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Discussion

Critical thinking ability

I just started in ICU and i am 2 weeks in. Orientation is only 3 months. So far, I am learning about the environment of ICU and the documentation system they have in place, and pretty much just getting comfortable touching things in the room and playing with the computer. I am starting to understand the procedures of documentation stuff, such as signing off orders (meaning all I do is sign my initials on orders that are folded under the "DR orders" tab of my patients chart)...but that's about it.

So my questions are....

1. IS IT NORMAL TO.....

(A)...Not be able to critically think your way through everything at first?

For example, I took care of a guy who's admitting dx was "Symptomatic bradycardia". A temporary pacemaker had to be put in him right away. On admission to ICU, I believe he was hooked up to oxygen with a venturi mask, he was confused, on dopamine drip, had terrible ulcers on his heels with wound van in place, legs were discolored and had patches on them that were brown, and was edematous from toe all the way to his groin.

He has a h/o DM, very very sedentary lifestyle, nephropathy, and I think he had heart disease...I don't know exactly what it was, but at home he was taking amiodarone, he also had recent double pneumonia.

--Critical thinking concern #1- At the time, I didn't understand the edema right away, even though I knew I had to assess for it and document it.

-----But, after just a little bit of studying, I realized that it is most likely from the ineffective pumping of his heart, which can cause pooling of blood that backs up into circulation. After what I thought was my "A-HAH" moment, I started to think about 5 million other reasons why things are happening.Maybe the edema is from kidney failure? At least throughout the stay in ICU he was barely putting out urine, so is he just retaining tons of fluid? I mean if the kidney disease is chronic for him, that would be the bigger culprit of this edema, rather than this new onset of symptomatic bradycardia (in the ER his HR was like 28). So, is it normal to not know exactly what's happening or what's causing what when the pt has not only the admitting dx, but a somewhat extensive med/surg history? My preceptor told me herself, "we don't know if he was in septic shock (recently had heels debrided) or what", so I guess I know we nurses can't know the cause of everything..

--Critical thinking concern #2 : My patient had told me he had chronic back pain. His sister asked me why his arm twitches, which is something I hadn't seen before during his stay. I knew I had put his oxygen up a little earlier because his sats were dropping while he was sleeping (he doesn't like to wear bipap). So my first thought out of being paranoid was "oxygen toxicity!". Then my preceptor was like "he has kidney disease, his electrolytes are out of whack". like, omg I feel like I can't critically think! I knew she was right and I was like "oh of course!" but damn, I feel so stupid sometimes.

(B) ...Not understand the "in between" stuff that needs to be done (aside from nursing judgement and skills)?

I know that frequent assessment and passing meds need to be done, but it's the in between stuff that I don't understand. Even after watching my preceptor do it for 5 days, I still don't fully understand the other RN responsibilities and I know she's mentioned the routines to me (sometimes in a manner that an experienced nurse would only understand). Is there anything that's routine everywhere when it comes to documentation and checking orders?

© ...Not know how to talk to a doctor and when to make the call?

Sometimes I don't know if I'll know when to call the DR. EXAMPLE: My pt was put on heparin, his platelets over the past few days have been around 108-112, then one day it dropped to 91k. My first thought was heparin induced thrombocytopenia. I asked my preceptor, "would u call the dr?". She said it's a concern, but no need to call the MD about. Btw, this is the day shift, so DR's are on the floor anyway. So all you need to do is just keep on top of the chart for the DR to look at when he walks by, and simply circle the lab value to bring it to his attention. I don't want to be that nurse who calls the doctor all the time, I don't want to look like an idiot (but I certainly will to be on the safe side). I also understand that nursing judgement and calling the DR goes hand in hand, and that this comes with experience and I'm sure is hard for you guys to explain to me, but maybe someone out there is capable of explaining :)

Sorry this is long and my thoughts are all over the place, and YES, I have and will continue to read other posts. In conclusion, my concern is nursing judgement and making the call...and documentation protocol (which I know is different everywhere...but i'm sure some things are routine everywhere).

I hope someone can address my questions, I really appreciate everyone reading this very long post and responding, I tried to put things in bold for those who don't want to read everything.

Thank you!

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    I am concerned about your attitude about "signing off orders." If you think that it simply means that you sign your initials, you are missing the whole point. The point is that an RN needs to check those orders to make sure that they were properly processed -- entered into the computer correctly, communicated to the team properly, etc. The RN review is also a safety check to help catch a mistake that may have been made by the physician writing the order. If you are simply signing your initials without actually checking the orders -- you are dangerous and should not be entrusted with that responsibility. I hope you did not actually mean what you wrote.

    As for the critical thinking ... No, you are not supposed to know it all - ever. And you certainly expected to be a little weak in the critical thinking as a new grad. There will be lots of stuff you don't know and that's OK. But you should be able to think through a few basics even at this point in your career (such as why RN's need to sign off orders) and identify some of the patient's nursing needs even if you don't understand all the pathophysiology. A few things should be clicking into place when someone demonstrates or explains something to you -- and you should see a little improvement in your understanding and ability to think for yourself as each week passes.

    Good luck to you.

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    LOL - I think nursing schools are really doing a number on students these days. There seems to be almost a mystical aura about the magical and ephemeral thing known as "critical thinking". First of all, I want to reassure you. If you continue to maintain the degree of reflection that is indicated in your post -- you're on your way to becoming an 'expert' critical thinker. Srsly.

    Learning is an "effortful" activity that does not just happen naturally. Everyone has experiences, but they don't result in learning unless you actually take the time to think about what happened, why it happened, and what you could have done to change the outcome or handle it differently in the future. People who don't make the effort can just go on about their business - repeating "year one" over and over again - LOL. Experience does NOT = Expertise.

    In order to think critically, you have to 'flip' through all those virtual files of information you have in your brain. At first , you may not have very many files & they're pretty thin. But as time goes on, your files get thicker & more numerous... you develop filing organizational systems that connect all the relevant files into 'mental models' of various situations (called "schema" by educators). These models will let you figure out things much more quickly. For instance, a mental model of chronic renal failure contains all of that related data (physical appearance, circulatory status, lytes, etc) that normally happens with CRF patients.

    With sufficient expertise, you'll bring up a mental model with just small pieces of information - all the while noting anything that is "off" from what you expect .... which will trigger the need for further investigation. I'm sure that you have come across those 'wonder nurses' who seem to know exactly what is going on & have the ability to accurately predict what is going to happen. That's because of robust mental models. They seem to be able to sense when something is going wrong with a patient before there is actually any specific diagnostic data. It's cognitive science, not ESP or intuition... just well-developed mental models & keen powers of observation.

    You'll get there if you keep putting forth the effort to learn. In a few years, the newbies will be looking to you for reassurance. It'll happen.

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    i wrote "...and the fact that doing research like I usually do is unrealistic, which overwhelms me" which isn't grammatically correct. I meant to say "Doing research like I do at home is unrealistic, and that overwhelms me"..lol

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    LOL - I think nursing schools are really doing a number on students these days. There seems to be almost a mystical aura about the magical and ephemeral thing known as "critical thinking". First of all, I want to reassure you. If you continue to maintain the degree of reflection that is indicated in your post -- you're on your way to becoming an 'expert' critical thinker. Srsly.

    Yes, I will always put forth the effort to learn, but I'm so insecure about myself when I don't have the answer to something, or when i seek information that maybe I should already know? lol. I will continue to seek information for the sake of patient safety, but I don't like doing it when I know that I should know the answer, but I don't :(.

    (as mentioned in my initial post), at least I was correct about symptoms of oxygen toxicity...but I failed to look at the whole picture. I still turned the 02 down to what it was before I turned it up, 10 L/min, (pt required bipap when sleeping, but is non compliant, sats went down, RN told me to turn 02 up to 15L/min from 10L/min because I asked her what I should do :o (because for some reason i thought 02 was an order unless it was an absolute medical emergency, such as a MI)...I don't want to be that new grad who has to ask questions, especially "what should i do?" when I could probably figure it out myself. I'm in student mode, so I will continue doing that, and I will ask questions no matter what, but i don't like to, and i don't want to get a bad evaluation saying I need to depend on the preceptors judgement too much and I can't be independent.

    You know?

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    I can understand how critical thinking can be challenging. I often struggled with this during my 2nd year of nursing school. What helped me the most was mind mapping. I learned that I wasn't an auditory learner rather I was visual and kinaesthetic. This meant that by drawing up a mind map, I was able to make the connections. Now that I am a new graduate, I feel confident with my skills. Although I still keep my textbooks and notes by my side as its always good to review back. Its nearly impossible to retain everything you've learned in Nursing School. Great nurses don't know everything, they teach themselves and find the information the need to make sound ethical judgements. Below I have sent you a link on how to mind map. Hope this helps and good luck. P.S. Believe in yourself. You've made it this far

    Concept Mapping... for the slightly confused

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    • Author
    I can understand how critical thinking can be challenging. I often struggled with this during my 2nd year of nursing school. What helped me the most was mind mapping. I learned that I wasn't an auditory learner rather I was visual and kinaesthetic. This meant that by drawing up a mind map, I was able to make the connections. Now that I am a new graduate, I feel confident with my skills. Although I still keep my textbooks and notes by my side as its always good to review back. Its nearly impossible to retain everything you've learned in Nursing School. Great nurses don't know everything, they teach themselves and find the information the need to make sound ethical judgements. Below I have sent you a link on how to mind map. Hope this helps and good luck. P.S. Believe in yourself. You've made it this far

    Concept Mapping... for the slightly confused

    Thanks for this, it was a refresher of what I had learned in NS, and it will help me during my shift.

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