SENARIO ONE.

Mr Adams is a 58-year and gentleman who was admitted to Ward B at 11.00 hours via the Accident & Emergency Department with acute chest pain that was described as 'crushing' in nature, which radiated to his left shoulder and around his jaw area. On admission he was clammy, pale and extremely anxious. His vital signs were recorded as BP 160/90, P 134/min Respiratory rate 12/ min and oxygen Saturation on air 91%. He was dyspnoeic at rest and complained of nausea.

A work colleague accompanies him. Mr Adams is married and has 2 daughters, aged 18 and 20. He is presently employed as a business executive in an IT unit. You have been assigned his named nurse during his stay on Ward B.

Discuss the approach that may be used to assess Mr Adams on arrival to the A & E Department.

Outline the priorities of care Mr Adams may require until his transfer to Ward B.

Mr Adams is admitted to Ward B @ 12.00 Midday with the possible diagnosis of angina pectoris. You have been assigned as Mr Adams named nurse; critically outline the priorities and management of care from admission to Ward B until handover @ 14.00 pm.

At 14.00 hours his BP was recorded as 110/60, P 62 beats per min with a ST elevation noted on the ECG. His chest pain has worsened. However, his main concern was his wife's reaction to his illness as she is presently being treated for depression. What is your role?

You are the student nurse working within the nursing team caring for Mr Adams, on entering the six bedded ward in which Mr Adams is located you notice that Mr Adams is in a state of collapse with no carotid pulse and making on obvious attempt to breath.

Draw a flow chart outlining assessment, intervention and outcomes for the next 30 minutes of care.

Discuss and critically evaluate the role of the qualified nurse in managing resuscitation interventions.

Mr Adams is successfully resuscitated and after a night in ITU is transferred to CCU for a 48-hour stay. After CCU Mr Adams is transferred back to Ward B. Discuss the role of the MDT in preparing Mr Adams for discharge and rehabilitation. Consider government policies/initiatives and evidence based practice.

Critically discuss the priorities and management of care from admission until discharge. Justify your nursing actions in light of the evidence base for practice.

SCENARIO TWO

David Nelson is a 16-year-old man who was admitted to the Accident & Emergency following an accident whilst playing football. He was 'kicked in the right side of his chest' and is now complaining of severe pain on inspiration with increasing difficulty in breathing. A chest X-ray in the department revealed a right-sided haemopneumothorax with 2 rib fractures.

David is awaiting the arrival of his parents but the surgical insertion of a chest drain is imperative.

On admission his vital signs were recorded as BP 95/55, P135/min, Respiratory Rate 26/min, shallow & irregular respirations & oxygen saturation 89% on room air.

Critically discuss the priorities and principles of nursing & medical management in light of the evidence base for practice.

Two police officers arrive at the A & E Department requesting to interview Mr Nelson in relation to a violent incident that occurred earlier in the day at the local sports fields. Discuss how you would respond to this request, rationalise your discussion.

David has a chest drain with under water seal drain inserted by the A & E registrar under local anaesthetic, outline how you can support David while he is having this procedure done. Discuss the potential risks that are attached to this procedure and how these risks can be minimised.

David’s condition improves and he is admitted under your care in a High Dependency Unit (HDU) for observation and pain control. Using evidence based health care discuss the management of a patient with a chest drain for a haemopneumothorax, two fractured ribs and associated pain.

David’s parents arrive together in the HDU, discuss the role of the nurse in meeting their needs.

David informs you that his parents are separated and the separation was acrimonious and at times his father was violent to David and his mother. David states that he does not want any association with his father and does not want to see father. Discuss how you would implement and maintain your patients’ wishes.

David is still in moderate to severe pain and is taking large doses of opiate analgesia. With reference to the pharmacological of analgesics, discuss how adequate pain control can be achieved.

SCENARIO THREE

Mr. Norman Wright is a 70-year-old retired teacher. He lives with his wife aged 68 years in a semi-detached house near Maryport. They have three sons and five grandchildren between the ages of 15 and 20 who live in Manchester area.

Mr. Wright likes to walk around the harbour area and the coastal path and he thoroughly enjoys meeting with his retired friends.

One morning, whilst preparing to go for his daily walk he suddenly develops pain in his abdominal region. His wife finds him lying on the front porch in a state of collapse. She immediately calls for an ambulance.

On admission to the hospital he is found to be in a state of shock. He is experiencing abdominal pain, nausea and lack of energy. He is later diagnosed with an acute intestinal obstruction.

With reference to your knowledge of normal and disordered physiology, explain the possible causes of intestinal obstruction. Also, explain the clinical features that Mr. Wright may exhibit.

With reference to evidence-based practice, critically discuss the pre-operative preparation (including the physical, socio-psychological and spiritual dimensions) that Mr. Wright is likely to have in order that post-operative complications might be minimised.

Mr Wright’s X-ray shows that his bowel is distended and is full of fluid and gas. It will need to be decompressed over the next 48 hours. With reference to the elements of Essence of Care assess, plan, implement and evaluate Mr Wright’s care.

On further investigation Mr Wright is found to have an “abdominal mass” that is causing his obstruction. Mr Wright informs you that he does not want his wife and sons told about his diagnosis. Discuss your role in upholding Mr Wright’s wishes and supporting his family during this distressing and uncertain time.

Mr Wright requires surgery to remove a tumour from his large bowel. It will leave Mr Wright with a stoma, with reference to “best practice” discuss how the MDT can prepare and support Mr Wright and his wife for his change in body image.

Mr Wright returns to the ward following an abdo-perineal resection of bowel and stoma formation. With reference to the physiology and pharmacology discuss how adequate pain relief can be achieved.

A central venous pressure line has been inserted into Mr Wright’s left external jugular vein. Explain how and what you are going to teach the student nurse in your charge about the monitoring, recording and interpretation of central venous pressure.

Discuss models of care that could be used to assess, plan, implement and evaluate Mr Wright’s care and assist with his rehabilitation.

SCENARIO FOUR

Mrs Broadbent is a 52 year-old lady with a history of Type I Diabetes Mellitus. She was admitted to the Day Surgical Unit for an oesophagoscopy. At 1pm she returns from the endoscopy unit, she is drowsy and her clinical observations were recorded as B/P

140/90, pulse 90/min and respirations 20/min. she appears a little pale and sweaty.

Discuss the priorities and management of Mrs Broadbent during the first two hours following this procedure.

Mrs Broadbent has a current blood glucose 5.8 mmol/l, discuss using the evidence the importance of “good” diabetic control to reduce the risk of the long, medium and short-term complications of Type 1 diabetes.

With reference to the pathophysiology explain how the long-term complications of diabetes occur and their clinical features.

Later, at 3pm, Mrs Broadbent complains of severe mediastinal pain accompanied by dyspnoea and cyanosis. Her B/P is now 90/60, pulse 135/min and respirations 30/min.

Discuss the immediate nursing and medicinal interventions, which may be required.

Following a bolus dose of 50mls of 50% dextrose IV, for hypoglycaemia, Mrs Broadbent has blood glucose of 17.3 mmol/l. Explain the clinical features exhibited by Mrs Broadbent that are associated with a high blood glucose level and with reference to the physiology, why she is exhibiting these clinical features.

6. The Day Surgical Unit it due to close at 18.00, the bed manager states that there are no beds in the Hospital and there are eight trolley waits in the A & E Dept waiting for beds. Discuss your role and response to this situation.

SCENARIO FIVE

Mr Smith is a 27 year-old bricklayer who is admitted to the Accident and Emergency Department at 1pm following a 20-foot fall from some scaffolding. His colleague who accompanied him says he was conscious at the time of the fall. On arrival to Accident and Emergency he is unconscious, has a laceration to his scalp, which is bleeding profusely but there are no other external signs of injury. His vital signs were recorded as B/P 160/80, pulse 50/min, respiratory rate 30/min and he has a Glasgow comma score of 9.

Critically discuss the priorities and management of care which will be required in the Accident and Emergency Department up to Mr Smith's transfer to ITU at 5pm. Mr Smith is newly married.

With reference to the pathophysiological changes, explain the clinical manifestations of head injury.

Mr Smith has been transferred to ITU where he remains unconscious and has required intubation and ventilation. Discuss the ethical issues regarding consent and the care of a ventilated patient.

Mr Smith is to be transferred to a neuro-surgical unit 70 miles away. Critically evaluate the nurse’s role in preparing for a transfer.

Following ventilation Mr Smith's right pupil becomes fixed and dilated, his B/P rises to 180/120 and his pulse falls to 40.

Identify the implications of these observations.

Before his transfer to the neuro-surgical unit Mr Smith is diagnosed as being brain dead. Identify the clinical features of brain death and discuss the implications for your care.

Mrs Smith arrives discuss how you would support her in an intimidating environment at a very stressful time.

How would you approach the subject of organ donation with Mrs Smith.

SCENARIO SIX

Mrs Smith, a 39 year-old married lady, is admitted to the gynaelogical ward at 1600 hours following an Antenatal Clinic visit. She is 8 weeks pregnant and is loosing red blood and clots PV.

Identify and discuss medical investigations and the physical and psychological care she will require in the first 12 hours of her admission. Justify your nursing actions in light of the evidence base for practice.

At 0430 hours, Mrs Smith complains of severe abdominal pain with further passage of blood clots. She feels dizzy, nauseated, her B/P is 70/50, pulse 140/min.

Describe the immediate nursing and medical interventions needed.

Mrs Smith is in a collapsed state. She has a history of Pelvic Inflammatory Disease. She has not responded to the intervention. It is suspected that she has an ectopic pregnancy. She is to be prepared for an emergency operation.

Discuss the implications of Pelvic Inflammatory Disease and why ectopic pregnancy may be suspected.

Identify the pre-operative care of Mrs Smith until she is 6 hours post operation.

Each group will be managing its own learning.

Each group will be managing its own time.

Each group will elect a team leader.

Each group will change its team leader with each new piece of information.

Each new piece of information will be available on the hour every hour. (10am, 11am, ect.)

Each group has the use of the full recourse of the campus.

The usual ground rules apply.

Have some fun, enjoy the learning experience and working as a team.

John and Simon are available as facilitators for the day.