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CORE CASE 1
Introduction:
In Simulation Laboratory, we are attempting to set the stage and integrate technology in
your learning experience Much time and effort is being spent on creating an environment
as real as possible, with electronic charts, equipment, and experiences as close to a true
clinical environment as possible, and have a simulator, we called ALEX (Adult Learning
Educational Experience), to respond like a true patient.
Our ALEX, patient simulator, can talk, breathe, have a heartbeat, bowel sounds, and can
have 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 a
patient introduction, contact with the patient, and then time to debrief about the care.
Core Case Scenario: Acute upper GI Bleed part 1
Estimated scenario time: 25 minutes
Debriefing time: 20 minutes
Lesson Overview:
The scenario takes place at a free community clinic. A team of 4 learners will be given a
patient presenting acute upper GI bleed symptoms. Learners will be expected to obtain
health information, perform relevant assessment, provide standard of care related to
patient safety and infection control, and communicate effectively.
Target learners:
Nursing students who have learned how to obtain health information, vital signs, and
perform basic physical examination.
Learning objectives:
1. Implements therapeutic communication
2. Implements patient safety measures
3. Identifies the primary nursing diagnosis
4. Demonstrates focus physical examination
5. Applies shared logical methods – making observations, inferences, and
predictions
Scenario learning objectives:
1. Demonstrates how to communicate and obtain health information from an ESL
patient.
2. Develops critical thinking to obtain relevant assessment information including
vital 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 to
build confidence and practice basic nursing skills and identify signs/symptoms of an
acute upper GI bleed.
CORE CASE 2
The Complex Case is for learners who have learned to insert large-bore IV, nasogastric
drainage, 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 primary
learner), and triage nurse (student), and a patient care assistant (student).
Required equipment:
Universal precaution equipment
Stethoscope
BP cuff
Thermometer
Pulse oxymetry
Trash can
Emesis basin
Tissues
Telephone
Signs for patient simulator describing facial expression during different phase of the
scenario
Technology resources:
High-fidelity patient simulator
Electronic medical record software
Accommodations
A student with disabilities may present validation of his/her disability and request
services by contacting the Student ADA Coordinator at (xxx) xxx-xxxx. It is the
student’s responsibility to request accommodations each semester/term. To request
academic accommodations, students are required to complete the application process
before or at the beginning of each term. Please refer to the university’s ADA
accommodations policy and procedure in your student handbook.
To accommodate students with disabilities, the role play assignment may be adjusted
subject to reasonable accommodation and/or assistive technology/devices such as
headphones/speaker and installing Dragon speech recognition software and/or MAGic ®
Screen Magnification software
Procedure:
1. Introduce Who is Who in the Simulation?
You will be assigned to a role during your experience at SON free clinic. The
following are the most common roles in the scenarios.
1. Charge Nurse
You are responsible for overall organization of safe, quality patient care delivery on
your unit. You are a resource to all staff members and are responsible for appropriate
staff assignments and delegation of duties. You are knowledgeable about all patients
on your unit including condition status, scheduled procedures, treatments and required
facility policy and procedure that may impact your decisions. You may serve as the
gate-keeper to facilitate communication and delivery of safe, efficient, and appropriate
CORE CASE 3
care. You provide leadership and guidance for the health care team members working
with you and you take care of your staff as well as your patients.
2. Primary and Collaborative Nurses
You 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 in
that implementation. You communicate significant patient events and any related
issues to your charge nurse. You provide guidance and leadership to the health care
team members working with you in your assigned area.
3. Recorder/Observer
You are a primary care giver to an assigned group of patients, however you provide
assistance 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 chart
assessments, interventions, and outcomes on the appropriate documentation tool. You
will perform other duties as requested by the charge nurse or primary nurse.
4. Support Members
This is a versatile role, governed by the individual scenario. You may be a physician,
radiology technologist, respiratory therapist, nursing assistant, spouse, friend, lab
technician, nursing student, volunteer, EMT, whatever! Be prepared to “walk” in that
person’s shoes as you depict this role.
5. Special Guests
Although the preparation materials will script out the scenario, be prepared for
anything! You never know when a faculty member may make a special guest
appearance in a role you were not anticipating.
2. Introduce phase in simulation
Phase Activities
Framing  NOS elements introduction: Shared methods – difference
among observation, inference, and prediction
 Scenario introduction
Activating  Shift report/patient report
 Scenario progression (cues are provided if needed)
CORE CASE 4
Debriefing  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 do
differently?
 Socratic questioning approach
1. What information including patient interview and physical
examination would you consider as subjective and objective
data?
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 clinical
situation?
3. Assign student roles
4. Discuss assessment method Lassater Clinical Judgment Rubric
5. Present the case scenario
Core Case Scenario
Initial 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 been
nauseous for the past day or so, has an upset stomach, and darker colored stools for these
past few days.
Anticipated actions: Learners will obtain recent health history, vital signs, and perform
basic 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 no
insurance. Previous occupation is a cook at Chinese restaurant. Primary language is
Mandarin. He reads, writes, and speaks simple English. His highest education is 3rd
grade. 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 fairly
active. He has not had travel history recently and has not eaten at any place unusual. He
confirmed 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 he
feels a little bit better now. He can walk around fine.
He has no known allergy except for lactose intolerance.
Patient’s past medical history:
CORE CASE 5
No surgeries, his wife adds that he had chest pain a few months ago and the doctor placed
a 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 any
medication for it.
Patient’s family history:
Father: CAD
Mother: DM type 2
Patient’s vital sign:
BP: 140/90 mmHg
HR: 90 bpm
RR: 24 rpm
Basic physical assessment:
Heart sound: regular clear no murmur
Lungs sound: clear no wheezes, no crackles
Abdomen: bowel sounds hyperactive in all 4 quadrants,
slightly tender to palpation in all quadrants
The rest of exam is normal
Progression 1:
Five minutes after the physical examination, Mr. Wong vomits a large amount of bright
red blood emesis, feels worse and is weak. He becomes pale and clammy. Both Mr. and
Mrs. Wong are very anxious.
Anticipated actions: Learners will have patient lie supine, recheck vital signs, and request
further staff assistance (call a physician). Learners will address patient and spouse
worries and demonstrate therapeutic communication.
Patient’s vital sign:
BP: 120/80 mmHg
HR: 120 bpm
RR: 24 rpm
Progression 2:
After five minutes, Mr. Wong still feels lightheaded, woozy and vomits another large
amount 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.
Time
Monitor
Settings
Patient/Mannequin
Actions
Expected
Interventions
Cue/Prompt
5 min none looks anxious, introduce self, start Role member
CORE CASE 6
alert & oriented;
speech clear, soft
voice, & slow to
respond
interview, identify
a ESL patient &
low education
level; speak clear,
simple English at
slower pace
providing cue:
spouse
Cue: if the learner
fails to adjust
patient’s language
needs, the spouse
will request the
learner to repeat
the question
10 min Baseline:
BP 140/90, HR
90, RR 24,
T 37.5 Celsius
reg,clear,○m
clear,no
wheezes, no crackles
hyperactive,
tender
shows compliance
states tender to
abdomen palpation
wash hands, obtain
a set of VS,
perform focus
physical exam
Role member
providing cue:
spouse
Cue: if the learner
fails to perform
focus physical
exam, the spouse
will ask about the
sound of his
husband stomach
5 min After
vomiting:
BP 120/80, HR 120,
RR 24, T 38 Celsius
Vocal sound:
Vomiting
pale & clammy
lie patient supine,
recheck VS, call
for help, address
patient & spouse
worries
Role member
providing cue:
spouse
Cue: if the learner
fails to recheck
VS, the spouse
will ask how’s the
patient’s HR, BP,
RR
5 min After
vomiting:
BP100/60, HR
130, RR 26,
T 39.5 Celsius
Vocal sound:
Vomiting
woozy &
lightheaded
arrange ER
transport & call
ER staff to give
report
Role member
providing cue:
other clinic staff
Cue: if the learner
fails to transfer
patient to ER, the
other staff will ask
whether or not the
situation is under
control or need to
call an ambulance
Debriefing 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?
CORE CASE 7
What 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 you
consider 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 least
1x 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 hands
Introduce self
Identify the patient
Obtain BP, pulse, RR, temperature including orthostatic vital signs
Position/comfort patient
Auscultate heart, lungs, & bowel sounds
Support patient/family
Call for help
Signs & Symptoms of upper GI bleed:
Bright red blood or coffee ground emesis
Melena (black, tarry stools)
Decreased B/P
Vertigo
Drop in Hct, Hgb
Confusion
Syncope
Orthostatic VS.
Predisposing factors of upper GI bleed:
Medication e.g. NSAIDs
Prior history of GI disease
Esophageal varicies
Esophagitis
CORE CASE 8
PUD
Gastritis
Carcinoma
Suggested 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
CORE CASE 9
References
Cayley, W. (n.d.) HPS acute GI bleed. Retrieved from
www.fmdrl.org/index.cfm?event=c.getAttachment&riid=1177
Health Canada. (2005). Chapter 5: Gastrointestinal system. In Clinical practice guidelines
for nurses in primary care. Retrieved from http://www.hc-sc.gc.ca/fniah-
spnia/pubs/services/_nursing-infirm/2000_clin-guide/chap_05d-eng.php
Krumberger, J. (2005). How to manage an acute upper GI bleed. RN, 68(3). Retrieved
from CINAHL with Full Text database (AN 2005072688).
Lasater, K. (2007). Clinical judgment development: Using simulation to create an
assessment 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.

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Acute GI Bleed Sim Case

  • 1. CORE CASE 1 Introduction: In Simulation Laboratory, we are attempting to set the stage and integrate technology in your learning experience Much time and effort is being spent on creating an environment as real as possible, with electronic charts, equipment, and experiences as close to a true clinical environment as possible, and have a simulator, we called ALEX (Adult Learning Educational Experience), to respond like a true patient. Our ALEX, patient simulator, can talk, breathe, have a heartbeat, bowel sounds, and can have 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 a patient introduction, contact with the patient, and then time to debrief about the care. Core Case Scenario: Acute upper GI Bleed part 1 Estimated scenario time: 25 minutes Debriefing time: 20 minutes Lesson Overview: The scenario takes place at a free community clinic. A team of 4 learners will be given a patient presenting acute upper GI bleed symptoms. Learners will be expected to obtain health information, perform relevant assessment, provide standard of care related to patient safety and infection control, and communicate effectively. Target learners: Nursing students who have learned how to obtain health information, vital signs, and perform basic physical examination. Learning objectives: 1. Implements therapeutic communication 2. Implements patient safety measures 3. Identifies the primary nursing diagnosis 4. Demonstrates focus physical examination 5. Applies shared logical methods – making observations, inferences, and predictions Scenario learning objectives: 1. Demonstrates how to communicate and obtain health information from an ESL patient. 2. Develops critical thinking to obtain relevant assessment information including vital 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 to build confidence and practice basic nursing skills and identify signs/symptoms of an acute upper GI bleed.
  • 2. CORE CASE 2 The Complex Case is for learners who have learned to insert large-bore IV, nasogastric drainage, 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 primary learner), and triage nurse (student), and a patient care assistant (student). Required equipment: Universal precaution equipment Stethoscope BP cuff Thermometer Pulse oxymetry Trash can Emesis basin Tissues Telephone Signs for patient simulator describing facial expression during different phase of the scenario Technology resources: High-fidelity patient simulator Electronic medical record software Accommodations A student with disabilities may present validation of his/her disability and request services by contacting the Student ADA Coordinator at (xxx) xxx-xxxx. It is the student’s responsibility to request accommodations each semester/term. To request academic accommodations, students are required to complete the application process before or at the beginning of each term. Please refer to the university’s ADA accommodations policy and procedure in your student handbook. To accommodate students with disabilities, the role play assignment may be adjusted subject to reasonable accommodation and/or assistive technology/devices such as headphones/speaker and installing Dragon speech recognition software and/or MAGic ® Screen Magnification software Procedure: 1. Introduce Who is Who in the Simulation? You will be assigned to a role during your experience at SON free clinic. The following are the most common roles in the scenarios. 1. Charge Nurse You are responsible for overall organization of safe, quality patient care delivery on your unit. You are a resource to all staff members and are responsible for appropriate staff assignments and delegation of duties. You are knowledgeable about all patients on your unit including condition status, scheduled procedures, treatments and required facility policy and procedure that may impact your decisions. You may serve as the gate-keeper to facilitate communication and delivery of safe, efficient, and appropriate
  • 3. CORE CASE 3 care. You provide leadership and guidance for the health care team members working with you and you take care of your staff as well as your patients. 2. Primary and Collaborative Nurses You 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 in that implementation. You communicate significant patient events and any related issues to your charge nurse. You provide guidance and leadership to the health care team members working with you in your assigned area. 3. Recorder/Observer You are a primary care giver to an assigned group of patients, however you provide assistance 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 chart assessments, interventions, and outcomes on the appropriate documentation tool. You will perform other duties as requested by the charge nurse or primary nurse. 4. Support Members This is a versatile role, governed by the individual scenario. You may be a physician, radiology technologist, respiratory therapist, nursing assistant, spouse, friend, lab technician, nursing student, volunteer, EMT, whatever! Be prepared to “walk” in that person’s shoes as you depict this role. 5. Special Guests Although the preparation materials will script out the scenario, be prepared for anything! You never know when a faculty member may make a special guest appearance in a role you were not anticipating. 2. Introduce phase in simulation Phase Activities Framing  NOS elements introduction: Shared methods – difference among observation, inference, and prediction  Scenario introduction Activating  Shift report/patient report  Scenario progression (cues are provided if needed)
  • 4. CORE CASE 4 Debriefing  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 do differently?  Socratic questioning approach 1. What information including patient interview and physical examination would you consider as subjective and objective data? 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 clinical situation? 3. Assign student roles 4. Discuss assessment method Lassater Clinical Judgment Rubric 5. Present the case scenario Core Case Scenario Initial 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 been nauseous for the past day or so, has an upset stomach, and darker colored stools for these past few days. Anticipated actions: Learners will obtain recent health history, vital signs, and perform basic 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 no insurance. Previous occupation is a cook at Chinese restaurant. Primary language is Mandarin. He reads, writes, and speaks simple English. His highest education is 3rd grade. 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 fairly active. He has not had travel history recently and has not eaten at any place unusual. He confirmed 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 he feels 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 5 No surgeries, his wife adds that he had chest pain a few months ago and the doctor placed a 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 any medication for it. Patient’s family history: Father: CAD Mother: DM type 2 Patient’s vital sign: BP: 140/90 mmHg HR: 90 bpm RR: 24 rpm Basic physical assessment: Heart sound: regular clear no murmur Lungs sound: clear no wheezes, no crackles Abdomen: bowel sounds hyperactive in all 4 quadrants, slightly tender to palpation in all quadrants The rest of exam is normal Progression 1: Five minutes after the physical examination, Mr. Wong vomits a large amount of bright red blood emesis, feels worse and is weak. He becomes pale and clammy. Both Mr. and Mrs. Wong are very anxious. Anticipated actions: Learners will have patient lie supine, recheck vital signs, and request further staff assistance (call a physician). Learners will address patient and spouse worries and demonstrate therapeutic communication. Patient’s vital sign: BP: 120/80 mmHg HR: 120 bpm RR: 24 rpm Progression 2: After five minutes, Mr. Wong still feels lightheaded, woozy and vomits another large amount 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. Time Monitor Settings Patient/Mannequin Actions Expected Interventions Cue/Prompt 5 min none looks anxious, introduce self, start Role member
  • 6. CORE CASE 6 alert & oriented; speech clear, soft voice, & slow to respond interview, identify a ESL patient & low education level; speak clear, simple English at slower pace providing cue: spouse Cue: if the learner fails to adjust patient’s language needs, the spouse will request the learner to repeat the question 10 min Baseline: BP 140/90, HR 90, RR 24, T 37.5 Celsius reg,clear,○m clear,no wheezes, no crackles hyperactive, tender shows compliance states tender to abdomen palpation wash hands, obtain a set of VS, perform focus physical exam Role member providing cue: spouse Cue: if the learner fails to perform focus physical exam, the spouse will ask about the sound of his husband stomach 5 min After vomiting: BP 120/80, HR 120, RR 24, T 38 Celsius Vocal sound: Vomiting pale & clammy lie patient supine, recheck VS, call for help, address patient & spouse worries Role member providing cue: spouse Cue: if the learner fails to recheck VS, the spouse will ask how’s the patient’s HR, BP, RR 5 min After vomiting: BP100/60, HR 130, RR 26, T 39.5 Celsius Vocal sound: Vomiting woozy & lightheaded arrange ER transport & call ER staff to give report Role member providing cue: other clinic staff Cue: if the learner fails to transfer patient to ER, the other staff will ask whether or not the situation is under control or need to call an ambulance Debriefing 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 7 What 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 you consider 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 least 1x 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 hands Introduce self Identify the patient Obtain BP, pulse, RR, temperature including orthostatic vital signs Position/comfort patient Auscultate heart, lungs, & bowel sounds Support patient/family Call for help Signs & Symptoms of upper GI bleed: Bright red blood or coffee ground emesis Melena (black, tarry stools) Decreased B/P Vertigo Drop in Hct, Hgb Confusion Syncope Orthostatic VS. Predisposing factors of upper GI bleed: Medication e.g. NSAIDs Prior history of GI disease Esophageal varicies Esophagitis
  • 8. CORE CASE 8 PUD Gastritis Carcinoma Suggested 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 9 References Cayley, W. (n.d.) HPS acute GI bleed. Retrieved from www.fmdrl.org/index.cfm?event=c.getAttachment&riid=1177 Health Canada. (2005). Chapter 5: Gastrointestinal system. In Clinical practice guidelines for nurses in primary care. Retrieved from http://www.hc-sc.gc.ca/fniah- spnia/pubs/services/_nursing-infirm/2000_clin-guide/chap_05d-eng.php Krumberger, J. (2005). How to manage an acute upper GI bleed. RN, 68(3). Retrieved from CINAHL with Full Text database (AN 2005072688). Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment 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.