Critical thinking/scenario practice

murphyle, BSN, RN · Dec 2, 2010

Try working through case scenarios instead. You see these frequently in medical school review books and physicians' journals (usually in the format "Case of the Week" or something similar), and I don't know why we don't use them more often in nursing education. Perhaps because we associate them with PBDS-type testing, which has received such a mixed review over the years? Not sure...

Here's one to get you started. Start from the "handoff report" and think about what the patient's key issues are, what the consequences are if they're not dealt with, and what you need to do for this patient as a result.

"You receive report from the off-going night-shift nurse about Mrs. A, a 72-year-old female who presented to the Emergency Department last night for mental status changes and right-sided weakness starting three hours prior to admission. She has a history of stable rate-controlled atrial fibrillation, for which she takes diltiazem and warfarin, and also of hypertension, for which she takes metoprolol and lisinopril. She does not remember the doses, and forgot to bring her medication list with her. She was worked up for CVA vs. TIA in the ED; a head CT came back negative, but her D-dimer was 655 and her INR was 1.4. Her other lab results are unremarkable. Given her history and symptoms, she was started on heparin IV drip in the ED and admitted to your unit for cardiac telemetry and neurological evaluation. As of handoff at 0700, her vitals were BP 165/95, HR 68, rhythm A-fib, RR 18, SpO2 97% on room air, temp 36.5, and 0/10 pain. She has a 20-gauge PIV in her left forearm infusing D5 1/2NS at 50 mL/hr, as well as heparin on a pump at 850 units/hr. She is alert and oriented to person, place and situation, is easily reoriented to time, moves all extremities and is calm and cooperative."

* The admitting orders call for neurological checks q4h. What will you look for? What will warrant a call to the admitting physician vs. what can you manage on your own?

* Are there any abnormal vitals you want to jump on? Why or why not?

* Will you be implementing bleeding precautions, thrombosis precautions, neither or both? Why?

Have fun!

Up2nogood RN, RN · Dec 2, 2010

You also have real live patients to practice with too, right?

elizabethgrad09 · Dec 2, 2010

Unfortunately, no, I don't have any patients to practice on right now, I'm looking for a job.

Up2nogood RN, RN · Dec 2, 2010

Unfortunately, no, I don't have any patients to practice on right now, I'm looking for a job.

I apologize for the assumption.

Everyone learns in their own way and what I found helpful was making patho maps for certain conditions when in school. You did have patients in clinicals so you could you some of those diseases to study up on? You could also do what the previous post suggested. I also went to my CC library and they some acute care nursing books (which were geared for critical care) on clearance which helped me quite a bit to understand rationales without all the NCLEX type questions. Good luck in finding something that works for you.

elizabethgrad09 · Dec 2, 2010

murphyle,

thanks for the scenario. i'm a recent graduate, so don't feel confident in my response to this complex scenario, but here goes.

for each neuro check, i would look for changes in vs and loc/mental status, pupil response, facial drooping, grips/pushes. i would call the dr. if any of these changes were significant.

re: abnormal vs, i would want to check her bp against recent values from the xfer orders and hx from h&p in deciding whether to notify the dr.

i was not familiar with d-dimer so looked that up. that value is high (> 500) and the inr is low, so she could clot, however, she is also on a heparin drip, so i would think both kinds of precautions would be wise.

note: i also looked up pbds testing, as i hadn't heard of that. here's a link for others who may be wondering:

http://www.zimbio.com/nursing/articles/958/what+is+the+pbds

elizabethgrad09 · Dec 2, 2010

Thanks, Uptonogood RN. I thought of reviewing pathophysiology, but had not thought of your idea of mapping the info to previous patients; I like it!

murphyle, BSN, RN · Dec 2, 2010

murphyle,
thanks for the scenario. i'm a recent graduate, so don't feel confident in my response to this complex scenario, but here goes.

yes, it's complex, but it's also a common scenario - we see this kind of patient at least three times a night in emergency, and nearly all of them get admitted for observation and a neuro consult, so i guarantee you're going to see this on the floor.

you pretty well hit all the salient points, so nice job. :yeah:i'd just throw in a few things:

* her inr is significantly sub-therapeutic (1.4

* you're right to check against past history before jumping on that blood pressure, for multiple reasons. we frequently see long-term htn patients who live with pressures like those quoted, and we frequently get yelled at by the floor for sending them up with a "dangerous" pressure. however, when the patient presents with neurological symptoms, throwing a ton of meds at her in pursuit of that magic 120/80 may actually do more harm than good by dropping her cerebral perfusion pressure. (cpp = mean arterial pressure - intracranial pressure; drop it below 70 or so and you lose cerebral blood flow, not a good thing). also consider that she has multiple home meds that have greater or lesser degrees of hypotensive effect (extra credit: which meds and which mechanisms of action?), so watch that you don't bottom her out. check pressures and pulses before and after each administration.

i also like up2nogood's suggestion of reading through acute care/critical care books to get a better grasp of clinical rationales. whatever study method you use, keep trying to take it back to "first principles," i.e. pathophysiology and pharmacology. understanding the underlying mechanisms of diseases and their treatments will go a very long way to helping you think critically through dealing with those entities in the real world.

hope this helps!