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?

[nekhismom]

Well, according to NCLEX priorities, you would assess ABC's. So, is the airway patent? Is this person breathing? Cyanotic?? Conscious??

I agree, check the probe and the tubing. Didn't think of O2 toxicity right off the bat, but sounds good to me now that someone suggested it.

[kimtab]

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:

I think I saw MacGyver do that once. And if the Foley on the first patient wasn't patent you could take another pen and do a quick suprapubic catheterization.

Those are good questions, as a last semester student I will just say that there is so much info in our heads at this point that there may be a tendency to overlook the obvious...There are still people in my class who want to get ABG's on a patient with dyspnea before they raise the head of the bed. Bless you for trying to inspire some confidence though!

kim

[MikeLPN]

Take a good hard look at pt. for being symptomatic and ask him/her how they are feeling?

[nurseshanti]

I'm a student too, in my third year... and these are great. Thanks for posting them.

I would probably first check whether O2 is actually on, whether the pulse ox is attached and whether the cannula prongs are sitting properly in his nares.

Do a set of vitals, Check his resp., lung sounds, ask him what he's feeling (short of breath?)...

In the back of my mind would be the thought that the O2 could have kicked out his drive to breathe, given that he's a COPD patient.... so if everything else seemed normal, I'd probably look into that. I would have thought though that if he was tolerating 4L before that it should be ok..... Can the resp. treatment alter his O2 needs? Although we've been taught that COPDers shouldn't really get more than 3L.... I guess that's not necessarily the case out in the real world.

Did I do ok? :)

[zumalong]

:) I would wash my hands

:chuckle :chuckle ROFLMAO!!!

[twarlik]

FIRST check to make sure that the pulse ox is on the finger correctly

Yes, I agree with your answer. We had a similar question on the HESI fundamentals exam last semester. We all got it wrong because we wanted to turn up the O2 and do a bunch of other things. The simple answer was that you would FIRST check the placement of the pulse ox.

Give us some more, Sue! This is fun!

[nurseT]

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?

Ask pt how he feels, check O2 and pulse ox function and go from there.

[Teacher Sue]

Again, the simplest answer is the best. See if the O2 is connected and turned on, and the pulse ox is on correctly. Oxygen toxicity is possible in theory, but in practice, I have never seen it in patients on 4 liters of O2. The PVCs would have been more likely to be caused by hypoxia. Of course, you want to be assessing your patients while checking these things out. You should be observing the patient, and asking questions while you are checking the foley and the O2.

It seems my students are catching on a little to the KISS theory. A few of them wanted to see if the O2 was on before they performed more drastic interventions. I think they are starting to feel a little more confidence in me as a teacher, and I am starting to feel like maybe I am going to be good at this. It was a big step for me to leave the hospital, but I have wanted to teach for years, and am so glad I finally did it.

[zambezi, BSN, RN]

As everyone else mentioned, check if O2 on, check if pulse ox is on correctly, if it were night time, I would watch the patient breathe and see if that 84 is a result of sleep apnea...which, actually, I see quite often...after, that, on to other interventions.

[BadBird, BSN, RN]

First thing I would do is call her name to wake her and check her vital signs, remember ABC'S airway,breathing, circulation. What is her pulse ox reading, what is her neuro status, is she arousable. Check the foley for kinks, irrigate if needed, bladder scan. Check her hydration status, is she receiving running IV's? Is she dehydrated? When was the last chest x-ray? Latest labs? Then call the doctor and inform him/her of your assessment.

[tiredfeetED]

GIVE ME A 8fr ETT with a Straight blade! Sir Relax Im a trained prof.! :)

I guess after a couple years in ER, one thing ive learned never trust what a monitor says. There is countless times our monitor says VTACH or fib pt is moving talking with family or 0 resp again talking and breathing. Always check connections and Get a Man. BP!

[CCU NRS]

see what the med was in the resp tx and assumne it is albuterol causing this trouble

I really do see this in COPDrs after nebs with albuterol they get tachy from the meds, the resp. goes up and sats come down.

Of course I treat the Pt, adequately attentive until the S/S are obvious and hyperventilation is past and Sats are returning to normal.