1. CORE CASE 1Introduction:In Simulation Laboratory, we are attempting to set the stage and integrate technology inyour learning experience Much time and effort is being spent on creating an environmentas real as possible, with electronic charts, equipment, and experiences as close to a trueclinical environment as possible, and have a simulator, we called ALEX (Adult LearningEducational Experience), to respond like a true patient.Our ALEX, patient simulator, can talk, breathe, have a heartbeat, bowel sounds, and canhave all physiologic functions vary depending on the patient’s age and condition.Your roles are generally to follow the nursing process of assessment, diagnosis, planning,intervening, and evaluation of care for a patient in a short time frame. Each scenario has apatient introduction, contact with the patient, and then time to debrief about the care.Core Case Scenario: Acute upper GI Bleed part 1Estimated scenario time: 25 minutesDebriefing time: 20 minutesLesson Overview:The scenario takes place at a free community clinic. A team of 4 learners will be given apatient presenting acute upper GI bleed symptoms. Learners will be expected to obtainhealth information, perform relevant assessment, provide standard of care related topatient safety and infection control, and communicate effectively.Target learners:Nursing students who have learned how to obtain health information, vital signs, andperform basic physical examination.Learning objectives:1. Implements therapeutic communication2. Implements patient safety measures3. Identifies the primary nursing diagnosis4. Demonstrates focus physical examination5. Applies shared logical methods – making observations, inferences, andpredictionsScenario learning objectives:1. Demonstrates how to communicate and obtain health information from an ESLpatient.2. Develops critical thinking to obtain relevant assessment information includingvital signs and patient medical history.3. Demonstrates focus physical examination.4. Recognizes signs and symptoms and predisposing factors of acute upper GI bleed.5. Develops nursing diagnosis.Complexity – Core Case to Complex Case:This scenario will adapt to different levels of learners. The Core Case allows learners tobuild confidence and practice basic nursing skills and identify signs/symptoms of anacute upper GI bleed.
2. CORE CASE 2The Complex Case is for learners who have learned to insert large-bore IV, nasogastricdrainage, and urinary catheter, obtain blood sample, and administer fluid bolus.Suggestion for role assignment:Mr. Wong (high-fidelity patient simulator), Mrs. Wong (student), RN (the primarylearner), and triage nurse (student), and a patient care assistant (student).Required equipment:Universal precaution equipmentStethoscopeBP cuffThermometerPulse oxymetryTrash canEmesis basinTissuesTelephoneSigns for patient simulator describing facial expression during different phase of thescenarioTechnology resources:High-fidelity patient simulatorElectronic medical record softwareAccommodationsA student with disabilities may present validation of his/her disability and requestservices by contacting the Student ADA Coordinator at (xxx) xxx-xxxx. It is thestudent’s responsibility to request accommodations each semester/term. To requestacademic accommodations, students are required to complete the application processbefore or at the beginning of each term. Please refer to the university’s ADAaccommodations policy and procedure in your student handbook.To accommodate students with disabilities, the role play assignment may be adjustedsubject to reasonable accommodation and/or assistive technology/devices such asheadphones/speaker and installing Dragon speech recognition software and/or MAGic ®Screen Magnification softwareProcedure:1. Introduce Who is Who in the Simulation?You will be assigned to a role during your experience at SON free clinic. Thefollowing are the most common roles in the scenarios.1. Charge NurseYou are responsible for overall organization of safe, quality patient care delivery onyour unit. You are a resource to all staff members and are responsible for appropriatestaff assignments and delegation of duties. You are knowledgeable about all patientson your unit including condition status, scheduled procedures, treatments and requiredfacility policy and procedure that may impact your decisions. You may serve as thegate-keeper to facilitate communication and delivery of safe, efficient, and appropriate
3. CORE CASE 3care. You provide leadership and guidance for the health care team members workingwith you and you take care of your staff as well as your patients.2. Primary and Collaborative NursesYou are responsible for planning and overseeing implementation of safe, quality,patient care for those patients assigned to you and the staff assigned to assist you inthat implementation. You communicate significant patient events and any relatedissues to your charge nurse. You provide guidance and leadership to the health careteam members working with you in your assigned area.3. Recorder/ObserverYou are a primary care giver to an assigned group of patients, however you provideassistance to other nurses when the situation arises. For the purpose of this sim lab,you will primarily be responsible for recording patient event activities. You will chartassessments, interventions, and outcomes on the appropriate documentation tool. Youwill perform other duties as requested by the charge nurse or primary nurse.4. Support MembersThis is a versatile role, governed by the individual scenario. You may be a physician,radiology technologist, respiratory therapist, nursing assistant, spouse, friend, labtechnician, nursing student, volunteer, EMT, whatever! Be prepared to “walk” in thatperson’s shoes as you depict this role.5. Special GuestsAlthough the preparation materials will script out the scenario, be prepared foranything! You never know when a faculty member may make a special guestappearance in a role you were not anticipating.2. Introduce phase in simulationPhase ActivitiesFraming  NOS elements introduction: Shared methods – differenceamong observation, inference, and prediction Scenario introductionActivating  Shift report/patient report Scenario progression (cues are provided if needed)
4. CORE CASE 4Debriefing  Guided reflection questions:What were your primary nursing diagnoses in the scenario?What nursing interventions did you use?What outcomes did you measure?Where is your patient in terms of these outcomes now?What did you do well in the scenario?If you were able to do this again, what would you dodifferently? Socratic questioning approach1. What information including patient interview and physicalexamination would you consider as subjective and objectivedata?2. How would you use the information you have gathered?3. What do you use to make inferences and predictions?4. How do inferences and predictions help in a clinicalsituation?3. Assign student roles4. Discuss assessment method Lassater Clinical Judgment Rubric5. Present the case scenarioCore Case ScenarioInitial presentation:A middle aged male comes to a free community clinic accompanied by his wife.He appears anxious and does not feel well. He says to the triage nurse that he’s beennauseous for the past day or so, has an upset stomach, and darker colored stools for thesepast few days.Anticipated actions: Learners will obtain recent health history, vital signs, and performbasic physical assessment pertaining to abdominal discomfort.Patient’s information:Mr. Wong, 60 years old, Chinese male, married, has been out of job for 6 months, and noinsurance. Previous occupation is a cook at Chinese restaurant. Primary language isMandarin. He reads, writes, and speaks simple English. His highest education is 3rdgrade. He has no siblings and no children. His weigh is 60 kg and is 165 cm tall.He smokes 1 pack per day, is a social drinker, and is active but no regular exercise.Patient’s recent health history:Mr. Wong claims overall in good health with no significant health problems and fairlyactive. He has not had travel history recently and has not eaten at any place unusual. Heconfirmed feeling nauseated for couple days with occasional heartburn with spicy foods.He slipped on some ice when shoveling snow recently and twisted his right knee, but hefeels a little bit better now. He can walk around fine.He has no known allergy except for lactose intolerance.Patient’s past medical history:
5. CORE CASE 5No surgeries, his wife adds that he had chest pain a few months ago and the doctor placeda stent in LCA. He also thinks he had an ulcer a couple years ago from stress.He denies having hypertension, diabetes, and COPD.He was diagnosed with hyperlipidemia a few years ago, but he has never taken anymedication for it.Patient’s family history:Father: CADMother: DM type 2Patient’s vital sign:BP: 140/90 mmHgHR: 90 bpmRR: 24 rpmBasic physical assessment:Heart sound: regular clear no murmurLungs sound: clear no wheezes, no cracklesAbdomen: bowel sounds hyperactive in all 4 quadrants,slightly tender to palpation in all quadrantsThe rest of exam is normalProgression 1:Five minutes after the physical examination, Mr. Wong vomits a large amount of brightred blood emesis, feels worse and is weak. He becomes pale and clammy. Both Mr. andMrs. Wong are very anxious.Anticipated actions: Learners will have patient lie supine, recheck vital signs, and requestfurther staff assistance (call a physician). Learners will address patient and spouseworries and demonstrate therapeutic communication.Patient’s vital sign:BP: 120/80 mmHgHR: 120 bpmRR: 24 rpmProgression 2:After five minutes, Mr. Wong still feels lightheaded, woozy and vomits another largeamount of bright red blood emesis. His vital signs are BP 100/60 mmHg, HR 130 bpm,and RR 26 rpm.Anticipated actions: Learners will arrange for ER transport and give a report to ER staff.Scenario progression outline:Approx.TimeMonitorSettingsPatient/MannequinActionsExpectedInterventionsCue/Prompt5 min none looks anxious, introduce self, start Role member
6. CORE CASE 6alert & oriented;speech clear, softvoice, & slow torespondinterview, identifya ESL patient &low educationlevel; speak clear,simple English atslower paceproviding cue:spouseCue: if the learnerfails to adjustpatient’s languageneeds, the spousewill request thelearner to repeatthe question10 min Baseline:BP 140/90, HR90, RR 24,T 37.5 Celsiusreg,clear,○mclear,nowheezes, no crackleshyperactive,tendershows compliancestates tender toabdomen palpationwash hands, obtaina set of VS,perform focusphysical examRole memberproviding cue:spouseCue: if the learnerfails to performfocus physicalexam, the spousewill ask about thesound of hishusband stomach5 min Aftervomiting:BP 120/80, HR 120,RR 24, T 38 CelsiusVocal sound:Vomitingpale & clammylie patient supine,recheck VS, callfor help, addresspatient & spouseworriesRole memberproviding cue:spouseCue: if the learnerfails to recheckVS, the spousewill ask how’s thepatient’s HR, BP,RR5 min Aftervomiting:BP100/60, HR130, RR 26,T 39.5 CelsiusVocal sound:Vomitingwoozy &lightheadedarrange ERtransport & callER staff to givereportRole memberproviding cue:other clinic staffCue: if the learnerfails to transferpatient to ER, theother staff will askwhether or not thesituation is undercontrol or need tocall an ambulanceDebriefing questions:Assessing learners’ perception:What are the patient’s vitals?What is the patient’s presenting history?Assessing learners’ comprehension:What is the most likely patient’s medical diagnosis?
7. CORE CASE 7What is the nursing diagnosis for this patient?What is most concerning to learners about this patient’s situation?Assessing learners’ projection:What factors place the patient at higher risk for adverse outcomes?What is likely to happen in the next few minutes?What is the anticipated nursing intervention on the patient’s arrival at ER?Assessing learner’s critical thinking skills:What information including patient interview and physical examination would youconsider as subjective and objective data?How would you use the information you have gathered?What do you use to make inferences and predictions?How do inferences and predictions help in a clinical situation?Note: If the clinic has IV starting kits, learners should be able to initiate starting at least1x large-bore IV access before sending the patient to ER.Wrap-up evaluation:What do you feel went well?What could have been done better?How could we make this scenario a better learning experience in the future?Proposed correct nursing procedure:Wash handsIntroduce selfIdentify the patientObtain BP, pulse, RR, temperature including orthostatic vital signsPosition/comfort patientAuscultate heart, lungs, & bowel soundsSupport patient/familyCall for helpSigns & Symptoms of upper GI bleed:Bright red blood or coffee ground emesisMelena (black, tarry stools)Decreased B/PVertigoDrop in Hct, HgbConfusionSyncopeOrthostatic VS.Predisposing factors of upper GI bleed:Medication e.g. NSAIDsPrior history of GI diseaseEsophageal variciesEsophagitis
8. CORE CASE 8PUDGastritisCarcinomaSuggested nursing diagnosis: Fluid volume deficit related to acute loss of blood, as well as gastric secretions Ineffective tissue perfusion related to loss of circulatory volume Anxiety related to upper GI bleeding, uncertain outcome, and source of bleeding Risk for aspiration related to active bleeding and altered level of consciousness
9. CORE CASE 9ReferencesCayley, W. (n.d.) HPS acute GI bleed. Retrieved fromwww.fmdrl.org/index.cfm?event=c.getAttachment&riid=1177Health Canada. (2005). Chapter 5: Gastrointestinal system. In Clinical practice guidelinesfor nurses in primary care. Retrieved from http://www.hc-sc.gc.ca/fniah-spnia/pubs/services/_nursing-infirm/2000_clin-guide/chap_05d-eng.phpKrumberger, J. (2005). How to manage an acute upper GI bleed. RN, 68(3). Retrievedfrom CINAHL with Full Text database (AN 2005072688).Lasater, K. (2007). Clinical judgment development: Using simulation to create anassessment rubric. Journal of Nursing Education, 46(11), 496-503.Lewis, S.L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P.G., & Bucher, L. (2007).Medical-surgical nursing: Assessment and management of clinical problems. St.Louis, Missouri: Mosby Elsevier.