Critical thinking excercise - need your thoughts, please!

When you are presented with a scenario like this you need to go through the nursing process.

Step #1 is assessment. You've been told the patient has a skin rash. As part of assessment you are going to ask some questions about the history of this rash. When did she first notice it? Has she had a rash like this before? If so, where, and when? What does she think might have caused it? Does it itch? Has she done anything to treat it? If so, what? Did it help at all? That is all subjective data. Now, for the objective data, that would be your physical observations. What does the rash look like? There are a number of descriptors that can be used for rashes such as erythema, macular, or papular. Does it hurt to touch the area of the rash? Can you feel heat? Is the rash rough or smooth to touch? Is the skin over the rash dry or moist?

Step #2 is the determination of a nursing diagnosis based on the symptoms, or defining characteristics, the patient has. In this case, you are kind of free to let your imagination go since all you are given was "rash". Understand that you wouldn't do this with a real patient. However, this is an exercise in critical thinking. OK, so lets say that this rash is red and she tells you it itches like the dickens. You can see where she's nearly scratched herself raw to the point that parts of the skin over the rash are weeping. Nursing diagnosis: Impaired Skin Integrity R/T mechanical trauma AEB open, weeping skin.

Step #3 is to plan your nursing interventions. You would develop interventions for treating the pruritis and open skin areas.

Step #4 is to implement the plan.

Step #5 is to evaluate the effectiveness of the plan.

However, as a nurse you understand that the patient is going to be seen by the doctor. The doctor is most likely going to prescribe something for the patient's pruritis or an anti-infective to help prevent the open skin areas from infection. A collaborative problem is a problem that needs the help of (an)other healthcare provider(s). It's a problem that you, as a nurse, can't fix on your own. In this case your collaborator will be the doctor. The collaborative problem: Potential Infection. With skin you worry about infection if there is any potential for a break of skin integrity. You can carry that one step farther and consider septicemia as a potential collaborative problem as well depending on the likelihood that it could happen. You, the nurse, cannot prescribe the medication that the doctor can that is going to be the most efficient way to clear this rash and prevent an infection, which is going to be his major concern. So, in developing your nursing interventions for this Impaired Skin Integrity you are going to carry out some very specific orders from the doctor. He may have you start some sort of prescription ointment or cream right then and there. He may order an injection of an antibiotic. Any treatments he orders will be based on HIS physical assessment and medical decision. As the nurse, you carry out those orders. Those are considered collaborative interventions because you cannot do them without the instructions of the doctor.

So, let's assume the doctor has decided that the patient has scabies (one of my favorites, since I've gotten this from patients twice over the years!). He's given the patient prescriptions for Elimite and Triamcinolone. Going back to Step #3 of the nursing process you need to develop some nursing interventions. For your collaborative problem of Potential Infection your interventions are going to include things such as going over the proper use of the medications and the signs and symptoms of any side effects, giving the patient information about the disease and that they need to wash all their bed linens and clothing in hot water after applying the Elimite. You wouldn't even do these things if the doctor hadn't made the diagnosis and ordered medication. Your independent nursing interventions will be things such as to avoid scratching at the itching areas with their fingernails and use the pads of their fingers instead, to try cold compresses to relieve the itching, etc.

Does that help you understand the critical thinking process going on? You could change this very easily. You could say the rash is due to rheumatic fever and go from there with it. You would have different collaborative problems, perhaps, but the idea of the difference between independent and collaborative problems is what I'm trying to get you to understand. There are those problems that we nurses can treat independently and those we just can't. The ones we can't and need other assistance in treating are called collaborative. You can get good explanations of collaborative problems in the care plan books by Lynda Juall Carpenito.