Posted by on Feb 6, 2017 in News |

Submitter Information

Author: Katie Morales, RN, MSN, CNE
Title: Assistant Professor of Nursing
Institution: Berry College

Competency Category(s)
AACN, competencies, Evidence-Based Practice

Learner Level(s)
AACN, competencies, Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s)
AACN, Classroom, competencies

Strategy Type
AACN, competencies

Learning Objectives

Objectives: Knowledge
1. Demonstrate knowledge of basic scientific methods and processes.
2. Compare the various methods of hemodynamic monitoring (e.g., central venous pressure, pulmonary artery pressure, and arterial pressure monitoring).
3. Compare and contrast the continuum of normotension, prehypertension, hypertension, and hypertensive crisis.
4. Describe the action, side effects, and adverse reactions of antihyperlipidemics and peripheral vasodilators.
5. Describe the nursing care of a client who has undergone cardiac surgery.
6. Summarize the pathophysiology, clinical manifestations, and treatment of myocardial infarction.
7. Compare and contrast diastolic and systolic heart failure (HF), including pathophysiology and clinical manifestations.
Objectives: Skills
Theory application included simulated lab experience and clinical practice along with the following objectives:
8. Describe/Demonstrate the assessment and management of clients with HF.
9. Develop a teaching plan for clients with HF. Base individualized care plan on client values, clinical expertise, and evidence
10. Describe/Demonstrate the assessment and management of clients with pulmonary edema.
11. Describe/Demonstrate the management of clients with cardiogenic shock.
12. Locate evidence reports related to clinical practice topics and guidelines.
13. Question rationale for routine approaches to care that result in less-than-desired outcomes
Objectives: Attitude
14. Value the concept of evidence-based practice as integral to determining best clinical practice.
15. Value the need for continuous improvement in clinical practice based on new knowledge.

Strategy Overview

Students were asked to troubleshoot cardiac function problems demonstrated with an aquarium and pump. The following principles were demonstrated: First, the aquarium pump is electrical. Therefore, the pump must be plugged in to receive an electrical charge. Positive cations (such as magnesium, potassium, calcium, and sodium) provide the electrical charge to the heart, which is represented by the plugging the pump into the electrical outlet. To help students retain normal laboratory values, students were taught the 2X4 Rule: representing ideal serum magnesium and potassium levels for cardiac electrical function being a serum magnesium 2 mg/dL and serum potassium 4 mEq/L. The extension cord was labeled with “K” and “MG” for demonstration.
Second, the pump requires sufficient volume (preload) to produce cardiac output. This is demonstrated by adding water from a container marked preload. The pump cannot function effectively or efficiently with a volume deficit or fluid overload. This is demonstrated by either submerging the pump or lifting the pump out of the water.
Third, the pump must be able to accommodate resistance (afterload) that is demonstrated by using an obstacle to obstruct outflow. Follow-up discussion addressed the effects of vasodilator and vasoconstrictor medications.
Finally, the (plastic) fish do not die from lack of water, but lack of oxygen (due to low perfusion). Follow-up discussion addressed cardiac perfusion, including differences in ventilation and perfusion, which were identified as difficult concepts for the students.

Submitted Materials


Additional Materials

No funding was received for this activity and no animals were used with this demonstration. The demonstration required no special adaptation of the aquarium or pump, other than a means to obstruct the pump. The equipment used included an electrical cord and pump to represent the electrical aspect of the heart, a basic aquarium, a bottle of water labeled preload, and a plastic turtle labeled afterload to obstruct the pump. For demonstration, the extension cord was also labeled with “K” and “MG”. This demonstration has since been presented at two NCLEX review programs, a professional educator conference, and in a peer-reviewed journal, receiving overwhelmingly positive feedback as well.
Strengthening QSEN Competencies in Nursing Education
This activity specifically strengthened the QSEN (2014) competency of safety and EBP by developing the students’ knowledge of the pathophysiology, clinical manifestations, and treatment related to altered hemodynamic function, the effect of hyperlipidemia and peripheral resistance, vasodilators. Classroom activities included comparing and contrasting assessment and management of clients with various types of shock. The strategy strengthened the QSEN (2014) competency of EBP as faculty shared clinical practice topics and guidelines. The simulated lab experience and clinical practice strengthened the QSEN (2014) competency of interdisciplinary teamwork & collaboration as students applied core measures to assess and manage clients with HF. The strategy strengthened the QSEN (2014) competency of quality improvement as simulation provided a safe environment to question care that resulted in less-than-desired outcomes. Furthermore, the strategy strengthened the QSEN (2014) competency of patient-centered care and informatics as students used technology to complete an individualized concept map based on client values.
In conclusion, this activity allowed students to grasp the difficult concepts of cardiac function and apply them in a classroom activity. Students’ performances on course examinations throughout the semester demonstrated their retention of the material. The results demonstrate this is an effective active learning strategy to introduce students to advance cardiac concepts. Additional studies may help provide evidence base strategies for active learning and methods to evaluate active learning.

Discussion Questions
Discussion questions focused on the QSEN (2014) competencies of safety and EBP related to preload, such as: What conditions could affect blood volume? How would the client with those conditions look? What assessment findings would the nurse expect? What treatment would the nurse anticipate? How would the nurse evaluate the treatment? Discussion questions related to afterload, such as: What conditions could affect vascular resistance? How would the client with those conditions look? What assessment findings would the nurse expect? What treatment would the nurse anticipate? How would the nurse evaluate the treatment?

National League for Nursing. (2009). Building a science of nursing education: Foundation
for evidence-based teaching- learning. New York: National League for Nursing
National League for Nursing. (2007). Nurse Educator competencies: Creating an evidence- based practice for nurse educator s. New York: National League for
Quality and Safety Education for Nurses. (2014). QSEN Competencies.
Retrieved from

Evaluation Description

Evaluation of the teaching strategy was accomplished via pre- and post-test of the class using audience response system and the students’ self-report of content comprehension. A. The pre-and post-test items were taken from pre-lecture item bank provided by the publisher of the required course text book. As such, pre-and post-test items were proprietary property of the publisher. Additionally, the audience response system questions have since been replaced with adaptive learning technology to assess class preparation, exam preparation, and remediation after exams. Suggested pre/post questions for future use include:
1. _______, such as potassium, magnesium, calcium, and sodium provide the electrical charge to the heart. (cations)
2. For optimal electrical cardiac function, the desired serum magnesium is __mg/dL and the desired serum potassium is __mEq/L (2,4)
3. Preload refers to ______. (volume)
4. Afterload refers to __________. (resistance)
5. Cardiac function is required for tissue _________. (perfusion)
Because this demonstration was not designed as a research project, Internal Review Board approval was not obtained and no additional data collected. Overall, students had higher post-test scores after this demonstration, with students consistently answering preload and after load questions correctly throughout the semester after the demonstration.
Students’ Self-Report of Content Comprehension
Students in subsequent cohorts were divided into “think, pair, share” groups, creating posters on the discussion questions to present to the class. Student feedback was overwhelming positive. One student said, “The use of the aquarium brought the ‘mystery of cardiac function’ to actually understanding the how’s and why’s of heart issues. I pictured the ‘stuck turtle’ during the test and it helped me choose the right answer”. After using an aquarium and pump to demonstrate advance cardiac function, students reported an understanding of concepts and terminology. Overall, higher post-test scores were obtained after this demonstration. A former student reported drawing on the concepts while providing client education related to preload/afterload.
To promote self-assessment and incorporate test-taking strategies, the educator ends each unit by asking the students to identify the most important concept they learned in class. Together the students and educator write a National Council Licensure Examination (NCLEX) style question with plausible distractors. Students in the original cohort wrote the following exam question:
To increase cardiac output, the nurse knows the goal of therapy is to: (Select ALL that apply)
A. Increase preload
B. Decrease preload
C. Increase afterload
D. Decrease afterload
The question has been subsequently modified as follows:
Which of the following would increase cardiac output? (Select ALL that apply)
A. Administration of IV fluids as ordered
B. Administration of a diuretic as ordered
C. Administration of a vasoconstrictor as ordered
D. Administration of a vasodilator as ordered
E. Administration of oxygen to keep oxygen saturation greater than 94% as ordered
Both questions demonstrated reliable item analysis on course examinations. These activities satisfy the National League for Nursing’s (NLN, 2007) Nurse Educator Competency of Facilitate Learning and the following NLN (2009) Ten Principles of Learning:
Students made and maintained connections mentally and experientially; learning was an active search for meaning by the student, constructing knowledge rather than passively receiving it; learning can be informal and incidental.