Critical Thinking Snapshot for Nurses&Students - page 3
by betts | 5,000 Views | 33 Comments
Patient: Mr. Jones Mr. Jones, a 38-year-old white male with no known previous chronic illness, was admitted six hours ago after being involved in a single motor vehicle accident. He was the unbelted driver of a vehicle that... Read More
- 0May 20, '03 by RNforLongTimeOriginally posted by maxthecat
And the point of all this was????
Most of the nurses who post here seem to me to be professionals who are perfectly capable of using critical thinking in their daily dealings with patients/families. They are not children who need remedial case studies. Personally, I found the tone of this exercise condescending, and my guess as to why you received so few responses is that many other nurses felt the same way and didn't waste their time replying.
I work in a Trauma/Surgical/Cardiac ICU and Mr Smith would've been admitted there rather than a Gen Nursing floor at MY facility anyway. Cardiac contusions are unstable usually.
- 0May 20, '03 by bettsThanks to all for posting but as I pointed out, this exercise wasn't to question anyones nursing knowledge or abilities. As for those that felt it condescending, say that to the nurses now in prison or lost their licenses for negligence resulting in the death of their pt.
It's on the tv, newspapers, lawyer ads, periodicals, and I could go on about deaths due to a nurses negligence. More than you think from situations such as above. I posted this with all good intentions of alerting my "Fellow Professionals" to be more scrupulous. I've 30+ years as a nurse, and continue to learn each and everyday as well as realize I too can make mistakes in judgement.
About this being posted in the General Nursing Thread, IMHO, I feel that it's appropriate in all forums and levels of Healthcare Education.
- 0May 20, '03 by gwenithI agree with Betts - we could all revisit some of these exercises not because one person wants to be condescending or superior to another but to get insight from a variety of views. Like a lot others I clicked on had a quick read and thought - too busy I'll come back to this. I wish I had now tried earlier.
One of the reasons why this sort of question is difficult to answer and is easily answered wrongly is the "index of suspicion" that is absent when reading the question. When I recieve handover I usually formulate an "index of suspicion" as to who are my most unstable patients. Sometimes we cannot do this as we have not the expereince in this field to notice the "red flags" for what they are or the infromation is given in a way that diminishes the alarm bells. (did I just mix a metaphor there?)
For those who liked this exercise - why don't we set up a continuing thread in the "student nurse forum" for critical thinking exercises. We could do it so that there is no shame or blame in getting the answer "wrong" and indeed in some questions the "right" answer might be one of several "rights".
Please give feedback on this and your thoughts about how you would like them run
i.e. Initial scenario - posted day one
extra information - posted day two
more information - posted day three
final infromation - posted day four
feedback - posted day five
Just a thought
P.S. Remember - hindsight is 100% effective!!!Last edit by gwenith on May 20, '03
- 0May 20, '03 by RNIAMI think the general nursing forum is a great place for this post and any other questions like it. I am a student of nursing. When I graduate I will still be a student of nursing. I will continue to learn each and every day I am a nurse. I hope I never stop learning. I have learned so much it is amazing to me. I can't wait to learn more. It is a great question. I hope their will be more like this one. It made me think. I knew it was a pnemo fairly quickly as I just finished learning about chest tubes and causing one if you clamp the tubing. The sternal shift is a little unclear to me. That happens due to pressure exerted from the collapsed side pushing against the side unaffected? Can anyone make that a little clearer to me?
- 0May 20, '03 by gwenithrn2b the question about "sternal shift". what actually happens is a tracheal shift. as the contents of the chest cavity are forced to the unaffected side by the build up in interthoracic pressure. this causes the trachea to shift. this sign is easily determined by running your fingers along the trachea and seeing if the high points of the trachea align to the sternal notch.
a cautionary warning however.
it is rare - not impossible, but rare for a spontaneous (i.e. non-ventilated patient) pneumothorax that is not associated with either a sucking chest wound or a broncho-pleural fistula / rupture to progress to a tension pnuemothorax. most commonly the pneumothorax will seal itself as the pressure builds up within the chest. the most likely scenario in a post-trauma patient as described in the original question would be the development of a pneumohaemothorax plus the development of pulmonary contusion. both of the last problems will cause an increase in dyspnoea as well as falling o2 saturations. the one sign listed that would scream "major problem" to me would be the development of the subcutaneous emphysema. especially if the development was rapid as this would indicate rupture of a major airway.
a lot has been posted on tension pneumonthoracies lately and although they are life threatening they are relatively rare. just as important is the pneoumothorax of significant size. ( i am not talking here about the 20 ml collection at the apex of the lung often seen in post trauma patients and just as often ignored by medical staff) i am talking about complete lung collapse without mediatinal shift. this is just as immediate a problem due to dyspnoea and decreasing saturations. what makes this life threatening is that the remaining lung cannot expand properly as the air in the collapsed side "gives" with each inhalation. these people are in trouble and they know it. they show classic dyspnoea - gasping and often gulping breaths, hyperpnoea, sweating and anxiety ++++++++ aucultation may have sounds on both sides (due to transmitted sounds) but usually there is diminished breath sounds on the affected side. usually there is time though for a check chest x-ray. so less immediately life threatening but you still do not want to twiddle your thumbs.
i might have missed it but i didn't see a time frame from when the mva patient had had his accident. a time frame would have heightened my "index of suspicion" with regard possible adverse outcomes. with post trauma chest injuries i have an almost "graph like" index. it looks like those graphs of cardiac enzymes - i.e. first hour increased possiblity of developing life threatening pneumothorax this possibility fades over the rest of the day while the possibility of significant haemothorax increases over 12- 24 hours we expect the devlopment of pulmonary contusion while 24 - 48 hours we expect the development of pneumonia.
just a ps - i have witness not one but two cases of tension pneumothorax on ventilated patients where they did not develop either the classic cardiac symptoms or the mediastinal shift. both cases were pseudomonas pneumonia patients both cases the pneumonia was so solid the lungs did not collapse but the patients diaphram blew out and both cases were in the days before oxygen saturations.
- 0May 21, '03 by betts"We could do it so that there is no shame or blame in getting the answer "wrong" and indeed in some questions the "right" answer might be one of several "rights"." quoted by gwenith
Ask yourself this; "Would I rather be here, in this forum, or on the floor where I'm employed if I'm mistaken?" Again, I would rather hear/learn from my colleague's than a medical review board/attorney.Last edit by betts on May 21, '03
- 0May 21, '03 by SmilingBluEyesWELLLLLLLLL I am new to the thread but believe me or not (just an OB Nurse here) I thought immediately Mr. Jones was the primary concern based on the old basic ABC's. Of course, it sounds easy for me to say AFTER you have already said who/what to Tx first, but that is honestly my first impression.