Critical Thinking - Need Help!

Take a deep breath. Really, take one. It sounds to me like you've answered your own questions at the end of your post. You're right where you should be after six months on a very busy unit.

People talk about critical thinking like it's a magical skill that needs to be taught or learned. If you look out the window in the morning and it's raining do you grab your flip flops or your boots? Critical thinking. You're coming to a light and it turns yellow, do you slow down or speed up? Critical thinking. You can do this because with time, assessing your patients will become as second nature as dressing for the weather or driving around town. But it does take time.

As far as your particular situation, do you have order parameters for notifying the MD of certain changes in condition? In that particular situation, I don't think that either of you were right or wrong. You could have notified the MD and you probably would have gotten similar orders to what the charge RN said, but at least you know the provider was aware. Or, you could wait and see whether your interventions, pain meds, Coreg and tylenol, were successful, which they were. Your reasoning was sound for suggesting you call and her reasoning was sound for holding off. Sometimes it will also depend upon the time of day, which provider is the attending, etc. Many factors go into these things. 

For sure you could use a boost in your self esteem. Try to leave each shift and think about something that went RIGHT. Because I bet you're going home and playing over in your mind all the things that you think went wrong. You're probably doing better than you think in a challenging position. Give yourself time and grace. Good luck!

On 3/29/2021 at 6:36 PM, jennsrn said:

I feel as though I need to just stop, take a breath and critically think problems through.

On 3/29/2021 at 6:36 PM, jennsrn said:

I need to work on my self-esteem and not be so nervous. 

You've got it figured out. Now you just need to do it. When you feel panic coming on, remember that the place is not going to go up in flames while you take 60 seconds or 2 minutes (or more) to think things through and decide what to do next.

You've made a good self-assessment here. That is also something significantly in your favor. You're doing much better than it sometimes feels like. Imagine all you are going to learn now that you've put this puzzle together and know that you need to process your assessment findings and think them through.

It's all good. ??

You got some good advice from colleagues here. Try to use it. You seem to be intelligent. Don't beat yourself up because you didn't learn something in school that you needed. Critical thinking can take time to master. It took me time to learn how to teach it. For a long time, if you asked 3 people what it was, you got 4 different definitions. We can nail it down a bit better now. But it is still a deep subject. The right class, the right mentor, the right environment can all help learn critical thinking.

You might benefit from a residency program. I would have recommended that to you as a new grad. Many of them will focus on the skills you feel you are lacking in. You can get there eventually, but many residency programs help the new grad to work and learn at the same time and to focus on skills that are not taught in school and are essential to survive in nursing. I am not telling you to quit your job, just look into a residency program.

Keep the faith.

On 3/29/2021 at 6:36 PM, jennsrn said:

Regarding critical thinking, I had a patient the other day where I walked in and got vitals. I got a BP of 204/80, and an oral temp of 102.5. I rechecked manually and got 190/76. Looking at her diagnosis, she was admitted for septic arthritis, and was being treated with IV ABT. I assessed for pain, gave her her IV ABT, scheduled Coreg, oxycodone for pain, and Tylenol for pain. I figured her BP was raised because she was running a fever and was in severe pain, and after looking at her BP trends, she did usually run on the higher side. But seeing this high number put me in panic mode. I quickly notified my supervisor and told her we should contact the doctor. Granted she was on BP medications, but it was a relatively small dose, so I felt it was right to reach out to the doctor. The supervisor told me to recheck the BP, and temp in two hours before reaching out to the doctor.

What is your take on this? I also feel like because I go into panic mode, my first reaction is to call the doctor instead of critically thinking and asking myself why this may be happening. Sometimes I jump at it before looking at PRN orders, or the patient's background and medical hx. I am also scared to make myself look like an incompetent idiot if I were to call the doctor unnecessarily. Thankfully her BP did decrease to the 130s, and her fever did break, but was I overreacting? I am scared to make a mistake, not take initiative, and feel like an idiot. I also still struggle with identifying situations that warrant a doctor's call versus me working through the problem myself. I feel as though I need to just stop, take a breath and critically think problems through. Any advice on this? I need to work on my self-esteem and not be so nervous. 

Bolding and paragraph break mine.  It's much Easier to read in paragraphs. Sounds to me as if you already know the answers. When you feel you are in a panic it's always wise to take a deep breath, step away, even for only 60 seconds or so. THEN think. And always be willing to bounce questions off more experienced colleagues or the supervisor in the future. You are learning; you don't know it all and are not expected to.

FOCUS. BREATHE. STEP AWAY for a minute. It clears things up very effectively.

Good luck.

16 patients with IV meds and other semi acute issues sounds really tough. I actually did see critical thinking in your post. You thought about why the pt was having abnormal vital signs and you thought about what to do! Calling the doctor wouldn't be wrong, and as @JBMmom mentioned, you will figure out which doctors like to be called for every little thing and which only want to be called for emergencies (doesn't mean you can't still call them when you feel it's necessary though!) To me it sounds like you did everything right = ) Over time you will see patterns and gain experience, and feel more confident. 

For me, I think about what the doctor might do If I called immediately versus if I try xyz intervention and then call with all of the info. 

Sure, I can call with a high BP but what Is the MD going to say if I've also just given a BP med besides re-check?  

When I was new I usually would run my thought process and rationale by my co-workers if I wasn't sure.  I still do. 

I agree with all of the above! Many times you have good evidence & both/either answer is right as for calling the Dr. 

My first year in nursing school, 35+ yrs ago, a very seasoned instructor gave us advice that has stuck with me ever since. (Miss Cheney had never married or had kids. She did, however, have cats, & told us about having to give one of her cats an enema. I figured that I had better take the advice of anyone who could give her cat an enema!) 

Her words of wisdom were “treat the patient, not the paper.” In other words, consider the patient not just the numbers. Was your patient w/the fever & high BP alert & oriented (or at least at his baseline)? Or was he declining and confused, etc? Were respirations easy or labored? Was he able to eat, drink, communicate, take meds? Or lethargic, difficult to arouse, in pain,  unable to take in liquids? Obviously your assessment findings will also determine whether the Dr should be notified NOW or can wait to see the effectiveness of interventions. 
 

I applaud you on rechecking the BP manually—automatic BP cuffs can be so inaccurate; I usually take BPs manually. If I get a very high temp I also check if the patient has just taken a drink of coffee or soup. ? 

sounds like you’re doing a great job on a busy unit! Try to count your successes every day—getting meds given on time, explaining a Med or diagnosis to the patient or family member, learning about a new med. and-as mentioned above—when you are feeling so anxious, STOP, close your eyes, and take a few deep breaths! 

You will never lose your license alerting the physician. You will lose your license if you fail to recognize an issue and fail to move it up to a higher level of care. So what if the physician gets upset or grumbles that he doesn’t want to be bothered? At least you let him know of a potentially dangerous situation. CYA is what I always say because if we don’t cover ourselves and protect our patients then what are we doing ? Your an excellent nurse! Keep up the great work! 

3 hours ago, vintagegal said:

You will never lose your license alerting the physician. You will lose your license if you fail to recognize an issue and fail to move it up to a higher level of care. So what if the physician gets upset or grumbles that he doesn’t want to be bothered? At least you let him know of a potentially dangerous situation. CYA is what I always say because if we don’t cover ourselves and protect our patients then what are we doing ? Your an excellent nurse! Keep up the great work! 

True, but I know in my line of work, notifying the MD multiple times in a night would cause me to be late with my other patients in addition to pissing the MD off - which for me is reason to try to wait until I have more information if appropriate and if I’m likely to need them again for other patients . 
 

not saying they shouldn’t be contacted - OF COURsE if in doubt - do it. But IMO learning when and why to call can really make a big difference overall. 

I can totally relate to this! I’ve been a nurse for almost 2 years but have moved from job to job but now that I am doing medsurg after more than a year (had 5 month medsurg experience as a new grad), I am struggling! Am I stupid or is this part of the new nurse journey. Like today, I have 2 patients in 1 modified contact room. A bed is confirmed c. Diff patient but the B bed does not have c. Diff not anything to be isolated. How didn’t I catch that?  I just feel extremely stupid, I had 12 hours to think of it yet I didn’t! I was also in a panic mode because A bed is running a fever. I noticed that every time I do have a situation going on, it ruins my focus. Is critical thinking automatically embedded in a nurse’s brain once he/she graduates? Am I like this because I almost failed nursing school too? All I can think of to improve myself as a nurse is to read books about medsurg nursing, go back into my recordings from school. I just feel like I failed as a nurse today, defeated! I want to be a competent nurse.

Hi, I'm also a subacute rehab nurse with 16 patients. I have a bit of advice because it is a real skill to learn fast assessment and to choose the most critical things to report. The first thing I want to say is again you are exactly at the level you should be. Telling the Dr about a patient with temp 102 and BP over maybe 160 or so is warranted especially on a known sepsis pt. 

I think the only thing I'd do differently is learn to think of what the doctor is going to ask you to do. That starts with the orders. Is the problem you are reporting a change in condition or is it a known symptom with orders in place to handle it? In your specific case, the pt had IV ABX, Tylenol (which reduces fever as well but you need specific order to give for that use), oxy for the severe pain, and your BP med. All these were ordered and administered. So unless you have orders stating to notify MD for certain parameters you addressed each of the problems. That's why your supervisor said to wait to report to the MD because then depending on the result the MD will know what to do next. The trick is to assess the patient and decide: how bad is it? Do I have orders in place I could address the symptoms with? Is it a new problem or known? 

Now on your unit things may be different but the supervisor on mine is another RN and is there to help the floor nurses with situations that pop up and communicate with the MD if needed. In your case, I would've done what you did and let the sup know that my pt was XYZ and I have these interventions that addressed the issues and if she could think of anything else I need to do. The other thing is at my work we have faxing for non emergent MD notification. I'd have faxed a brief summary and then when I got favorable results just faxed over confirmation that the patient returned to WNL. If not then you can call and say interventions didn't work what would you like next. 

The other thing is learning to assess the information you have to come to conclusions about how healthy they are or aren't. You're only in the room a couple times a shift but even so you have more info than you think. You have their vitals, by talking to them you know if they are alert/oriented, if they are brand new to you the previous shift can give you a rundown on their baseline behavior, you have their med list and medical hx to tell you what problems they have that you are treating them for. That last one is a biggie. Lots of my new nurses get so caught up by the number of patients and the flow of med pass they forget to ask or know why is the patient here? What are we treating them for? What health goal are we trying to reach. Mostly the answer is PT/OT but lots of times we get patients with active infections to manage, wounds to heal, sometimes they have secondary problems like a fall at home sent them here for pt/pt but they have high blood sugars or dialysis so we are managing those chronic health conditions while they are with us. Critical thinking is a big scary term that intimidates a lot of new nurses bc they feel like it means something extra special. But no matter what level of nursing you are in your job is task and goal oriented  and a lot of each job is a learning curve of what facts you need to know and then how to use that to address the patients problems. I learn my patients by seeing them everyday and checking in when I do my rounds. I can tell from planning ahead which pts are more dicey than others and may need careful monitoring. Active infection, active sepsis, with IV ABX is a priority over a pt recovering from a hip replacement who has routine pain medication. But if my formerly walky, talky hip replacement pt is lying in bed, lethargic, not able to communicate well, and just feels listless then I know from the door I need to investigate bc that is another change in condition. Might need to look for infection at the surgical site. The more you do it the more you'll learn to recognize the signs and the more you ask questions the more you'll learn what to do when you see those signs.

Don't worry about looking like an incompetent idiot and being afraid to report on things. When I train new nurses I am much more worried about ones who are impulsive and think they know exactly what to do without asking first if they have doubts. I've seen new nurses straight up not know how to do something and just wing it without a plan and when that happens no one can save them from the outcome bc no one knew what was happening until it was too late. Always communicate with someone when you're feeling unsure. That can be other floor nurses, your supervisor or even the doctor. A truly incompetent nurse is one who cannot admit to their shortcomings and tries to push through anyway without asking for help. People might be annoyed if you ask every time but remember you have lots of questions now but one day you'll find you have the answers because you've seen or experienced the problem before. It feels like it won't but I promise it will. 

The last piece of advice I have is stay organized! Before I start my shift I have a paper that has each pt, their reason for being there, important dx, and details like if they have lines, ports, drains, IV fluids or meds, fluid restrictions, oxygen, if they can take WP, if they're diabetic, who is the Dr. I build it through out my time and update it each time I get a new admit. The second sheet I have organizes what time the meds are due. I have 2 med passes so I organize what they need in 1st pass or 2nd. Do they need both? Just one or even more frequently? Any treatments? I'll put if they need insulin or bs check. Or if I need to watch the clock for PRN pain meds. Then I use that list as my checklist and use that to manage my time. I'll know who needs what and when at a glance and check them off as I go without only relying on the MAR. 

Create your own strategies for organizing yourself and helping decide your priorities. I'm a visual person and I have an awful memory so I have to write things down and have a place to check them off and add thoughts. So if fast things happen like a random verbal order or stat labs I can write them down next to the person name on my to do list. You'll find whatever works for you and you'll have more confidence if you feel like you have some kind of plan for how the day will go. 

Good job, keep at it and keep asking questions!!