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What to do?
This happened one day when I was working as the shift supervisor at a metro Detroit hospital…
An elderly patient with COPD was very anxious- she was restless, could not get comfortable and kept fidgeting in the bed.
The RN called the physician and obtained an order for ativan to help her settle down.
The patient went into respiratory arrest shortly afterward and almost died
What happened?? The elderly patient had COPD, and her restlessness was
due to hypoxia, not “nerves”
When the RN obtained the order for the ativan, the respiratory depressant effects of the drug further impaired the patient’s breathing until she went into cardiac arrest
The patient was intubated, placed on a ventilator, and sent to the ICU where she survived the incident
So why learn about critical thinking?
Nurses need to make critical decisions all the time
Nurses are the ones with the patients all day and night, unlike doctors who usually only spend a few minutes with patients (sometimes from the doorway)
Nurses are the ones who are most likely to pick up on slight changes in patient conditions and then decide what to do…
Who to call? Call the doctor?
Watch & wait? What to do first?
Critical thinking
Not having the answer but being able to intelligently think through the problem
Ability to consider a variety different causes and solutions for a given problem
Knowing when and where to look for help with a problem
“Next to the possession of knowledge itself is the ability to turn where knowledge can be found”
Critical thinking If you ask 12 RNs what critical thinking is, you will
probably get 12 different answers
But RNs will all agree:
Nursing is much more than just passing meds and leaving stuff for the next shift
Judgment calls are a very important part of nursing practice
The biggest threat to critical thinking is just focusing on tasks to be done and not thinking about what you are doing and why
So that means…
If the RN in the incident above had used critical thinking skills, she might have realized that…
The patient’s anxiety and restlessness might have been due to something other than “nerves”…
A thorough physical assessment might reveal other causes of the patient’s distress…
Other causes of anxiety should be ruled out before obtaining a sedative order for an elderly patient with COPD.
Assumptions
Part of critical thinking is being aware of assumptions and working to make sure that they aren’t flawed
For instance… I decided not to assume that my patient who had been
admitted with a drug overdose didn’t have any more drugs in her belongings that were brought with her from the ER
Thank goodness I checked- I found some Xanax, some Tylenol and some other white pills!
My patient could have taken these when nursing staff were not in the room!
Assumptions
Another for instance- I was charting at the nurses’ station and I heard the
water running for a long time in a room near where I was sitting
I became curious, and I went to check… A patient (not mine) was at the sink trying to stop the
bleeding from where he had pulled his IV site out. He was very unsteady on his feet and should not have been out of bed
If I hadn’t gotten up to check on the sound, he might have fallen on his way back to bed, especially with the blood that was on the floor
Critical thinking
Successful organizations are staffed by people who think, not just follow orders
The biggest threat to critical thinking is just focusing on tasks to be done or “putting out fires” and not thinking about what you are doing and why
Critical thinking is… Active, organized thought processes to analyze, draw
conclusions, make decisions, and form inferences
Taking nothing for granted
Identifying and challenging assumptions
Prioritizing
Imagining and exploring alternatives
Applying reason and logic
That goes for nursing students, too!
A few years ago, an OU nursing student in clinical received report about a patient who had just undergone an angioplasty the night before
The night nurse said that the patient was fine, and resting comfortably. But…
The nursing student did her assessment and found that the patient had hemorrhaged from the angioplasty site during the night and had been vomiting!
The nursing student notified the clinical instructor right away and worked with the patient’s day nurse to contact the doctor and send the patient to emergency surgery
Critical thinking & assessment
Data collection is not an end in itself-
it isn’t done just to get the forms filled out
and assignments completed
Assessments are done
so that the findings can be analyzed
and problems can be identified
Cognitive dissonance
A fancy term for when you get that bad feeling in your gut when somebody tells you one thing but your gut tells you that something else is actually going on
Sometimes you get a bad feeling about a patient’s condition even though the doctor says that the patient is just fine…
Intuition vs. physician
I was working on a medical-surgical unit when a new patient was admitted from ER with a diagnosis of pancreatitis
The young woman was clearly in shock- pale and lethargic, a 70/40 BP, and very cold extremities
I was told that the patient’s doctor was aware of the patient’s condition, was not concerned, and wanted her admitted to the regular floor, not the ICU.
Hmmm…. Who to believe? What to do?
Intuition vs. physician
Regardless of whatever the doctor thought, I realized that this patient was in serious trouble
I decided to call the house doctor to see the patient right away and offer her opinion of the situation
She was extremely concerned about the patient, did a quick yet thorough assessment, and contacted the patient’s doctor herself
It turned out that the patient’s attending doctor had not seen the patient himself, but had relied on the assessment findings of the ER doctor
Intuition vs. physician
The patient was immediately transferred to the ICU, and the patient’s attending doctor came to see the patient there
He was very upset at the ER doctor, who had neglected to order some lab tests that would have indicated the seriousness of her condition
The ER doctor also thought that the patient was “faking it” when she first came to the ER, and didn’t monitor her condition as she progressed to shock.
Intuition vs. nurse
The ER nurse noted that the patient was going into shock, and believed that the patient should have been admitted to the ICU, not to a medical floor
However… instead of speaking to the doctor or notifying the nursing supervisor about it, she decided that “I’m just not going to talk to that doctor any more!”
If you are ever in doubt about a patient’s condition or have concerns about a physician’s order, ask the charge nurse or clarify with the nursing supervisor!
Autonomy Patients have the right to self-determination
That means that they have the right to decide for themselves about their health and treatment options
Patients have the right to refuse treatment or medication even if they may die without it
If the patient is a minor, parents are expected to make these decisions
If an adult patient is unable to make decisions for himself, decisions are made by the family members or a court-appointed legal guardian
Delegation
RNs may delegate tasks to other members of the health care team Licensed practical nurses (LPNs) Nursing assistants (NAs)
Do not delegate tasks that require nursing assessment or judgment Formulating nursing diagnoses Notifying doctors of changes in a patient’s condition Changing plan of care for a patient Advanced nursing procedures & interventions
Delegation
So what might you delegate?
Bed baths and bedpans Changing incontinent patients
Feeding patients Taking vital signs
Walking patients in the hall Getting patient up in the chair
Making beds Bringing ice water to patients
But there’s a catch…
You have to use your nursing judgment to know if a particular tasks should be delegated!
For instance… Your elderly patient just had a stroke and has difficulty
swallowing. Since there is a good chance that the patient might choke on his food, it would not be a good idea to have the nursing assistant feed this patient
If your patient is very unstable (going into shock, perhaps!) you would want to take the vital signs yourself to make sure that they are accurate
Delegation
Make sure that the task is OK to be delegated at that particular health care facility…
Some hospitals allow NAs to give enemas, while other hospitals do not
Some hospitals allow NAs to check patients’ blood sugar (with a bedside monitor)
Some hospitals allow LPNs to do admission assessments for patients with a co-signature from the RN
Other hospitals require the RN to do admission assessments
Delegation
Make sure that the staff member knows how to do the task correctly!
If the NA or LPN makes a mistake or does not perform the task, the RN is responsible for the error
The RN must go back to make sure that the task was completed
Do not delegate tasks that you are unwilling to do- This creates hard feelings with the staff- very bad!
Delegation
You must work nicely with others!
For instance: If you are in a room and the patient asks for a bedpan
or a pitcher of ice water, don’t spend 15 minutes hunting down a NA to do it…do it yourself right then.
This will foster a good relationship with the patient (who recognizes that you will meet his needs right away)
This will foster a good relationship with the staff (who won’t feel like you are dumping on them)
Delegation
When LPNs or NAs do a great job on a task that you have delegated to them, let them know!
Be sure to thank the LPNs and NAs for their hard work- it makes them feel appreciated and respected.
It is important to keep a good working relationship with assistive personnel- when you help them out, they will be more willing to help you out
When delegation doesn’t work out…
If you are unhappy with the work that an LPN or NA has done: Pull the NA or LPN aside privately- do not say
anything in front of a patient! Be constructive and appropriate feedback, and be
specific about your expectations for the task. You may need to review the correct procedure for the
task- sometimes the problem is due to lack of knowledge, not lack of trying