Critical thinking exercise

[Teacher Sue]

I used this case study with my students today, and got quite a few different answers. What do you guys think?

Mrs. M was admitted four days ago with CHF. She has a long hx of the disease, and is usually admitted several times a year. She has been treated with IV lasix and dig, and has been diuresing well. When you get shift report from the daylight nurse, she tells you that Mrs. M's urine output has been dropping, and she emptied 500 ccs from her foley at 1400. You have to give a pain med to another patient, then answer phone calls from two other patient's families before you get in to see Mrs. M. When you go into her room at 1600, she is sleeping, but you notice immediately that there is no urine in her foley bag. What is the first thing that you do?

[Teacher Sue]

Most of you got the answer I wanted from my students. Of course, check the foley for kinks. None of the students thought of doing this. Most wanted to assess the patient, check labs, then call the doc, which of course would be the right thing to do if there was no urine. One wanted to call the doc immediately, and one young man wanted to put a PA line in to check her fluid status.

This is only my second semester as a teacher, after 20 years in a hospital setting, so maybe I am doing things wrong, but I don't know why everything has to be so complicated. Of course I want my students to know that patients with CHF are at a higher risk for kidney failure, and that lasix can cause kidney damage. But I also want them to know that sometimes the simplest answer is the correct answer. This is their last semester, and some of them seem so unsure and frightened. I just want to give them some confidence and let them know that it isn't always going to be a struggle.

So now, here's another one.

Mr. J was admitted two days ago with COPD and pneumonia to a monitored bed. He has been getting IV ATB and IV steroids. His sat has been 93% on 4 liters of O2. He had a respiratory treatment a few minutes ago, and now his monitor is alarming with a sat of 84%, and he is having a few PVCs. You assume he took his O2 off again since he has a tendency to remove it. So you go into his room to put it back on, but the cannula is in place. What do you do next?

[Paige Turner RN]

make sure its connected to the source................

[Erin RN]

Make sure the O2 is on..many times the resp therapist turns the O2 off while giving a treatment...:) Erin

[RN_Amy, RN]

Hee hee... nothing like nasal cannula in situ... with the oxygen tubing not connected or kinked or not turned on..... and a pale bluish-looking patient.....

I get lost in translation re. USA and Australian medical terms..... PVC's? Is that Pre-Ventricular Contractions?

[Noney]

Is the pulse ox attaqched to his finger correctly?

Noney

[treddrn]

scream at the top of my lungs

oh my god there is no urine

:rotfl:

duh, assume she hasn't urinated???? :chuckle

seriously,

check for kinks in the tubing first!!

[canoehead, BSN, RN]

Look at the patient, if he looks sick then turn up O2, vitals, full assessment- if he looks the same ask him how he feels and check connections and moniters.

[Erin RN]

scream at the top of my lungs

oh my god there is no urine

lol first thing wake her and ask her if she feels the urge to relieve her bladder and then palpate her bladder, then check for kinks and then see when her bag was emptied.

in keeping with ccu's assessment of scenario number 1..on number two, i would perform an emergency trach using one of the 200 bic pens in my pocket...sorry, just couldn't resist!! :rotfl:

[bellehill, RN]

Make sure O2 is turned on, check pulse ox, try another finger...talk to the patient-are they coherent, are they SOB, are they in pain? If all that is normal get a mask.

[zumalong]

Great thread!!! I, too, would check to see if O2 was turned on--and check if pulse ox was on finger (ear) whatever correctly. Then I would check vitals- lung sounds etc. and take it from there.

Reminds me of when I was a NA and one of the night nurses comes running out of pt room at 4am screaming because patient's temp was 106. When we all went down to room patient was sitting up in bed rubbing eyes and looking quite healthy (this was in Nursing Home) wondering who was screaming. Turned out nurse took temp with thermometer that had been cleaned under hot water!! :angryfire :angryfire She never shook down thermometer. :uhoh21: :uhoh21:

(this was many many years before we had digital)

Remember--you can teach all the facts you want and offer all the critical thinking skills you have--but you can't give away common SENSE. :chair:

[laurakc]

by saying she is sleeping, i hope that as I observe that I also notice how she is breathing..listen to the heart/lung sounds..which would be far more important than urine...what is her rhythm, other vitals..I find it hard to believe that she would be in distress with her breathing (as most are anxious, and obvious) and be sleeping...i also find it hard to believe that her bladder would be about to explode and she would be sleeping...

and yes check the foley for kinks..

oh, by the way, first questions kill me..I do look, listen and feel at the same time..see the effort while listening to lungs, check perifpheral pulses, is she cold, move the foley tubing around and see if it is kinked..further actions as neccessary

[ShelleyERgirl, LPN]

Remember--you can teach all the facts you want and offer all the critical thinking skills you have--but you can't give away common SENSE. :chair:

You aint kidding, Zumalong! :) Once worked with an Rn in an Ob/gyn office who had a couple of kids at home. She actually asked me how many trimesters there were in a pregnancy? :uhoh21: Uh, Hello?! Doncha have a couple of kiddies at home and work in an OB/gyn office and you DON"t know this? Scary.....very scary.....