that were applied to a simulation in the pathophysiology course.
K. EXPERT RECOMMENDATIONS AND WORDS OF WISDOM
It seems the more simulation that can be used for NP students, the more in depth the teaching and learning can become for the students. Not only does the student assist in creating the case scenario, but also seems to enjoy the “competitive edge” being experienced by all of the students. Everyone wants their case to be the most interesting and to provide “pearls of wisdom” to the class. This seems to motivate everyone to work harder and develop a very challenging scenario for the class. Of course, the faculty needs to review each simulation scenario and add or even, at times, correct content, and, of course, this is labor intensive. However, using simulated scenarios and the Socratic method of questioning has resulted in higher grades on student quizzes and exams as well as, according to student evaluations, more confident, prepared students for clinical practica.
407L. EVALUATION OF BEST PRACTICE STANDARDS AND USE OF CREDENTIALED SIMULATION FACULTY
Many of the ah-ha moments and “Wow, I really get this now” statements are a result of a successful debriefing. The International Nursing Association for Clinical Simulation and Learning (INACSL, 2013/2016) developed the INACSL Standards of Best Practice: Simulation, which are very helpful when designing and revising simulations and can be accessed at www.inacsl.org/i4a/pages/index.cfm?pageid=3407. For example, Standard VI: Debriefing Process, explains various techniques on how to best debrief nursing and other health care professionals after simulation (Chikotas, 2008).
At our school of nursing, some faculty are getting certified in simulation pedagogy and these faculty will serve on the school’s Innovative Simulation committee. Under the direction of our new director of simulation we are also integrating interprofessional simulated scenarios into many undergraduate and graduate courses.
REFERENCES
American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf
International Nursing Association for Clinical Simulation and Learning. (2013, updated 2016). INACSL standards of best practice: Simulation. Retrieved from: http://www.inacsl.org/i4a/pages/index.cfm?pageid=3407
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