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Ep215: ICU Nurse? You Sure as Hell Better be Critically Thinking

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Here’s the deal . . . you’re patients deserve a nurse who knows how to critcally think.

Here’s the OTHER deal . . . nursing schools aren’t teaching “Critical Thinking” like the should.  SOOOOO, once again it is on the shoulders of NRSNG to clear the concept up.

In this episode we discuss critical thinking in the ICU using real life examples.

We’ve written a master post on Critical Thinking and Nursing Care Plans . . . you can view it HERE.

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Podcast Transcription

What’s up, guys? Jon Haws, RNC’s Hearing with NRSNG.com. Today I am really excited to bring you an episode in our series on critical thinking and nursing care plans. Before we get rolling into the episode, I want to let you guys that if you go to NRSNG.com/CritcalThinking, 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.

 

Now, that’s something that nursing professors and 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 that 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?

 

Now, let’s roll into this. This is another episode in our series on critical thinking and nursing care plan, so I hope you guys enjoy it.

 

What’s up, guys? Welcome, welcome to my Critical Thinking Podcast episode. Today, I’m going to talk about critical thinking example scenarios that I worked through that I personally experienced in the Neuro-ICU.

 

I want to talk about this, specifically critical care-wise, because my critical thinking, while it was the same kind of concepts, the scenarios are quite different when you’re looking at the ED versus the Critical Care Unit versus the floor. You’re still using critical thinking in all of those aspects and all those areas, but it looks a little different. Be sure to make sure that you check out our free nursing care plan template, because critical thinking and nursing care plans really go together. Seems like they don’t, but I promise, promise, promise that they do.

 

We created a free template for you to utilize and download and add your own thing in there, just so you’re not having to worry about creating that document at home, on the computer, which is quite a headache. We went ahead and did that for you. It’s at nursing, NRSNG.com/CarePlanTemplate. That’s NRSNG.com/CarePlanTemplate. I’ll remind you guys that a couple times, so you don’t forget.

 

Let’s talk about these specific scenarios. Let’s talk about my first one. My patient had a subdural hematoma; blood on her brain in the subdural space. She had fallen and started getting blood collecting on her brain. Got to the point where it was big enough to justify evacuating it. A subdural hematoma evacuation.

 

It’s always important to do the least invasive interventions, right? The least-invasive intervention is to drill a hole into her head, and drain out the blood. If that doesn’t work, then we go to the OR and do full craniotomy incision, then take out the blood. We don’t want to do that if we don’t have to. Let’s drill a little hole and see if we can get most of it out through that little hole. That’s what was happening.

 

She was a little confused, little sassy, didn’t really know what was going on, kind of followed commands. The doctor ordered for her to have a little bit of morphine during this procedure. She was a little out of it, enough where we could just give her some morphine and she’d probably tolerate the procedure pretty well. We gave her I think it was 4mg of morphine and, boy, did her blood pressure tank. It’s like, “Okay.” The neurosurgeon’s like, “So, what do you want to do?” I’m like, “Okay.”

 

Normally, the neurosurgeon, they’re in the OR; they’re not managing the blood pressure. The CRNA, the anesthesiologist; pother people are taking care of that stuff. They are solely focused on the head and what they need to do in the brain. Seamlessly, my self and my co-workers that were helping her, like “Let’s do reverse trendelenburg. Let’s go get a [boliss 00:04:29]. We want her to have some onboard, but we want to have her blood pressure up.” We were critically thinking about, “What would it take to get this patient’s blood pressure up?”

 

We put her in reverse trendelenburg while I grabbed a [boliss 00:04:46], because it takes a second to run to the Pixus, pull a boliss out, get it on the pressure bag and what not. She had one IV that was kind of bigger, but my other nurse was like, “Hey, you know what? We’re going to give her a bunch of fluid at once. Let’s make sure we’ve got another IV. We were going to go ahead and start one earlier, but we were starting with … We wanted to intervene with a subdural, and we had a good IV, but hey, let’s have a second one.”

 

She’s putting her in reverse trendelenburg. I’m grabbing a boliss. The other nurse is starting an IV. We’re critically thinking about low blood pressure, what can we do to address low pressure immediately to bring her blood pressure back up? We didn’t really want to reverse the morphine, because hey, even if she’s got a blood pressure that’s kind of low, we still got to do this procedure. We gave her a liter and, in between the liter and the reverse trendelenburg, her blood pressure popped right back up, did great. Morphine went fine, then we were able to drain the subdural and she did okay.

 

I thought that was a really quick scenario, but it was just … You’ve got to think on your feet, and you’ve got to think about, “Hey. I’ve got to do this stuff right now, really fast.” A lot of times, the physicians are nearby, and that’s really helpful.

 

Talk about another situation. I had a patient come in, and she had … What’d she have? … aneurysm rupture. She had this aneurysm ruptured, and we did the CTA, figured out her aneurysm ruptured, and we were watching her in the Neuro-ICU, because they were going to clip the aneurysm when they could. I was doing my neural assessments, and got my baseline one, things were okay. Then, I’m noticing, “Man. She’s getting harder and harder to wake up.” What’s the sign? The first sign of increased inner-cranial pressure? It is changes in the level of consciousness.

 

I’m thining, “She’s difficult to wake up.” It’s not like, “I’m sleepy,” difficult. Even if someone is sleepy, you can still wake them up if you really have to. If you want to know someone that knows how to wake somebody up, those are Neuro nurses. I’m flipping on the lights. I’m shaking her arm. I’m doing a trap pinch. I’m doing nail bed pressure. When I did the painful stimuli, she would kind of wake up, but then fall back asleep. I’m like, “This is a problem.” Before, she’d wake up earlier.

 

I’m thinking about the disease process. She has an aneurysm rupture in the circle of [willis 00:07:43]. Her pressure is probably increasing in her brain because her level of consciousness is going down. We need to relieve pressure in her brain. Okay. Let me call the physician, call the neurosurgeon. I let the neurosurgeon know my neuro exam, and I expect, what I thought was, he’s going to say, “Hey, we’re going to go a ventriculostomy at the bedside. Get that set up.” That means there is blood, most likely, in her ventricles of her brain, not her heart. You have 4 ventricles in your brain, and there should not be blood there, but there is because she had an aneurysm rupture.

 

Your brain can accommodate so much, but in your ventricles or your brain, you have CSF. It’s continually made and reabsorbed. If you have blood in there, where it shouldn’t be, like she did, because she had an aneurysm rupture, it does not absorb as fast as it should be absorbed, so it starts collecting. It starts making those ventricles get bigger and bigger and more pressure and more pressure because there’s more fluid created, but not reabsorbed.

 

We got to get rid of that extra fluid. Got to do it. How are we going to do that? We’re going to drill a hole into her brain, and we’re going to put a catheter down into those ventricles to allow that pressure to go out. Now, she got real, real sleepy and that takes a little time to do all this, to get the neurosurgeon to the bedside. She was no longer protecting her airway. That meant, “Hey. I’ve got to call the pulmonologist or the critical care doctor, because she’s not breathing the way she needs to.”

 

Pretty simultaneously, she went from waking up when I would assess her to not waking up, and it turned into this patient is not only getting an extra ventricular drain, but they’re getting intubated because her pressure in her brain’s so great, and you can’t fluctuate it significantly in a short amount of time. We decided to go ahead and throw a breathing tube down to enable her to breathe the way she needed to. Then, her blood pressure was not responding the way it needed to, and then they wanted to insert a central line. Within a matter of 30 minutes, this patient’s getting a hole drained into her brain, a catheter placed in her superior vena cava, a breathing tube down her trachea, but it’s all absolutely important because of her decreasing neuro exam.

 

As a neuro nurse, as that nurse constantly at the bedside, to notify the physician of when these changes occur. It was just like, “Okay. I notice her neuro status is decreasing. Let me call the physician. Okay. We’re going to intubate her. We’re going to put a ventric in, and we’re going to put a central line in. Get all that stuff. We’re going it now.” I let all my co-workers know, “Hey. I need some help. We got some stuff going on.” They ran and grabbed all the stuff. We got it together. Patient got intubated, got the drain, got the central line and got her situated.

 

We call those neuro codes. She didn’t actually code, but it was a slow neuro code where it was like, “Hey. She will have a respiratory arrest, because she’ll have so much pressure in her brain, where she can’t maintain her airway.” We want to prevent that from happening.

 

Third example, I had a younger patient that went to the OR for a craniotomy. I can’t remember why she had a crani. I think it was a tumor or a mass in her brain. It was something, one of those things where she would have this major surgery, comes up to the neuro ICU for one day and typically goes out to the floor, home a few days later. Brain surgery doesn’t sound like something that should be routine, but actually if you don’t have complications, you can have a brain surgery and do pretty well, depending upon the reasoning, again.

 

I had a younger chick, and the surgery went fine. Surgery went beautifully. I don’t remember what the surgery was, but I remember surgery is fine. They get her into the PACU, and they try to extabate her. All of the sudden, they extabeted her and they had to reintubate her. Can’t remember exactly what happened, but they have to reintubate her, which was really surprising because she was younger. Surgery went well. They couldn’t figure out what the deal was. They reintubated her, and left all of her lines in. They got her back up to me in the Neuro-ICU, but I was like, “What is going on?”

 

She was on the breathing tube. I was noticing that, before surgery, she had normal sinus rhythm, no cardiac issues. I notice, “Man, her heart rate’s like 120. I wonder why her heart rate’s 120.” Her O2 set, even though she was on the breathing tube. If you’re someone that’s on a ventilator, with no respiratory issues, theoretically, she should be set and 100%. We shouldn’t have an issue getting her to 100%. Then, also, her heart rate was 120, and her blood pressure … I had her on neo synephrine. I had to use a decent amount to maintain her blood pressure. Low blood pressure, high heart rate and she had a mild fever.

 

I’m looking at this clinical picture. What is going on? I wonder if she has a pulmonary embolism. High heart rate, low blood pressure, having trouble … Her O2 tests were like 93, 94, which, technically is within range. Theoretically, you’re on a breathing tube, you should be at 100%. I call the physician, and technically at that point, she didn’t have any alarms going off. Her blood pressure was technically where it was supposed to be, but I had to use a vasopressor to get it there. Her heart rate, it wasn’t setting off the alarm, but it was on the high … Maybe her heart rate was 115, but the alarm is at 120. Technically, I don’t have alarms going off, physically. Mentally I do. I’m like, “Man, something’s going on. I got to call the physician.” Her heart rate’s up. Her blood pressure’s low. Her O2 stat is technically not going off, but, man, it should be higher.

 

I call the doctor, let him know. He’s like, “Man, sounds like she’s got a PE,” a pulmonary embolism. We take her down and get a CT done and, sure enough, she has a pulmonary embolism, and we had to start treating her for that. I can’t remember, because it was toward the end of my shift, but I think she ended up having some sort of hematology interesting clotting. I don’t know if it was a disorder, but there was something going on. They drew a ton of labs. I actually don’t remember what the end-all issue was for having … I can’t remember why she had the surgery or anything, but I do remember she ended up having the PE.

 

It’s things like that where you have to think, “Okay. I’ve got problems here. What could the cause be? What could the treatment be? How can I communicate this to the provider in a way that they know that this is an urgent, urgent situation?”

 

Those are just a few examples of critical thinking and how it practically looks in the critical care environment. You can tell it’s quite different then the critical thinking that happens on the floor, but it’s no less valuable. The same thing with the ED. I hope you check out Susan DuPont’s episode about critical thinking in the ED. We’ve got this 3-part series, so I hope you check it out.

 

Don’t forget to go check out our free nursing care template. You go over to NRSNG.com/CarePlanTemplate. Again, NRSNG.com/CarePlanTemplate. I hope this helps, hope this brings to life some critical thinking scenarios that are pretty typical in the Neuro-ICU world. Susan will talk about typical ED ones, and I talk about some floor ones. I hope this helps this bring it to life.

 

All right, guys. Thank you for listening to this episode on 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 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. That’s what we’re doing. We’re providing care for a patient. 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. You guys are part of that. You guys are everything that we do at 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.

 

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 17, 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.