Help with Patient Scenerio Using Skills of Critical Thinking

Home Health Columnist / Guide · Jan 5, 2012

Moved from patient safety thread to Nursing Student Assistance

What don't you understand about assignment? Have you looked in nursing textbook for info how to perform nursing assessment + critical thinking involved with assssement of each body system? What work have YOU done on the assignment.... need that info to help guide YOU to complete assignment.

LadyinScrubs, ASN, RN · Jan 5, 2012

hi! help me solve this.
scenario using skills of critical thinking
here is the situation:
during assessment, mr. fellows relates a history of sudden onset chest pain rated at 10 on a 1 to 10 scale, relieved by rest, which started while he was mowing the lawn. he describes the pain as "crushing, like a truck ran over my chest." his blood pressure is 200/110 mm hg, temperature is 36.7, pulse is 106 beats/min, and respirations are 24 beats/min. the pulse is irregular and thready, and the respirations slightly dyspneic (labored). the cardiac monitor reveals atrial fibrillation. during the assessment, his wife confides to the nurse that mr. fellows was treated 3 years ago for alcohol dependence. currently, he is complaining of nausea and indigestion. his skin is pale and diaphoretic. he is restless and anxious. his wife is sitting at the bedside very tearful and emotional.
based on the scenario, discuss your interpretation, analysis, evaluation, inference, explanation, self regulation and how would you use these to resolve a situation related to the patient's pain.
interpretation (clarify what the behavior means)
analysis (during the assessment, what questions should the nurse ask to determine the best plan of care?)
evaluation (what outcomes do you expect to achieve with your patient today?)
inference (what conclusion [explanation for behavior] could the nurse make, based on the analysis)
explanation (during implementation, how can the nurse justify the actions being initiated)
self-regulation (what issues should the nurse reexamine to correct or improve the nursing care?)

welcome to nursing school. sounds as if you are frazzled and stressed. take a deep breath. now, read the question. underline anything that is unusual.

now, go to what the question is asking: "discuss your interpretation, analysis, evaluation, inference, explanation, self-regulation and how you use these to resolve the situation related to the patient's pain".

wow, a lot to think about--but eventually you will be doing this in your head as this is nursing is all about. you will you use everything you see, assess, understand, etc. to resolve your patient's pain.

break down the question. do interpretation (clarify what the behavior means). what patient behavior does the problem give you. what does the patient's behavior mean to you as a nurse or what does it mean to the patient's pain. here you will use your psychology info. i like to over think the question. i will get info and use citations (as well as get a web address should i need to go back again).

next thing: analyais -"during the assessment, what questions should the nurse ask to determine the best plan of care?" as a nurse, you will do an assessment on your patient; part of the assessment is asking questions. you have a patient who comes in with the problems presented above, what questions would you ask to get you the best information about the patient and/or the problem and his pain? say you have a patient who is a female latina who presents over weight, c/o thirsty, pees "a lot", has ravinous hunger, and feels weak. what questions would you ask to get to the following answers: she does not exercise, eats lots of junk/fast food, prefers high sugar goodies, her mother and brother are diabetics.

what questions would you ask the pt to understand what is going on with the patient and how the he got this way? when this is done, take a break, get a cup of coffee, and then come back and start another question.

evaluation (what outcomes do you expect to achieve with your patient today?). so, what outcomes do you want from this patient? clearly, you don't want the patient to remain at the hospital/facility forever. what outcome do you want for the patient? sometimes a good nursing diagnosis handbook helps to come up with outcomes. remember we are focusing on pain.

continue on with the rest of the assignment. take one question at a time and answer it completely. how will you resolve the situation your patient finds himself in relation to his pain? if you give evidence based information, make sure you cite it. the first time you do this type of assignment will be the most difficult; in time, you will become more comfortable and your stress level will reduce.

NCRNMDM, ASN, RN · Jan 5, 2012

I am going to pick and choose a few of these to answer, I hope that's okay. For the ones I don't delve deeply into, I will try and provide some guidance. Let's start with analysis first. What questions are you going to ask the patient during assessment? You might ask questions like this: "Have you ever had this pain before?" "Are you having a hard time catching your breath? Do you feel short of breath?" "Does the pain go anywhere else (radiate) or is it just in your chest? If the pain is anywhere else, tell me where." "Have you ever been told that you have an irregular heartbeat called atrial fibrillation?" You may also want to ask the patient if he is still sober, or if he has started drinking again. In addition to these questions, you need to check the patient's oxygen saturation, and record it with the rest of the vitals. Since this is the assessment phase, you would also probably want to obtain an ECG. To me, this sounds like the classic symptoms of cardiac related chest pain, but I don't want to jump to conclusions.

Let's move on to the evaluation section of the question. What outcomes do you expect to achieve with this patient today? Obviously you want to decrease his pain, but you also want to find out what's causing the pain. You also want to decrease his blood pressure, stabilize his heart, and try to get him out of atrial fibrillation (unless it is a chronic rhythm for him).

The inference section is asking you what conclusions you can make. What do you think is happening with this patient based on this data? Personally, I think he may be having some type of cardiac or vascular event. The inference section is asking you to look at all the data and decide what is happening to the patient to cause his presenting symptoms.

For the explanation section, you would first have to know what types of actions you would take in this situation. You would want to establish IV access (to administer pain medication, antihypertensives, and, possibly, an antiarrhythmatic agent). You would want to obtain an ECG (to rule out MI or other cardiac explanations for the pain). You would want to obtain an oxygen saturation value, and place the patient on oxygen if needed (if the patient is tachypneic and dyspneic, then his O2 sat may be low, and he may need oxygen. Also, if the patient is having ischemia or an MI, he needs oxygen therapy even more). You may eventually want to draw an ABG (in order to see if there is an acid-base imbalance going on). You will be drawing blood (to test for elevated cardiac markers, signs of ischemia, or other possible explanations for the pain). The list goes on and on.

I think you see the point I'm trying to make, and I hope that this has helped you. Apply this same method of thinking to the rest of the questions, and try to answer them to the best of your ability. Good luck, and I hope I helped you.

Esme12, ASN, BSN, RN · Jan 5, 2012

welcome to nursing school. sounds as if you are frazzled and stressed. take a deep breath. now, read the question. underline anything that is unusual.
now, go to what the question is asking: "discuss your interpretation, analysis, evaluation, inference, explanation, self-regulation and how you use these to resolve the situation related to the patient's pain".

wow, a lot to think about--but eventually you will be doing this in your head as this is nursing is all about. you will you use everything you see, assess, understand, etc. to resolve your patient's pain.

break down the question. do interpretation (clarify what the behavior means). what patient behavior does the problem give you. what does the patient's behavior mean to you as a nurse or what does it mean to the patient's pain. here you will use your psychology info. i like to over think the question. i will get info and use citations (as well as get a web address should i need to go back again).

next thing: analyais -"during the assessment, what questions should the nurse ask to determine the best plan of care?" as a nurse, you will do an assessment on your patient; part of the assessment is asking questions. you have a patient who comes in with the problems presented above, what questions would you ask to get you the best information about the patient and/or the problem and his pain? say you have a patient who is a female latina who presents over weight, c/o thirsty, pees "a lot", has ravinous hunger, and feels weak. what questions would you ask to get to the following answers: she does not exercise, eats lots of junk/fast food, prefers high sugar goodies, her mother and brother are diabetics.

what questions would you ask the pt to understand what is going on with the patient and how the he got this way? when this is done, take a break, get a cup of coffee, and then come back and start another question.

evaluation (what outcomes do you expect to achieve with your patient today?). so, what outcomes do you want from this patient? clearly, you don't want the patient to remain at the hospital/facility forever. what outcome do you want for the patient? sometimes a good nursing diagnosis handbook helps to come up with outcomes. remember we are focusing on pain.

continue on with the rest of the assignment. take one question at a time and answer it completely. how will you resolve the situation your patient finds himself in relation to his pain? if you give evidence based information, make sure you cite it. the first time you do this type of assignment will be the most difficult; in time, you will become more comfortable and your stress level will reduce. end quote]

this is excellent advice...where have you started? what have you though about? what questions would you ask some if they were telling you how bad they felt. what would you want to happen for them. we are happy to help but we need to see what you are thinking and why. nursing is the development of critical thinking skills that we learn in shcool.

we will be happy to help if you tell us what you have done so far....but we won't do the work for you. tell us what you've doen so far :)

nurseprnRN, BSN, RN · Jan 5, 2012

you will find that on an, as in most nursing milieus, experienced nurses won't do your homework for you (sorry @matt..i know you mean well ). but we will bend over backward to help a student who says, "i got asked this question, and i thought it might be xyz because of xyz, but then i wondered about abc and i couldn't figure out why abc would have anything to do with it. i did read about ghi and jklmnop, and that said.... why is that? what am i missing?"

in other words, going to an online forum and putting up your homework for answers is not research and it's not the way to learn much, and it will probably not get you what you seek. i know that in this day and age everyone thinks that googling is the be-all, end-all of getting information. but this assignment is only a little bit about information. it's about learning to think like a nurse.

an is not "ask jeeves,":d, and your faculty doesn't want to know that you are not reading in your books and thinking about how to apply what you find there. we can help you but you have to show us you now how to start to help yourself. that is how your faculty's assignment is beginning you down the road to...critical thinking. :nurse:

so, now that we've got that cleared up :loveya:.... what do you think about that scenario? what's most important here with this man with the crushing chest pain? why might he have it? what should happen first (safety first)? how do you know? why?

chocoberry · Jan 6, 2012

What I've noticed not good is about the wife's presence being very tearful and emotional at the bedside of the patient. I think she is not supposed to be there and let the patient see that she is very emotional. Concerns should be shared privately within the family members and they must give attention to him when pain is not exhibited.

What makes me confused about this scenario is the relation of patient's complain of nausea and indigestion to chest pain which the patient verbalized during the assessment. Will I focus on the current complain of the patient or on his assessment history which he verbalized? His wife reported that he was treated with alcohol dependence 3 years ago. What does that mean? (what she said is an objective data). Currently, the patient's skin is pale and diaphoretic. He is also restless and anxious. What does that imply? Is it not the focus of the analysis and so on?

JustBeachyNurse, LPN · Jan 6, 2012

Focus on the signs & symptoms in front of you; history can be relevant but don't let that overshadow objective signs.

Always think airway-breathing-circulation; Maslow's Hierarchy of Needs, and basically "what is going to kill him first" and why?

Will a history of alcoholism be a priority?

Will his hypertension, elevated heart & respiratory rate, and other symptoms need to be addressed first?

What is the possible cause(s) of his current condition/symptoms?

Then list out your priorities in care. What additional assessments & evaluations (x-ray, labs, ECG, monitoring, consults, questions) need to be performed? What treatments should you expect to be ordered? What treatments are within a nurses' scope of practice to initiate while waiting for orders? (such as oxygen, comfort measures)

Use your medical-surgical text book & fundamentals book for reference.

Try googling the symptoms to see what you come up with for a possible diagnosis and explanation for the chest pain with subsequent nausea, diaphoresis, dyspnea, anxiety...you may end up at a link like this: http://journals.lww.com/em-news/Fulltext/2002/09000/The_Symptoms__Chest_Pain,_Diaphoresis,_Dyspnea,.14.aspx (when you click on this link, click "next page" to get the answer)

Here's a starting point to look at the situation as a medical professional: Medscape: Medscape Access

As far as his nervous wife, Wife likely needs reassurance and support, perhaps offer to call another family member to be with her while her husband is evaluated? Or even if there is a social worker or patient relations representative available they might be of assistance (Generally they are trained to help a worried family member cope & navigate the healthcare maze that they are entering)

LadyinScrubs, ASN, RN · Jan 6, 2012

Aren't you to be focusing on your patient's pain?

nurseprnRN, BSN, RN · Jan 6, 2012

you might also take a look at the american heart association website that gives you information on possible first signs of myocardial infarction. warning signs of a heart attack

huge hint: when somebody says, "crushing chest pain," we don't worry that much about his wife.

is the op still in the house?

chocoberry · Jan 7, 2012

Patient's pain must be put into focus. That must be the center of the analysis.

LadyinScrubs, ASN, RN · Jan 7, 2012

Patient's pain must be put into focus. That must be the center of the analysis.

Chocoberry, you are correct to remember the focus is the patient's pain. However, the nurse must understand the problems the patient exhibits or complains of. If the pt comes in with acute anxiety and one of the complaints is chest pain, you must put s/s together in order to help the patient. The nurse employs her knowledge of pathophysiology, A&P, psychology, mental health, etc. to help the patient.

Your pt has certain s/s. Understanding those s/s and how they can make or have made his pain worse is the starting point of your homework. Armed with that knowledge, the nurse will devise a plan to reduce his pain and this is what your assignmentis all about. What will you do to reduce the patient's pain based on the subjective and objective findings?