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?

[kc ccurn]

Teacher Sue, I have another scenario for your students....

I had a patient once with a chest tube for pneumothorax, intubated and sedated. Some co workers were in the room with me, chatting, when we noticed that his pulse ox dropped to mid-high 80's, we assessed his airway-he was still intubated, on the vent with oxygen flowing, breath sounds he had absent breath sounds on the left side (same side as the chest tube), he had a pulse and good BP. He had been stable and without change in vital signs, medications. What happened?

Yep, a fellow nurse was standing on the chest tube tubing, kinking it off and causing the lung to re-collapse. After she stepped off the tubing, his breath sounds and pulse ox improved and all was right in the world. Sometimes it's the little things that make the biggest difference.

Please please please, also make sure there is no pulse BEFORE you start compressions....

[linfull]

What a great thread! Keep posting more of these. I can't wait to start school so I can apply the KISS method or the old "when you hear hoves, think horses not zebras."

[MikeLPN]

Yeah, and people standing on the O2, dead portable tanks, people with generally poor peripheral circulation, foleys getting kinked by the aides every way possible, collection bags splitting/leaking.

[Peeps Mcarthur]

Teacher Sue, I have another scenario for your students....

I had a patient once with a chest tube for pneumothorax, intubated and sedated. Some co workers were in the room with me, chatting, when we noticed that his pulse ox dropped to mid-high 80's, we assessed his airway-he was still intubated, on the vent with oxygen flowing, breath sounds he had absent breath sounds on the left side (same side as the chest tube), he had a pulse and good BP. He had been stable and without change in vital signs, medications. What happened?

Yep, a fellow nurse was standing on the chest tube tubing, kinking it off and causing the lung to re-collapse. After she stepped off the tubing, his breath sounds and pulse ox improved and all was right in the world. Sometimes it's the little things that make the biggest difference.

Please please please, also make sure there is no pulse BEFORE you start compressions....

Standing on the tubing? That's a good one. With a patient on a vent I would not have thought of that first.

[Pab_Meister]

Hey teacher sue,

How about starting a new thread for every scenario. This thread is getting a bit long.... I think you just bought yourself a part time job! This is pretty cool.

[Chrislynn2003]

The first thing I would do is to check for kinking in the foley tubing. I am just basing this on experience; whenever I was in the hospital with a foley, it would always kink and I felt like my bladder was gonna explode. Also, check the patient.

[Shotzie]

One thing no one has mentioned is that if you have a serial-02-remover maybe you should start with asking the patient if they had just put their tubing back on. By doing this you can assess whether he is too s.o.b to speak and how alert he is, as well as his general skin color and you can observe for signs of cyanosis.

I used to have a patient who would remove his tubing every time we left the room but when he heard us coming he would quickly put it back on. We tried everything to figure our why his sats were always dropping and why he only threw PVCS's when no one was in the room. With a little spying we finally figured it out... when we confronted the patient he grinned and said he "just likes visiting with pretty nurses when they come to check on him"!!!

[Audreyfay]

First I would look to see if there was a puddle of urine under the bed. Amazing how some of those collection bags don't get reclamped after opeining! :rotfl: