Critical Thinking

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    Throughout the rest of your school and nursing career, you will hear the term “Critical Thinking”. What is it really? How do you do it? So I wanted to walk you through a scenario so you can understand it and see it in a clear picture. I will do this through the skill of “taking a blood pressure” all the way to understanding the problem and knowing what to do when the numbers are "crazy".

    Critical Thinking

    I wish someone would have explained exactly what it meant to "think critically" when I first started nursing school - it sure would have saved me a lot of time trying to figure out how to answer my assignment questions and create better careplans! My hope is this article will help you delve deeper into your patient care by looking holistically at your patient - from the cause of injury/illness to the pathophysiology to the interventions and WHY you are using the interventions you chose. Let's start with you as a student nurse tech in an emergency room.

    Level 1: You are a new student nurse and you have just learned how to take a blood pressure. Your job is to take vitals on patients who come into the Emergency Room and record them. This is the first level of the pyramid.

    Level 2:
    You understand the numbers – diastolic and systolic – and what a normal range is.

    Level 3: You understand that you need to report the "abnormal" range numbers to someone because something is not right with the patient.

    Level 4: You are now a nurse working in the Emergency Room. You understand your patient, who just came in the ER because of an auto accident and has no external bleeding, has a lower than normal BP that could be due to some sort of internal bleeding that you cannot see. You call for help (Rapid Response/Code, depending on the situation) because this patient may turn into a code. You draw labs and a type & cross for blood matching, radiology in to do x-rays, and respiratory in for oxygen support.

    Level 5: You understand that your patient (in the ER) needs you to provide fluids through an IV so that he/she will not "bottom out" and die. You remember your ER has a protocol for this situation and you begin to follow that protocol: You take steps to help the patient, including starting an IV, elevating the feet, keeping the head flat. You set the monitor to record BP every 5 minutes (or 2, depending on your situation). You understand you will need to monitor the urine output for this patient so a foley is needed.

    Level 6: You begin to classify your patient's hemorrhage level from a class I – class IV

    Level 7: You understand that a low BP due to hypovolemia (low fluids in the body) can cause the heart rate and respiration rate to increase and perfusion failure/tissue hypoxia. You know you need to begin to administer IV fluids – but you know that you cannot use ISOTONIC fluids, instead, you will need a crystalloid. You anticipate the need for blood and (you can then discern if your patient needs whole blood versus packed red blood cells). You also know the amount of fluids you can give in a certain time frame so that you don't turn the patient's remaining blood into "kool-aid" with a fluid overload and thinning it out too much.

    Level 8:
    You understand if your patient continues down the present road, the next step will be organ dysfunction and possibly multi-system organ failure and death, so you need to perfuse those organs and prevent shock.

    Level 9: You understand your patient needs to go to the operating room to find the source of bleeding. You prepare to administer medications to prevent shock – specifically inotropes like dopamine – because you know it has a positive chronotropic and inotropic effect and if a higher dose is used will have a vasoconstrictive effect that can help your patient's perfusion, can help with cardiac output, and can help your patient live!

    As your knowledge base increases, you will be able to anticipate what is needed for your patient and why. You will be able to intervene before the next problem arises and help fight off the Grim Reaper in some cases. Critical thinking is thinking deeper than the surface level - it means understanding what is happening and why, what will happen to the patient if interventions are not done, and what is needed to make the issue normal - or as normal as possible - again.
    Last edit by tnbutterfly on Feb 21
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    About Julie Reyes, DNP, RN

    Joined: Aug '08; Posts: 263; Likes: 1,546
    PICU RN; from US
    6 year(s) of experience in pediatrics, occupational health

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  3. by   Julie Reyes
    I always like it when my patient's turn into a cod. LOL! I wonder how that typo got there?!
  4. by   tnbutterfly
    I edited it for you......However I was very tempted to leave it... Made me laugh.

    You call for help (Rapid Response/Code, depending on the situation) because this patient may turn into a cod.

  5. by   Julie Reyes
    Right?! I laughed out loud when I read it! I thought - well, ok, that makes this WAY more entertaining!
  6. by   jitomim
    ....begin to administer IV fluids – but you know that you cannot use ISOTONIC fluids, instead, you will need a crystalloid
    All the cristalloids I know of are isotonic or, in the case of Ringer Lactate, discreetly hypotonic. A colloid, perhaps ?