[Sharon]

Nurses use critical thinking skills every day. Think of a time you used critical thinking in your nursing role; now share your example online explaining why you feel it was critical thinking and not just decision making or problem-solving.

[Melanie]

I previously worked on a program with an oncology IV drug. This drug was to be infused 3 times per month (weekly on the same day each week) The drug required a cytotoxic hood in order to be prepared and once mixed was viable only for a an 8 hr window. Once past the 8 hrs it was to be wasted.

On the days the infusions took place for these patients, the MD’s were to send us the bloodwork results before 8 am. Once we receive the results and the “ok to proceed” from MD, we immediately had to advise our pharmacy to go ahead and mix and ship the IV med to the infusion clinic the pt was attending.

On one occasion I had an infusion clinic call me to tell me the pt was there waiting however, the drug hadn’t been delivered. It was 2 pm in the afternoon. I pulled up the pt file and could see my notes from that same morning indicating I had received the all clear from the MD and had advised the pharmacy as well to proceed with mixing and shipping. I asked the nurse at the clinic to kindly allow me to some time to look into this and that I would get back to her asap as this was an urgent matter.
I contacted the pharmacy who confirmed they had mixed and shipped the drug and sent it via courier to the clinic. I advised pt is there now and drug hasn’t arrived. Can they please track the delivery and get a status update. ( at this time the drug had already been mixed for 4 ¾ hrs so it was only viable for another 3 hrs and 15 mins).

I contacted the clinic to find out how late they were open in case drug was late showing up. I was advised they close at 5 pm. I then contacted the Scheduling team to find out if there were any clinics in the same vicinity who may have later opening hours. I was told there were not. I asked if they had any “on call staff” who could possibly go in on short notice to give this infusion. I was advised they would start calling around but they needed authorization from the Clinic Manager to stay open past 5 pm before proceeding.
I got a call back from the Pharmacy to let me know they tracked the package and due to inclement weather, the deliveries were delayed the courier was unable to provide them with a delivery time window. The pharmacy Manager contacted the courier to explain the urgency of this situation and that if at all possible to try to make this delivery a priority.

I then called the insurance company seeing as the drug may need to be wasted, and since it’s only given 3 x per month, would they allow a claim to go through for a 4th dose in this situation. I was advised that no, they cannot authorize a 4th dose as the prescribed dosing is once a week for 3 weeks. I advised that the drug would likely need to be wasted as the viability is only 8hrs once mixed. They said there was nothing they could do. I asked if it the dose is wasted are they able to reimburse it to the pt seeing as it was through no fault of their own I was advised again, that no, that was not possible.

I contacted the MD to advise them of the current situation and that it may be possible this pt won’t get his infusion as scheduled. The MD wasn’t thrilled with this news but understood the situation was out of our control as its weather related and we are doing all we can to try to get this infusion to happen as scheduled.
I called the clinic back and advised them the tracking situation with the courier, and of my calls to the Scheduling dept as well as the insurer and that I didn’t yet have a solution but I was doing everything I could.
I received a call back from the Scheduling team who advised me that the Clinic Manager had approved keeping the clinic open until pt received his full infusion.
I called the Clinic again to advise them that if the pt is able to stay longer and keep waiting to see if the drug will arrive he can get his infusion ( as long as it’s within the viability window) Thankfully , the patient was very understanding and was ok with staying at the clinic to wait for the delivery.

At 3:35 pm I received a call from the pharmacy advising me the courier was now on route to the clinic with the medication and delivery should be there soon.
I once again contact the clinic and provide the update advising them that the medication is on the way and thankfully it’s still viable, it won’t need to be wasted.

In the end it all worked out but this is one day/scenario I have never forgotten. It was very stressful, very urgent, it took a lot of investigating and multiple calls and even though there was decision making and problem solving involved I do I think this would be a critical thinking situation.

[Sandra]

Yikes that sounds like one heck of a day. Thank goodness you remembered how long the medication was good for and advocated for your patient in that situation. Nursing can be very stressful and sometimes I don’t think the the patients or families realize how much we do for them.

[Sandra]

Im my previous job I worked on a cardiac floor. I had this patient that came from out of town and was having chest pain so of course you would think it was cardiac. The nitrospray was not helping to relieve the pain even by a little. the pain this patient was having was right in the middle of the chest between the breast and radiating right to the back. They had all the test and blood work and everything came back negative that it wasn’t heart issues but the pain was still there, then I asked the paint to show exactly where she was having pain point it out to me and it was in the same place as my gallbladder pain. I ended up talking to the charge nurse about it and contacted the Dr. the Dr came to see the patient and ended up consulting general surgery. In the end the patient didn’t have any heart issues and it was definitely her gallbladder, the good thing was she never had the angio which yes is a procedure that they do many a day but it’s also playing with your heart and the patient ended up getting the surgery for her gallbladder later and went home.

[Heather]

The patient you had was very lucky that you had such good assessment skills and were able to pinpoint the gallbladder issue and get that resolved with surgery. I think that you saved that client a procedure she did not need and the risk it has. Great work on your part.

[Andrea]

Two weeks ago I had a pt come home from hospital. The pt informed me that he had been admitted for 2 days due to “heart troubles”. Pt is currently on service with us for IV hydration. We had recieved no orders to resume or hold hydration from prescribing oncologist.
I sent a fax requesting instruction. Reply was recieved that the pt had only been in hospital for chemotherapy for the day and to please give hydration before next reatment in 2 days.
Caling pt back, I learned that he had in fact been at hospital for chemotherapy just a day prior to admission for cardiac concerns and pt had not told ER doctor about his cancer treatment.
I then tried to contact the oncologist to ensure he had all of the information regarding pt’s recent ER admission but he was gone for the weekend.
Next, I contacted my nurse manager as I was concerned re causing fluid overload if pt’s heart was compromised. Nurse manager was in agreement that I had made the right call to hold hydration to avoid potential harm to pt.
In the end pt’s chemotherapy was placed on hold due to recent hospitalization, although IV hydration has continued after clarification from oncologist and cardiologist.
I feel this was Critical thinking as I had to weigh to consequences of both giving or holding hydration, using scientific knowledge, before making my decision.

[Melanie]

Good thinking on your part for sure Andrea! Whether pt forgot to mention his cancer treatment to the ER doctor or decided to omit it, the actions you took were definitely in his best interests. Having to make critical decisions like that when the MD’s can’t or don’t respond is stressful. Good to know you have a Nurse Manager available to you as well when in these situations.

[Maame]

I can recall a time while working on my unit there was a resident that will always complain of pain and only had PRN pain medication only. Whenever the prn medication was given the relief of pain didn’t lost for long and was always requesting for more. I decided to communicate with the RN and also write in the doctor’s book about including a scheduled pain medication within the resident’s medication regimen. During doctor’s rounds the doctor did asess that particular resident and was in agreeance with my finidngs that the resident will benefit from a scheduled pain medication.

[Suzanne]

Pain management is so important for patients. The fact that you advocated for the patient to have scheduled pain medication is such an important factor in the patient’s overall quality of life.

[Heather]

Part of my job is to do assessments on home care clients. I arrived at a home one day to check in on a client. I was aware this client had been having difficulty with her bladder and her g tube feed. I arrived to find this patient extremely weak and dehydrated and had not had a g tube feed in days. There was just drops of urine in her catheter bag which were very dark. I spoke to the family and found out they could not afford the feed and did not know what to do next. I decided to call an ambulance due to the weakness and dehydration. I felt that if I did not do this, this patient would not survive. I later got a call from the patients’s sister thanking me for getting the patient to go to the hospital. I feel that I did use some critical thinking to arrive at the decision to send her to hospital as this was the only viable alternative in a bad situation.

[Taraneh]

Im not quite sure if this would count as “critical thinking” but while working as a surgical nurse, I had a patient who came in to have kidney stones removed. As a pre-op assessment was completed, this gentleman presented with severe pain that most people (including himself) wrote off as pain due to the stones. He also presented with a greyish tone to his skin, cool to the touch and diaphoretic, and I was not convinced it was solely pain from the kidney stones. I opted to complete an ECG prior to surgery under the anesthetist order as I presented all facts while he was in the OR and it did in fact show this man was having a heart attack. He then was sent to ER for a cardiology consult.

[Suzanne]

I would definitely think this is critical thinking. You recognized that the patients pallor was off and that it was not necessarily contributing to the pain from his kidney stones. You definitely played a huge role in saving this patient’s life!

[Marilyn]

You all used critical thinking skills as your knowledge helped you to make a decision outside of the “normal” information you received. Taking the time to assess the situation shows the initiative you’ve taken as a leader. Great job!

[Suzanne]

I work for a family health team and count myself lucky to know enough information about many common diseases and illnesses through seeing patients for many different concerns. I once had a patient come in for a routine general physical. We do have automatic blood pressure machines and I had difficulty obtaining this patient’s blood pressure reading. I did know that one thing that can contribute to this is atrial fibrillation. I did mention this to the family doctor who did a cardiac consult for the patient. The patient was indeed diagnosed with atrial fibrillation and the doctor was very thankful for my attention to detail with the patient.

[Author]

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