Critical Thinking Snapshot for Nurses&Students

Nurses General Nursing

Published

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 skidded off the road and hit a tree at approximately 45mph. He reported losing consciousness at the scene. Mr. Jones was admitted in stable condition with a diagnosis of myocardial contusion and fractured ribs (4,5, & 6) on the left thorax.

Vital signs on admission were:

-BP 138/84

-P 80

-R 18

-T 98 degrees F.

Past Medical History: No chronic illness. No previous hospitalizations. No medications. Patient is a non-smoker and does not drink ETOH.

Family History: Father died at the age of 50 from a "heart attack". Mother is alive and has lung cancer. No siblings.

Patient: Mrs. Smith

Mrs. Smith, a 64-year-old female with known coronary artery disease, was admitted for coronary artery bypass surgery. Her risk factors for arteriosclerosis include a strong family history, smoking, and hypertension. She has been admitted to the CCU several times with angina. Cardiac catheterization demonstrated a high grade (>90%) stenosis of the left anterior descending (LAD) artery. Surgery was performed 3 days ago with a left internal mammary artery (LIMA) graft.

Mrs. Smith stayed in the Cardiovascular Surgical Intensive Care Unit (CVSICU) for two days. On the second day, her Swan-Ganz catheter was removed, IV medications tapered off, and her Foley catheter removed. On this, the third day, Mrs. Smith was transferred to the step-down unit with a heparin lock IV in place.

The Situation

Welcome to the night shift!

You are an experienced nurse working with three new graduate nurses on a 16-bed multitrauma acute care unit in a remote community hospital. You just finished receiving a brief report on your patients and return to the main nursing station to find two call lights activated. You answer both lights over the in-room intercom, asking the patients what they request.

Patient A, Mr. Jones, states that he is experiencing difficulty breathing.

Patient B, Mrs. Smith, states that she is experiencing chest pain.

Your shift is only 30 minutes old, and it appears that it will be a long night!

What would you like to do first?

Go and see Mr. Jones

Go and see Mrs. Smith

Review each patient's history

Call their Doctor

Go on Break

Reasoning?

I 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?

Specializes in ICU.

rn2b 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.

I would go see Ms. Smith first because of her known history and the chest pains.

Student Nurse

"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.

ABC's always first...

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

WELLLLLLLLL 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.

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 skidded off the road and hit a tree at approximately 45mph. he reported losing consciousness at the scene. mr. jones was admitted in stable condition with a diagnosis of myocardial contusion and fractured ribs (4,5, & 6) on the left thorax.

patient: mrs. smith

mrs. smith, a 64-year-old female with known coronary artery disease, was admitted for coronary artery bypass surgery. her risk factors for arteriosclerosis include a strong family history, smoking, and hypertension. she has been admitted to the ccu several times with angina. cardiac catheterization demonstrated a high grade (>90%) stenosis of the left anterior descending (lad) artery. surgery was performed 3 days ago with a left internal mammary artery (lima) graft.

mrs. smith stayed in the cardiovascular surgical intensive care unit (cvsicu) for two days. on the second day, her swan-ganz catheter was removed, iv medications tapered off, and her foley catheter removed. on this, the third day, mrs. smith was transferred to the step-down unit with a heparin lock iv in place.

the "trigger" for me on this one is comparing the 2 patients, granted mrs. smith could possibly be reinfarcting, however when you consider that mr. smith was admitted only 6hrs ago from a mva, unbelted and 3 rib fx's you have to consider a tension pneumo here which can quickly progress into severe complications. i'd go check on mr. smith 1st listen for diminished breath sounds on the left. meanwhile mrs. smith was transferred back as stable.

beyond that i'd delegate to other staff to check on mrs. smith and her cp, possibly get here a nitro tab see if that helps and slap some 02 on her. mr. smith on the other hand has a much shorter timespan, if it was a tension pneumo he'd need a ct fast. if i had checked on mrs. smith 1st, mr. smith could have expired in that time, and it would be too late to save him. hence litigation.:eek:

Originally 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.

AMEN> -- I'm a hemodialysis nurse these days....such situations are EXACTLY why I got out of the hospital. You can't know the entire situation that quickly (especially with it on paper and the patient is sight unseen) and I didn't have the benefit of v/s and assessment data in the original scenario....also, my experience is in coronary care much more than in trauma care. We always shipped those out to the trauma centers.

But I still say if you can talk, you can breathe.

And I STILL say that leaving the whole thing unanswered in a freakin' bulletin board doesn't say anything at ALL about those who chose to read and not respond. We all have that right.

Originally posted by sandgroper

And the number of staff for this unit is very dangerous to start with. If you allowed yourself to be in this position, only one person will be responsible for any adverse outcome.

That's how it is in the real world.

Wow can we get more of this betts?

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