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Ep214: Critical Thinking on the Nursing Floor (real life examples)

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We are back with another in our series of episodes about critical thinking in nursing and how it applies to nursing care plans.

In today’s episode Kati tells of two real life examples of using critical thinking on the nursing floor.

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What’s up guys? John Haws RN CCRN with nrsng.com. Today I am really excited to bring you an episode in our series on Critical Thinking and Nursing Care Plan. Before we get rolling into the episode, I want to let you guys know that if you go to nrsng.com/criticalthinking, that’s nrsng.com/criticalthinking you will find a massive monster post on creating nursing care plans and how to apply critical thinking in nursing school. That’s something that nursing professors in nursing schools love to mention. They love to mention you need to be critical thinking but they don’t ever really tell you how or how it applies. In this post we’ve done that for you. That’s nrsng.com/criticalthinking.

 

On that post as well there is a free download of a care plan template, you can download and just fill in. It has all the spots where you can just fill in exactly what you need to have a really effective good nursing care plan. That’s nrsng.com/criticalthinking. All right. Let’s roll into this. This is another episode in our series on Critical Thinking and nursing care plan. I hope you guys enjoy.

 

All right guys. Welcome to this podcast about critical thinking. I have worked on the floor, I have worked in the ICU, and by the way my name is Katie Cleaver, BSN RN CCRN. I have worked in various units and I’ve noticed my progression of critical thinking. It looked a little different on each unit and I wanted to just go through a few scenarios, a few examples of things so you can understand that progression. In this episode we’re going to talk about three examples of my critical thinking on working on a nursing floor/step-down.

 

Basically, we could take care of step-down patients except they just couldn’t have arterial lines or ventilators, it’s basically cardiac step down. One of the big things of the patients that I care of was, they were recovering from Coronary Artery Bypass Grafts or it’s called the CABG surgery. One of the things that frequently happens after a patient has had this surgery is they flip into AFib. Approximately 30% of post-op patients that have had open-heart surgery or Coronary Artery Bypass Grafts, because CABGs are not open-hearts, but they are heart surgery, they can flip into atrial fibrillation.

 

What is atrial fibrillation? You can go check our cardiac course to check that out. Basically the atrial cells are irritated and they fire way too frequently, and what happens is they flip into AFib. The concern is they flip into AFib but it’s AFib with RVR, Rapid Ventricular Response. The ventricles are responding rapidly. You see their heart rate, and it is 100, 120, 130, 160, and when we have a real high heart rate we get real concerned about strokes. When a patient flips into AFib with RVR we get very concerned.

 

I’m working on my patient, things are going fine, I’m working night shift, and I’m seeing that I did my telestrip at the beginning of the strip, normal sinus, 80’s, 90’s, can’t remember exactly what it was. Then later, I’m like, “Hey, wait, that doesn’t look regular anymore,” when I looked up at the telemetry. “Wait, his heart rate’s like 120.” Our alarms were set at 125, so it hadn’t alarmed on me. We have telemonitors but they routinely go through systematically. If this patient had flipped in the last few minutes, they may not have noticed. I noticed that he flipped into AFib; I notice the heart rate was much higher, and then all of a sudden we’re looking at, “Now we’re in AFib, and now we’re in heart rate of 120 and now we’re in a heart rate of 140; uh oh.”

 

Okay, the alarm’s starting to go off on the monitor and I’m starting to get a call from telemetry, “Hey, you’re patient in bed 86 has a heart rate of 150, and they are in AFib.” All their job is to do is to tell me what to do. So I hung up the phone and I go, “Okay, I got to think. My problem is AFib, what are my interventions, what am I going to do about it?” I’ve got to critically think about this situation while I have alarms going off in the back. I know I got to let the doctor know. Okay, but I’ve got to anticipate the questions the doctor is going to ask me. Before I call and page the physician, I got to get my ducks in a row.

 

Let me go get a set of vitals because I know the doctor’s going to ask me, “Hey, is the patient symptomatic? Are they feeling any different? What is their vitals?” Or what are their vitals. So let me go do that, and get that taken care of before I call the physician because I want to have the answers to these questions. I go in, I assess my patient, patient feels totally fine. They’re actually surprised that I’m in there like, “Hey, kind of concerned.” I decide I need to take their blood pressure. On the floor a lot of hospitals have these machines where you put on the blood pressure cuff and it takes the blood pressure for you, but when a patient is in Rapid AFib with RVR, those machines aren’t really designed to read AFib appropriately, so you’re not going to get an accurate blood pressure. Half the time it can’t even read it.

 

Instead of screwing around with that, I’m like, I’m just going to go take a manual blood pressure. I would need to know what their blood pressures were running beforehand, before we flipped into this. Did they have a normal pressure? Were they maybe 140’s over 90’s? Where they 130’s 120’s, or did they sit in the 90’s? I need to know what’s normal for this patient. I’m kind of working through that, and this sounds like it’s taking a while, but this is happening very quickly. Take the blood pressure, I get an accurate blood pressure, I get a quick assessment on the patient; they’re feeling fine, no symptoms. Take a peek at their labs; okay, I’m going to go page the cardiovascular surgeon.

 

I page the surgeon, and I page him and make sure that I can be at the bedside, or I’m sorry, be at the computer so if they ask me about various lab values, I’m prepared to answer the questions. Page the surgeon, they call me back and, “What’s the blood pressure? What’s the potassium? What’s the magnesium? What’s this, what’s this, what’s this? Okay, I want you to give a Cardizem Bolus and I want you to start the patient on a ten milligram Cardizem Bolus, and I want you to start them on a Cardizem drip at 5, and I want you to titrate up to 15 to maintain a heart rate less than 120. If they flip back into normal sinus,” and we call that being chemically converted, “Don’t just stop it, give us a call back and we’ll see what to do. If the blood pressure starts going down, just give us a call.”

 

Oh my gosh, okay. Then I got to figure out critical thinking wise, who am I going to delegate this, what can I delegate, I need to get this task done as quick as possible. My other patient put on the call light that wants a warm blanket, they’ve got to wait. The assessment I didn’t chart on that other patient, it’s got to wait. I’ve got to put these orders in; I’ve got to implement them quickly. You kind of realize with situations, “Hey, this is now a priority.” I got a blood pressure I need to check the blood pressures frequently. I’m going to give Cardizem. If I’m not familiar with Cardizem, and administering it, I got to look up the policy for starting a Cardizem drip, or Diltiazem drip.

 

Okay, I got to critically think a little bit too. Let’s say I have in my Pyxis, or in our med machine on our floor, I have Cardizem Boluses, but I don’t have a drip. The pharmacy has to mix it. All right, with I put that order in, I got to put it in stat so they do it immediately. I’ve also got to think about, “Okay, well I have the Bolus in hand, I don’t want to give that until I have the drip to start because if I push this Cardizem right now, and it takes 45 minutes or an hour to get my bag, my drip, then that doesn’t do much good if I’m trying to convert them and then I don’t have anything to maintain them on it.

 

Those are kind of little critical thinking pieces so I can actively work through this situation, and seamlessly address this problem. Let’s kind of review: flipped into AFib, got vital signs, got an assessment, called the physician, got the orders, implemented the orders, knew to prioritize this over other things. This is a get done now thing. Knew when to call the physician again; they gave me when to call them back, boom. So that’s some critical thinking, working through a patient that’s flipped into AFib with RVR. Assess, call, intervene.

 

My next one; this is one I will never forget about. I wrote a book called Becoming Nursey: From Code Blues to Code Browns, How to Care for Patients and Yourself. Available on Amazon. One of the stories I tell in that book, I’m going to tell right now. Okay, so I had a patient, again working on this unit again; he was brought into the hospital by his son because he wasn’t acting right. Then when his son went over, and he hadn’t been over to his house in a long time, noticed he was living in filth, multiple wounds, wasn’t caring for himself, but didn’t let anybody know. I guess people had been out of town and hadn’t been over there in a while.

 

We get him to our unit because he was having a lot of pain in his foot, and realized that he’s got gangrene. He was being admitted by cardiovascular surgery, a lot of other physicians had been consulted because he had quite a few medical issues that were underlying that weren’t addressed. Kind of a complex guy in general. He’s my patient, I can’t remember what he … He was on isolation for something and I can’t remember, VRE or something like that. You had to be in your isolation gown and do all that. He’s rolling up to the unit, and I notice on assessment, you know because basically what I learned and gathered from a chart, that they think they’re going to have to amputate the guy’s foot because he’s got gangrene. Hasn’t gotten blood flow down there, long term diabetic, with Neuropathy and everything.

 

I’m going in to take care of this patient like I take care of any of my other patients, and do my assessment. Then I assess the foot in question; his other foot’s fine. Diminished pulses, but they’re still palpable and I could clearly hear them on my Doppler. I get out my Doppler and try to assess pulses. While I’m doing that, because I’m pretty sure I can’t find them, this ED nurse can’t find them, but you know, I thought I’d give it a whirl. I’m looking at his foot and I see something wiggling in his foot. Oh my God, what is that? What is moving on his foot?

 

I’m a little bit of a newer nurse; I’m not a veteran by any means at this time, and I’m like, “Oh my God, that is a maggot in that man’s foot.” Talk about keeping your nurse face together. I said to the man, who was kind of aloof, I don’t know if that was his baseline neuro thing, but he was just a little different. Anyways, I made some excuse to get out of the room because I had to process that. He’s totally stable, he’s totally fine, I’m doing my assessment and oh my gosh. I had to get out of the room, and get out of my isolation gown, and I go up to the nurse’s station and I desperately find someone who knows more than I do.

 

I was like, “I think he’s got maggots in his foot.” This story isn’t really about my critical thinking, it’s about someone else’s. I was so shocked that I had no idea what to do. Newer nurse, had never had a situation like this. The charge nurse that day, wonderful nurse, she’s actually a nurse practitioner now, she said, “Okay, here’s what we’re going to do. I don’t know exactly how to deal with these things either, so we are going to call infection control and ask them how we have to properly dispose of these things. It’s not like we can just throw them in the trash.”

 

Good, okay, all right, I get that, so we call them. Also, we have to call the physician to make sure that they know because we need to make sure that they’re aware that this is there. She’s thinking practically, critically. “Okay, the guy has got an infectious,” or not actually an infection, “But he’s got this insects, he’s got things on his foot that we have to get rid of. We have to think about the best way to get rid of them so that we’re not screwing up our trash and we’re not making problems worse. Let’s think about practically how we’re going to work through this. We have a problem, maggots, what are we going to do about it?

 

I called who I needed to call, they said, “Hey, you need to collect them into a container,” and I just used one of those UA cups. “Collect them into a container … ” I can’t remember what she said I had to pour something on them, and count how many there are, make sure I documented it appropriately and notified the physician. I thought, let me do this first, and know how many are there and how bad it is, so I know that before I call the physician. Of course they’re going to ask me how many there are and if I haven’t done it yet, then, you know.

 

We get all geared up, and keep in mind it smells horrendous because it’s essentially rotting flesh. It was really stinky situation, actually you could even smell it in the hallways. We were spraying stuff a lot, but you got about three doors down from the guy and you started smelling it. If you weren’t a health care professional, you probably had no idea what you were smelling, but essentially it’s rotting flesh. Sorry if I’m grossing you guys out. Sorry, not sorry, this is nurse life. We got gowned up, we put on the things we’re supposed to put on. We actually ended up putting masks on so that we could bare the smell because it was that bad.

 

We’re working on his foot, and it had dawned to me, I haven’t even told this guy. I don’t even know if he knows he’s got maggots crawling out of his foot. While I’m doing whatever it was she told me to do, sorry I can’t remember exactly it was, I’m like, “Sir, do you know that you have maggots in your foot?” He said, “Oh, no, I didn’t know I was feeding a farm down there.” You know that little emoji where it’s like the eyes are two horizontal lines, and the mouth is a longer horizo- that was me, I was that emoji. I don’t know how to …

 

I had talked about how severe that is. That’s a big deal. That means your skin is rotting and they’re eating the dying flesh. I can’t remember how many there were, and we got disposed of them properly, and I called the physician like the person told me to, and documented appropriately, and the physician, I thought, was just going to lose his mind like I did. It’s a cardiovascular surgeon, I didn’t think about this, of course they’ve seen this before. I tell him like, “Oh my God, we found 8 or however many maggots in this guys foot.” Without skipping a beat, the guy goes, “Gross!” and hangs up. He already knew how bad the foot was, he was pretty sure we were going to cut it off anyway. He’s like, “Okay, great he’s got maggots, their just eating the dead flesh,” like whatever. I was like, “I can’t believe I just did that and you don’t even care?”

 

That was my maggot foot story, got a couple more in my book if you want to check them out. My third, and final, critical thinking one, so again back on that unit, and a lot of you may know what sun-downing is. Alzheimer’s, or patients with Dementia, at night they get more confused at night and it can be hard to manage. I had this patient; typically you got your bed alarm on, you want people to sleep. Well, she woke up at night, she’d take some naps during the day, but she woke up at night. I could not get this woman to be calm. We didn’t really want to medicate her with a bunch of Haldol, and it wasn’t like she was super aggressive, but she was just up and picking at things, and hitting the call button, messing with her IV, and messing with this.

 

I’m sitting with the nurses up front. Even though she’s in a room by the hall, or by the nurse’s station, I feel like it’s not good enough, like she’s going to keep getting up or trying to get up. She had already ripped out an IV, and she had to have the sequential compression devices on, but it’s like she’d get tangled up in those. When she had to pee, it’s like I have to get up, right now. She wouldn’t wait, she wouldn’t remember the call light. It was like, you put the bed alarm on; if you put it on too sensitive she was setting it off every three seconds, but if you put it on the second step, she was half way at the door by the time the alarm started. She was quick.

 

I’m sitting there like, “Guys, I don’t know what to do because I can’t be in there all day,” and we needed a sitter for another patient, I knew I wasn’t going to be able to get one for her, so what do I do? It’s not like she’s aggressive or agitated, she just needs to be entertained. I can’t sit in there with her for 12 hours, I’ve got four other patients I got to take care of. I don’t know if I decided, but I was working through this with a couple other nurses like, “What can we do?” They’re like, “Hey, why don’t we get one of those cardiac recliners, let’s put it up at the nurse’s station,” and it was night shift so it wasn’t like we had all these people coming in and out. “Let’s put her in front of the nurse’s station, let’s put a bedside table over her, and let her fold towels.

 

I had given her little tasks to do in there, and then when she’d get done, she’d just forget what to do and get up again. That’s what we did, and that kept her entertained for quite a while, and then eventually she was like, “I want to go to bed.” We just put her back in her room, and she went to bed for the rest of the night. It was wonderful. That’s exactly what that patient needed, she didn’t need restraint, she didn’t need Haldol, she didn’t need a sitter, she just needed something to do and someone to watch her. That’s what we did, and it worked wonderfully, and then during the day, she was fine.

 

She did much better during the day. That was just some ways that it was like, “Okay, here’s our problem: patient is getting up, not aggressive, but definitely a fall risk hurting herself. What can we do to address this? Let’s distract her, and let’s give her something to do, and let’s put her where we can see her. Let’s put her where someone always is if she needs something, someone can answer it right away.

 

Those are just three scenarios that working through on the floor, where I was working through critical thinking, identifying a problem, here’s a solution, here’s a way to attack the problem and address it, and get to a solution, and how did that go? I hope that kind of helps you understand critical thinking a little bit better from the perspective of the floor. I’m going to have another one where I talk about critical care and how those situations are a little different. I really felt like the way I developed my critical thinking for the floor was different that critical care, but still the concepts where the same. Thank you guys for listening, and if you want to check out our cheat sheets, we got cheat sheets, we’ve got a great blog post about this, it is Critical Thinking and Care Plans Go Together like Chicken and Waffles.

 

I know they sound like they don’t go together, guys, but I promise they do; absolutely promise. We actually also have cheat sheets, and I want to make sure I give you the right place to go find the cheat sheets. Let me pull up your cheat sheets for you. Here we go, so basically, you’ll go to nrsng.com/careplantemplate and you can go there and get this free cheat sheet on a template for a care plan, and remember care plans, critical thinking, they both go together. I just want to encourage you to check that out. I think it’s going to be really helpful.

 

Check out that blog post, got a lot of great info on there. Helpful things about subjective and objective data, tips for critical thinking, not just examples but practical tips, and practical tips for walking through a care plan and how you can really rock creating a care plan. Hope you guys enjoyed this, and check out my other episodes.

 

All right guys, thanks for listening to this episode on critical thinking and nursing care plans. I hope this was helpful for you guys. I hope it’s going to help you piece together how to critically think as a nurse, and then what that means, and how the nursing care plan is really so vital to everything we do. I know we hate them, I know they’re difficult, but it’s really everything that we do in nursing is critical thinking around the care plan for patient. All right, that’s what we’re doing, we’re providing care for a patient, and that’s what this is all about.

 

Head over to nrsng.com/criticalthinking to get this massive outline post with audio, with video, with explanations, with examples, and with the free template of nursing care plans. That’s nrsng.com/criticalthinking. All right guys we appreciate everything that you do, we appreciate you being part of this NRSNG family. We are growing, we are reaching nearly every country in the world, and you guys are a part of that. You guys are everything that we do with NRSNG.

 

Okay, I want you guys to know that. This isn’t about us, this is about you guys, and you’re the heart and soul of everything we do. So with that said, you guys know what time it is now. It’s time to go out and be your best self today. Happy Nursing.

 

Date Published - Oct 10, 2016
Date Modified - Jun 25, 2018

Kati Kleber RN CCRN

Written by Kati Kleber RN CCRN

Kati Kleber RN CCRN is a Neuro ICU nurse with experience in MedSurg. She joined the NRSNG team in 2016. Her passion lies in helping new grads navigate the complexity of being a new nurse. She runs the blog: NurseEyeRoll.com and is a published author.