I had a patient that was scheduled to go to get a pacemaker placed at 0900. The physician wanted the patient to get 2 units of blood before going downstairs for the procedure. I administered it per protocol. About 30 minutes after that second unit got started, I noticed his oxygen went from 95% down to 92% down to 90%. I put 2L of O2 on him and it came up to 91%. But it just sort of hung around the low 90s on oxygen.
I stopped. And thought. What the heck is going on?
I looked at his history. Congestive heart failure.
I looked at his intake and output. He was positive 1.5 liters.
I thought about how he’s got extra fluid in general, and because of his CHF, he can’t really pump out the fluid he already has, let alone this additional fluid. Maybe I should listen to his lungs..
His lungs were clear earlier. I heard crackles throughout both lungs.
OK, so he’s got extra fluid that he can’t get out of his body. What do I know that will get rid of extra fluid and make him pee? Maybe some Lasix?
I ran over my thought process with a coworker before calling the doc. They agreed. I called the doc and before I could suggest anything, he said “Give him 20 mg IV Lasix one time, and I’ll put the order in.” CLICK.
I gave the Lasix. He peed like a racehorse (and was NOT happy with me for making that happen!). And he was off of oxygen before he went down to get his pacemaker.
My patient just had her right leg amputated above her knee. She was on a Dilaudid PCA and still complaining of awful pain. She maxed it out every time, still saying she was in horrible pain. She told the doctor when he rounded that morning that the meds weren’t doing anything. He added some oral opioids as well and wrote an order that it was okay for me to give both the oral and PCA dosings, with the goal of weaning off PCA.
“How am I going to do that?” I thought. She kept requiring more and more meds and I’m supposed to someone wean her off?
I asked her to describe her pain. She said it felt like nerve pain. Deep burning and tingling. She said the pain meds would just knock her out and she’d sleep for a little while but wake up in even worse pain. She was at the end of her rope.
I thought about nerve pain. I thought about other patients that report similar pain. Diabetics with neuropathy would talk about similar pain… “What did they do for it? ” I thought. Then I remembered that many of my patients with diabetic neuropathy were taking gabapentin daily for pain.
“So if this works for their nerve pain, could it work for a patient who has had an amputation?” I thought.
I called the PA for the surgeon and asked them what they thought about trying something like gabapentin for her pain after I described my patient’s type of pain and thought process.
“That’s a really good idea, Kati. I’ll write for it and we’ll see if we can get her off the opioids sooner.”
She wrote for it. I gave it. It takes a few days to really kick in and once it did, the patient’s pain and discomfort were significantly reduced. She said to get rid of those other pain meds because they “didn’t do a damn thing,” and to “just give her that nerve pain pill because it’s the only thing that works”.
And that we did!
She was able to work with therapy more because her pain was tolerable and was finally able to get rest.
What the HELL is Critical Thinking . . . and Why Should I Care?
What Your Nursing Professor Won’t Tell You About Critical Thinking
by Ashely Adkins RN BSN
When I started nursing school, I remember thinking,“how in the world am I going to remember all of this information, let alone be able to apply it and critically think?”You are not alone if you feel like your critical thinking skills need a little bit of polishing.
Let’s step back for a moment, and take a walk down memory lane. It was my first semester of nursing school and I was sitting in my Fundamentals of Nursing course. We were learning about vital signs, assessments, labs, etc. Feeling overwhelmed with all of this new information (when are younotoverwhelmed in nursing school?), I let my mind wonder to a low place…
Am I really cut out for this? Can I really do this? How can I possibly retain all of this information? Do they really expect me to remember everything AND critically think at the same time?
One of my first-semester nursing professors said something to me that has stuck with me throughout my nursing years. It went a little something like this:
As my journey throughout nursing school, and eventually on to being a “real nurse” continued, my critical thinking skills began to BLOSSOM. With every class, lecture, clinical shift, lab, and simulation, my critical thinking skills grew.
You may ask…how?
Well, let me tell you…
These are the key ingredients to growing your critical thinking skills.
Time.Critical thinking takes time. As I mentioned before, you do not learn how to critically think overnight. It is important to setrealisticexpectations for yourself both in nursing school and in other aspects of your life.
Exposure.It is next to impossible to critically think if you have never been exposed to something. How would you ever learn to talk if no one ever talked to you? The same thing applies to nursing and critical thinking.
Over time, your exposure to new materials and situations will cause you to think and ask yourself, “why?”
This leads me to my next point.Questioning.Do not be afraid to ask yourself…
“Why is this happening?”
“Why do I take a blood pressure and heart rate before I give a beta-blocker?”
There are so many pieces to the puzzle when it comes to nursing, and it is normal to feel overwhelmed. The beauty of nursing is when all of those puzzle pieces come together to form a beautiful picture.
That is critical thinking.
Critical thinking is something you’ll do every day as a nurse and honestly, you probably do it in your regular non-nurse life as well. It’s basically stopping, looking at a situation, identifying a solution, and trying it out. Critical thinking in nursing is just that but in a clinical setting.