Critical Thinking Snapshot for Nurses&Students

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    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 patientís history
    Call their Doctor
    Go on Break

    Reasoning?
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  4. 33 Comments so far...

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    Ok, I'm not a nurse yet but I'll give this a try. Someone tell me who you can send if you can't be in 2 places at the same time?
    Ok, If Mr Jones is having trouble breathing I would go in and assess him first. He could have a blood clot in his lung d/t the contusion of the heart and fx ribs?? Next Mrs. Smith has chest pain.....I would think that she would have some pain after the surgery and a she has hx of angina. (Nitro ordered??)

    Depending on the results of the physical assessments, I suppose you would have to call the dr. for the first patient.

    Ok, guys whats next?????????????
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    31 Views/1 Reply......? This is basic nursing 101; those that read w/o replying, I'm guessing would opt for the break?

    Let's think again
    This is not a good choice if you value your job. Is there additional information you might want to obtain before you do this?
    Last edit by betts on May 19, '03
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    Originally posted by betts
    31 Views/1 Reply......? This is basic nursing 101; those that read w/o replying, I'm guessing would opt for the break?

    Let's think again
    This is not a good choice if you value your job. Is there additional information you might want to obtain before you do this?
    OK, Betts, lay off those who clicked on it to read it and decided that they were (a) too busy or (b) too tired from dealing with the same sort of stuff to worry with it. Not everybody answers tough questions when they're off work....

    But for my part....

    I will send another nurse in to assess the pt who has diff. breathing, but who can apparently still talk, while I go assess the chest pain complaint. She's the less stable patient in my book. Since I'm the only one with experience, what I will do next depends entirely on the results of the assessment of Ms. Smith. IF she's in distress I will page the supervisor STAT and then the MD, have another nurse grab the crash cart and check in on the nurse assessing the other patient.

    You can still rely on your supervisor to help out in a pinch like that. At least I always could.

    IF she's not in distress I'll avail myself of any prn standing orders I might have and notify the MD of any change and move on to check in on the other patient.


    Ditto the situation in reverse.


    Barb
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    Unfortunately, the pt you should have seen has expired and now you have to contend with a medical review board with your license in question.

    This is also on the NCLEX...

    Remember the simple ABC's of basic life support. A patient's airway, breathing, and circulation are the most critical elements to maintain life functions.

    Read the histories again and again if necessary, you all know the answer but, leaving this one unanswered draws a RED FLAG!
  9. 0
    babs_rn, this wasn't a tough question but it is one that will give cause for additional probationary periods.
    Your answer is incorrect. Remember the simple ABC's of basic life support. A patient's airway, breathing, and circulation are the most critical elements to maintain life functions.

    Mr. Jones is complaining of extreme shortness of breath, light-headedness, and a feeling that he is going to die.
    Vital Signs
    ∑ BP 86/40
    ∑ P 140
    ∑ R 32
    ∑ T 98 degree F.
    ∑ Pulse oximeter = 82% saturation
    Physical Exam
    Mr. Jones appears anxious, alert and is oriented. He follows commands. Pupils equal and reactive to light at 3mm. Skin cool and clammy. No edema. Neck veins are distended with the head of the bed elevated 45 degrees. Respirations are labored, rapid, and shallow. Lung sounds are clear on the right, hyperresonant on the left. His trachea shifted to the right of midline. Heart tones are muffled. As you gently palpate his rib cage you feel a sensation similar to that of "Rice Crispies" snapping beneath the skin. When you percuss his chest, you hear sounds characteristic of hypertympany.
    Mr. Jones is suffering from an acute closed tension pneumothorax. This is a rapidly fatal emergency that is easily resolved with early recognition and intervention.
    Tension pneumothorax occurs when an injury to the chest allows air to enter the pleural cavity but not to escape. Air accumulates in the pleural space with each inspiration and as intrathoracic pressure increases, the lung collapses. The increased pressure then causes compression of the heart and great blood vessels toward the unaffected side as evidenced by a mediastinal shift and distended neck veins. Cardiac output falls significantly producing signs and symptoms of shock.

    Tension pneumothorax may be the immediate result of primary traumatic injury, a delayed complication of an occult injury such as bronchial tear, or the undesired complication of necessary therapies such as mechanical ventilation.
    Hallmark signs and symptoms of a tension pneumothorax include:
    ∑ anxiety
    ∑ rapid, labored breathing
    ∑ distended neck veins
    ∑ tracheal deviation from the midline
    ∑ weak pulse
    ∑ rapidly falling blood pressure
    ∑ subcutaneous emphysema
    ∑ diminished breath sounds on the affected side
    ∑ muffled heart tones
    This sure describes Mr. Jones. There is no time to waste so let's manage this emergency before he expires on "your shift".

    Needle thoracostomy is the treatment of choice for a tension pneumothorax prior to the insertion of a chest tube.
    Once the needle entered Mr. Jones' pleural space, where all the pressure was built up, you heard a "gush" of air come rushing out. This maneuver released all the pressure in the cavity. In addition, his vital signs returned to his baseline.
    ∑ BP 130/82
    ∑ P 78
    ∑ R 18
    ∑ T 98 degrees F.
    ∑ Pulse oximeter = 93% saturation

    You just saved this patient's life.
  10. 0
    Brand new nurse here and I got this wrong. I have to remember ABC's but I assumed that he was having problems because of broken ribs. This is the kind of case scenarios that need to be empathized in nursing school. Thanks for reinforcing a very basic lesson!
  11. 0
    Making the case look more difficult than it is, is used widely in most nursing programs simply to trip us up. That's where our Critical Thinking comes into play.

    Case in point: Mr. Jones was admitted in stable condition with a diagnosis of myocardial contusion and fractured ribs (4,5, & 6) on the left thorax.
    Mr. Jones, states that he is experiencing difficulty breathing. I'm thinking; broken rib(s) punctured lung? Often the PT History is what we're considering relative, not the additional injuries.

    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.
    Reading above, we see that Mrs.Smith has been taken off meds, she's evidently mobile and feeding, Swan is removed indicating good blood flow/pressure so she's considered stable w/no complications.
    Its been 8/16 hours(your night shift) and she's experiencing chest pains. Nothing in report indicated any complications.

    I'm not meaning to question any others nursing ability, just wanting to impress upon all the need for Critical Thinking, and to take the time to assess,read and read again. Afterall, their lives depend on us.
  12. 0
    Well, I hate to say that I knew that Mr. Jones was more unstable but a MVA, unbelted and fx ribs is just begging for a pneumo. Plus the fact that he is already set up for tamponade as well.

    I would have sent one of the grad nurses to assess Mrs. Smith gathering PQRST, VS and calling for an EKG, and throwing on some O2.

    Nurses can't be everywhere, a matter of prioritization and delegation.

    Good example Betts.
  13. 0
    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.


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