Session 1 Surgery care (7 hours)

A 42-year-old woman has complained the severe pain in the lower quadrant of the abdomen for 6 hours. She has had nausea and vomiting for two days. She was pale and painful. She was admitted to surgery department. The doctor ordered a complete blood picture, and renal and liver function test, and amylase level and other blood tests. They are all in the normal range except for his white blood count. The white blood count is 12,700/mm³. The client was diagnosed with appendicitis and needs an emergency appendectomy immediately.

What makes you think it was appendicitis?

What kinds of contingencies or emergencies may happen at this moment?

How do you assess the patient’s condition?

In each session, the learning activities are the followings:

Preparation for learning: case clarification followed by cuing questions, and information searching for learning. (2 hours)

Symptom assessment: students explored the main complaints and the provoking and relieving factors. (0.5 hour)

Physical examination: Students conducted the physical examination meanwhile the results of laboratory were present. (0.5 hour)

Patient education: Students identified the abnormal signs and symptoms, and provided an appropriate explanation for the clients. (0.5 - 1 hour)

History inquires: Students took health history and managed any patient condition, such as pain, breathless, vomiting, nausea, cough, thirst and hunger. (0.5 hour)

Nursing diagnoses: Based on the results of health assessment and laboratory examination, students defined the problems which required nursing care and their priorities. (0.5 hour)

Reflection: Students reflected on their performance and wrote a reflection paper. The reflection questions are: (1) What were the knowledge and skills you used in this session? (2) What needs to be improved in the next session? (2.5 - 3 hours)

In each session, two tutors observed students’ performance and evaluated their assessment skills using the health assessment evaluation rubric, and gave the comments on students’ learning activities.

Session 2 Chronic obstructive pulmonary disease (COPD) (7 hours)

A 68-year-old man, was diagnosed with COPD 10 years ago. He has a 40-year smoking history (is still smoking) and has been hospitalized twice due to chest infections during the last 12 months. He has trouble getting his breath. The physician prescribed the low-flow oxygen therapy. His FEV1 is 26% and FEV1/FVC is 38%. SpO₂ is 83%, Two hours later, SpO₂ is 80%. The arterial blood gases are reported as pH 7.25, bicarbonate () 23 mEq/L, PaCO₂ 55 mmHg, PaO₂ 56 mmHg.

What are the meanings of FEV1, FEV1/FVC, SpO₂ and blood gas report?

What kinds of contingencies or emergencies may happen at this moment?

How do you assess the patient’s condition?

Session 3 Gastrointestinal bleeding (7 hours)

A 73-year-old man, presented to clinic with 2 hours of massive rectal bleeding. He had an abrupt onset of passing a large amount of red blood with clots from the rectum. He had no abdominal pain, but he began to experience dizziness and unsteady gait. Digital rectal examination revealed no mass or tenderness, but bright red blood coated the exam glove.

Laboratory studies: The hemoglobin level dropped from 10.4 g/dL to 7.8 g/dL. Nasogastric aspirate produced bile-stained gastric contents but no blood. He had never undergone colon cancer screening. He had been diagnosed with chronic liver disease for 5 years. He has had no excessive alcohol or tobacco use. The physician ordered a proctoscopy in the emergency department.

What is the possible reason for the bleeding?

Why is a proctoscopy performed?

What kinds of contingencies or emergencies may happen at this moment?

How do you assess the patient’s condition?

Session 4 Myocardial infarction (7 hours)

A 72-year-old man, complained of acute chest pain. He was admitted to the emergency department. He had spent the afternoon cleaning out the rooms and has had chest pain for the last four hours. The pain is knife-like, unrelieved by rest.

The patient becomes restless, and sounds anxious. SpO₂ is 93%. The electrocardiogram (ECG) showed ST segment elevation, T wave inversion and Pathologic Q waves (duration > 0.04 seconds or >25% of R-wave amplitude) on II, III, AVF leads. Blood tests showed high levels of serum creatine kinase (CK)-MB is 45 U/L (norm 0 - 23 U/L).

Why does the client have chest pain?

Is it the possibility of cardiac dysthymia? Why?

What kinds of contingencies or emergencies may happen at this moment?

How do you assess the patient’s condition?

Session 5 Critical care: Trauma (8 hours)

A 32-year-old man was injured while working in a high place. He fell and slid against a sharp stone on his way down, landing almost in a standing-up position and then slumping to the ground. He had multiple scrapes over his anterior torso and a large gash over his right anterior upper thigh (near the groin) which was bleeding profusely. His friends called an ambulance. The client became increasingly disoriented on the way to hospital. The client was admitted to the emergency room. SpO₂ is 93%. Skin was cold and clammy, and nail beds, palms, and mucous membranes were pale. He had multiple abrasions over his chin, neck, anterior thorax, and abdomen. A 15 cm-long, 2.5 cm-deep laceration was noted in the right inguinal region, extending into the right, upper thigh.

What would happen after severe bleeding?

What additional data would you collect? Why?

What kinds of contingencies or emergencies may happen at this moment?

How do you assess the patient’s condition?