Hypothetical Curriculum: Surgical Nursing

As a condition of completing the degree path for the bestowal of a Baccalaureate of Science in Nursing (BSN) Program, the undergraduate is required to create a module for a hypothetical curriculum aimed at training the student entering the singular area of medical surgical nursing. Parameters for the assignment are that the writer must tailor the learning to either blood gases or fluid management. While they are of equal concerns in the purview of surgical nursing; for the purposes of this assignment all experiences will target competency in facility with fluid balance. Each of the two clinical activities submitted will be aligned with national standards and the mock training will commence with the common understanding that paramount to post-operative care is constant fluid level monitoring as is with many other procedures. According to one noted expert on the subject; “fluid management is a serious concern and challenges nephrology nurses to enhance their critical thinking skills” (Dale, 2012, p.510). In light of this, the greatest challenge to developing a dynamic and innovative series of lessons is to incorporate opportunities for the nurse in training to have multiple contrived but ‘faux authentic’ scenarios in which one is required to critically analyze fluid levels. 

Let us begin this task by iterating the learning objectives pertaining to ‘fluid balance’ as listed in the syllabus that elucidates the subdomain of curriculum design and evaluation. The four elements that must be integrated into the lessons include: a) an explanation of the distribution of fluid volume in the adult body, b) a description of how body fluids and electrolytes move between intercellular and extracellular compartments, c) a comparison and contrast of the ways in which skin, lungs, gastrointestinal tract, and kidneys help to maintain fluid/electrolyte balance; and d) a nursing care exercise in which the nurse must address patients who are more prone to dehydration; perhaps as a result of a state of circulatory overload post-kidney-transplant-surgery or general care of a patient in ‘circulatory overload’ (hemodialysis).  

The reader is advised to review the lessons within this essay in light of the ardent expectations across the continuum of academic delivery. Research confirms that providing the learner with strategies that allow for active acquisition and internationalization of information and skills, and that additionally require the student to utilize this new knowledge as a demonstration of ability; is the leading paradigm on which to scaffold experiences. Referred to as ‘hands-on’, the nurse-in-training must assume a pro-active stance – both in their own learning and in its application to the patient. The incorporation of advanced medical technology is a natural antecedent to premier academics because it allows the student ample opportunity to manipulate automated devices and associated high tech materials and machines. 

This imperative is important in the delivery of nursing care and reflects expectations of evidence-based medicine; a concept underscored in a breadth of research-based findings articulated in nursing journals and texts.  An example of this can be found in the following comments: “nursing programs must integrate informatics content into their curricula in preparation for nurses to competently manage these specialized computer skills” (Ornes & Gassett, 2007, p. 75). However, it would be disingenuous to overlook the fact that this basic concept is confirmed repeatedly throughout the literature. Furthermore, it is possible to posit that the development of a command of medical technology such as E-monitoring patients is the cornerstone of optimum nursing care delivery in today’s advanced hospitals; its use insinuated across the application spectrum from an accurate recounting of the patient’s medical conditions to understanding readings from various equipment.  The following chart will aid the reader in comprehending the progression that is the sophisticated taxonomy of fluid management in nursing education.

(Chart omitted for preview. Available via download) 

The reader should note that – just like in the real world – learning may overlap across the curricular spectrum of expectations, but all experiences are designed to meet the requirements as reiterated in the National League for Nursing Accrediting Commission BSN Guidelines 2013.

Let us now consider the individual and elemental aspects of fluid and its management from a surgical nursing perspective. Those who wish to fill this role must have mastered the advanced scientific units of knowledge and the manner in which they interface in order to undertake fluid management in a post-operative setting; realizing its importance particularly to the hemodialysis patient due to the requirement for balance in body fluid composition and distribution. This is, of course, once all concepts regarding the changes in a peri-operative setting are understood. Remember, the patient is wholly reliant on a machine for fluid filtration in place of their defunct kidneys. All salt, waste, and fluid in the blood that affects patient well-being must pass through the hemodialysis process in accordance with a disciplined treatment schedule. It is imperative that the accomplished nurse be proficient in maintaining the delicate fluid balance among the lungs, skin, kidneys and gastrointestinal tract. This would begin with a fundamental understanding of the behavior of electrolytes and body fluids and, subsequently, the manner in which they are brought into balance; a skill that is tantamount to the health and recovery of the patient. Succinctly, electrolytes travel between intracellular and extracellular fluids. The human body is composed of sixty-percent water; forty percent of which is intra and the other twenty percent extracellular. Transcellular fluid is specialized and moves within the blood vessels themselves; its most important function is to convey erythrocytes that aid in oxygen transportation. Since the value of electrolytes in human physiology cannot be understated; this will be the focal point of the following lessons. Prior to detailing the framework and contents of two separate lessons; it would be helpful to relay basic curricular delivery suggestions that would ensure student nurses capture the essence of the learning and are able to employ this knowledge in authentic circumstances.  The hypothetical class will be entitled Cellular Fluid, Electrolyte Balance and Blood; the aim of which would be to demonstrate mastery of content and hands-on manipulation of technologies related to body-fluid physiology. This would include but not be limited to such concepts as homeostasis, identification of body-fluid levels such as extracellular fluid and the meaning of various amounts in the body; and identifying and reacting to blood-fluid loss. 

Research shows that cooperative learning is the ideal teaching strategy to facilitate the acquisition of knowledge aligned with the simpler processes of the cognitive domain in the hierarchy of learning. While class size may dictate the number and size of groupings; assemblages of between 3 and 7 students is best. In each instance, groups would be run through a series of simple exercises such as matching models to their corresponding chemical compounds. In the initial lesson, the emphasis will be on the elementary (but essential) ability to match the chemical identification of electrolytes with the scientific name and/or composition.  The value of knowledge acquisition (and, therefore, this session) cannot be overstated. In order to manipulate and apply information one must first be in possession of such. According to the recognized sage of erudition, Benjamin Bloom, who conceived the taxonomy of learning, “knowledge involves the recall of specifics and universals, the recall of methods and processes, or the recall of a pattern, structure, or setting” (Bloom et al. 1956 p 201) (Anderson, 2001)..  In other words, one must have recall of units of information before one is able to utilize it as the foundation on which to construct new knowledge. In light of this, the relevancy of the first task is immediately evident. At the completion of this phase of the instructional experience, students would then be asked to apply this knowledge by identifying these compounds in blood taken from the students during the course of the lesson; and smeared on slides that are then placed under microscopes. Today’s SMART technology will allow the professor to attach a camera to the microscope and project it on a SMART board; thereby creating a dynamic academic experience in which students have an opportunity to practice the skill of identifying electrolytes in a real blood sample.

LESSON PLAN ONE

Lesson Title:  Electrolytes, Body Fluids Management & Introduction to Nursing Protocols

Topic: Electrolyte & Body Fluid Physiology &Pathology; & Application to Nursing Care

Grade Level: Baccalaureate Nursing Program (BNP)

Instructional Setting: Laboratory and classroom; small-group seating arrangements

STANDARDS, GOALS, AND OBJECTIVES

Standard 6:  “Evaluation of student learning demonstrates that graduates have achieved identified competencies consistent with the institutional mission and professional standards; and that the outcomes of the nursing education unit have been achieved”.

Nursing study is rigorous, and assessment of content mastery as well as evaluation of student competencies must be continuous and in accordance with NLNAC standards. Comprehensive university program appraisal is conceived from aggregated data that is utilized to inform instructional design improvements. Evaluation results are also not held in secret but shared among the separate university colleges that could benefit from the findings. It is expected that BSN graduates will reflect mastery of competencies required to perform in authentic medical settings. 

Ultimately, the purpose of the standard is to ensure that the nursing program requirements turn out graduates able to demonstrate the following outcomes: 

-Program completion (as determined by the multiple factors of the program’s history as well as student academic progression)

-Program satisfaction (as reflected in qualitative and quantitative measurement tools given to students and employers)

-Performance on licensure exam (at or above national standards)

-Job placement (quantified measurements based on program demographics)

We should note that distance learning (an increasingly accessed learning format) criteria mirror on-campus training requirements.

Lesson Goals

A. Students will explain fluid and electrolyte exchange; and the role of kidneys, lungs, the gastrointestinal tract, and skin in fluid volume distribution. 

B. Students will have a command of fluid balance concepts and management techniques in a post-operative setting. 

Lesson Objectives:

1. Identify and describe the physiology of predetermined electrolytes; their normal serum values; and the methods to assess fluid and electrolyte status. 

2. Identify the normal blood values for pH, PCO2, PCO3, PO2.

3. Identify fluid and electrolyte solutions commonly used to correct states of deficiency or excess.

4. Identify the etiologies, defining characteristics, and treatment modalities for common fluid, electrolyte, and acid-base imbalances.

5. Identify factors affecting the homeostasis of normal body fluid, electrolyte, and acid-base balance and the risk factors for and causes and effects of them.

Instructional Plan

1. Identification of Student Prerequisite Knowledge and Skills

In this lesson and the next; knowledge is lateral and perpendicular. As one would expect – there will be an overlap of skill acquisition and mastery.

a. memorization of applicable terms including but not limited to electrolyte ions

b. review of cell functions related to fluid retention and dehydration

c. review the interrelatedness of heart to kidneys

d. review & practice the task of taking and reading vital signs

e. review & practice utilization of patient-related technology and software

2. New Knowledge and/or Skills to Be Taught

a. fluid management and electrolyte information 

b. proper nursing protocols related to normal and distressed fluid management

3. Four Activities to Promote Pro-Active Learning 

Incremental self-assessment and instructor assessment should be a regular component of each learning experience; occurring at the completion of a task to ensure there is no ‘disconnect’ in the learning process. Multiple rubrics should be created for each step of the lesson.

1. Notetaking, collaborative discussion of electrolyte and fluid management techniques following along with a pre-constructed powerpoint on the topic. 

2. Use various gaming techniques to reconfirm knowledge acquisition of electrolyte and fluid management data.

3. The first round of role modeling of nurse/patient interactions (in general and specific to fluid management).

4. Identification of various electrolytes in blood samples.

Critical Thinking Assignment:

Working in pairs, students will create a data set for two differing fluid management scenarios that are indicative of problematic and/or potentially terminal fluid irregularity; after which the information will be communicated as a hypothetical patient condition. Students will role-play authentic care responses by “communicating the situation to the patient”; in front of the whole class with an evaluative component built into the conclusion of each presentation.

Strategies:

The use of role-playing accesses both the Cognitivism Learning Theory and Constructivism Learning Theory.  

Rubric to Score Critical Thinking Assignment:

The critical thinking assignment will be a 9 point scale.

1. Proper patient/nurse interactions

a. Listens and responds to the patient with no mistakes: 3

b. Listens and responds to the patient giving some misinformation: 2

c. Does not listen to patient completely; makes some mistakes in identifying the problem: 1

d. Is totally incorrect in all aspects of patient interaction: 0.

2. Identification of data set 

a. Identifies relevant data set information correctly 100% of the time: 3.

b. Identifies relevant data set information correctly 80% of the time: 2.

c. Identifies relevant data set information correctly 60% of the time: 1.

d. Is unable to identify relevant data set information: 0.

3. Fluid management techniques identification

a. Can identify no less than 6 fluid management techniques: 3.

b. Can identify no less than 4 fluid management techniques: 2.

c. Can only identify one or two fluid management techniques: 1.

d. Fails to identify any fluid management techniques: 0. 

LESSON PLAN TWO

Topic: Charting, Cooperative learning, Electrolytes, Skin, Lungs, Gastrointestinal Tract, Kidneys

Level: Baccalaureate Nursing Program (BNP)

Instructional Setting: classroom, nursing laboratory, library

STANDARDS, GOALS, AND OBJECTIVES

Standards: 6 of NLNAC standards: “Evaluation of student learning demonstrates that graduates have achieved identified competencies consistent with the institutional mission and professional standards and that the outcomes of the nursing education unit have been achieved”. 

Lesson goals:

A. Demonstrate mastery of electrolyte and all aspects of fluid management.

B. Demonstrate mastery of nursing protocols in response to multiple distress scenarios.

 Lesson objectives:

1. Demonstrate mastery in the identification of nursing diagnoses and the goals/outcomes for clients with fluid, electrolyte and acid-base imbalances (this is a continuation of the same task from the first lesson. 

2. Create a prototype nursing care plan for the separate scenarios that require the evaluation, maintenance, and restoration of fluid and electrolyte status.

3. Practice implementation of prototype nursing plan in the nursing laboratory by:

a. measuring exercises in bloodstream bicarbonate level

b. identifying patient risks for dehydration and kidney failure

c. identify risk factors evident in electrolyte balance failure 

d. identify risks associated with age and other extraordinary factors

e. demonstrate the ability to determine patient weight using of liter fluids

f. regulate daily intake of IV fluids, oral fluids, or catheter irrigation techniques

g. manage the bodily fluid output of waste caused by diarrhea, vomiting, drainage control

4. Able to describe and apply Evidence-Based Theory and Transcultural Nursing Theory

5. Demonstrate technology facility by accessing and documenting patient data; and general record keeping and administrative skills as needed.

INSTRUCTIONAL PLAN:

Identification of prerequisites:

a. demonstrated acquisition of knowledge related to electrolytes, fluids & management, respiration, relevant body functions 

New knowledge and skills to be taught:

a. Vital signs assessment of body temperature, respiration, heart rate

b. Q&A with patients

c. The individualized practice of tasks

d. Simulator fluid management 

Four Activities

1. Hold the first session for this second lesson in the university library. With the support of the librarians; have students utilize resources to complete a two-page essay on a topic related to post-op fluid management best practices. Students may choose from several scenarios such as a failed kidney transplant or child with a challenging disease diagnosis unresponsive to normal protocols. 

2. Model patient/nurse dialogue probing for indications of physical and/or emotional stress. The students will then break into pairs and practice this skill with each other. This task should be repeated for the most common types of fluid management complications.

3. Demonstrate fluid management techniques utilizing the Patient Simulator. Students should be shown how to maintain normal fluid levels and how to tend to fluid management with hemodialysis and diabetic patients. 

4. Students will practice implementing all tasks related to fluid management in multiple scenarios. This is to include all skills described in objective 3 and as part of the prototype nursing plan. 

Critical Thinking Assignment: 

  Students will be given a set of ten authentic patient files (redacted) and be required to clearly identify the fluid irregularities in each – or explain why there is no indication of such. 

Strategies:

The use of role-playing accesses both the Cognitivism Learning Theory and Constructivism Learning Theory.  

Rubric to Score Critical Thinking Assignment:

The critical thinking assignment will be a 9 point scale.

1. Identification of symptoms

a. Identifies every relevant symptom: 3

b. Identifies each relevant symptoms and additional irrelevant symptoms: 2

c. Identifies a few but not all relevant symptoms: 1

d. Is unable to identify any relevant symptoms: 0.

2. Identification of fluid irregularities

a. Identifies every possible fluid irregularity: 3.

b. Identifies every possible cause of fluid irregularity but misidentifies others as well: 2.

c. Identifies few of the possible causes of fluid irregularity: 1.

d. Is unable to identify any possible causes of fluid irregularity: 0.

3. Explanation of fluid irregularities

a. Comprehensive and accurate and thorough explanation of all fluid irregularities: 3.

b. Provides a correct but incomplete explanation of fluid irregularities: 2.

c. Provides a partially incorrect and incomplete explanation of fluid irregularities: 1.

d. Fails to provide any explanation of fluid irregularities.

References

Anderson, L. & Krathwohl, D. A. (2001) Taxonomy for Learning, Teaching and Assessing: A Revision of Bloom's Taxonomy of Educational Objectives New York: Longman/

Bloom, B. (1956). Taxonomy of educational objectives: the classification of educational goals; Handbook I: Cognitive Domain New York, Longmans, Green

Cognitivism. (n.d.). Learning Theories. Retrieved April 27, 2013, from http://www.learning-theories.com/cognitivism.html

Dale, W. (2012). Education on fluid management and encouraging critical thinking skills. Nephrology Nursing Journal, 39(6), 510-512.

National League for Nursing Accrediting Commission, Inc. (2013). NLNAC accreditation manual 2013 standards and criteria Baccalaureate [Data file]. Retrieved from http://www.nlnac.org/manuals/SC2008_BACCALAUREATE.htm

NDT. (n.d.). Teaching with the Constructivist learning theory. NDT Resource Center. Retrieved April 26, 2013, from www.ndt-ed.org/TeachingResources/ClassroomTips/Constructivist _Learning.htm 

Ornes, L., & Gassert, C. (2007). Computer competencies in a BSN program Journal Of Nursing Education, 46(2), 75-78.