[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.

[Maria]

Working in the ER for 14 years we always have to practice critical thinking at all times. However, my example is an event that happened last year while working as an agency travel nurse in a LTC. A resident had been complaining right lower abdo pain for 2 days. I had brought this to the attention of the charge nurse in the building but was told to continue to monitor as the resident voiced that he is not nauseated nor vomiting or having any other symptoms. Vitally the resident was stable. I did my head to toe and abdominal assessments and the resident remains asymptomatic other than the intermittent right lower abdo pain. I asked the resident that day if he had a Hx of appendicitis. The resident stated that he had it when he was young. I was doing a 16 hrs shift in the same unit. Just after lunch, the PSW reported the the resident vomited. The resident at the time was laying on his bed and I figured that back then they use to have big incision for an appendectomy. I checked for any surgical site and there was none. The resident then said that it was his brother now that he thinks about it who had the appendicitis and not him. The pain now radiate to his right upper quadrant. I reported my findings with the charge nurse. The charge nurse decided to place him on isolation for Covid. Since this was during the height of Covid, almost everyone gets isolated. Before isolating the resident, I asked the charge nurse to have a seat in my nursing office and encouraged her to brainstorm the presentation with me. I had told her that it may look like Covid since the symptoms pertains to that but it can be gallstones as well and it’s best to send him to the ER to get some diagnostic tests and blood work to rule out other possible cause of pain. The charge nurse agreed and decided to speak to the doctor. I was able to convince the doctor to send the resident to the ER. He was later on admitted with Cholecystitis and admitted due to a high WBC.

[Johanna]

Maria,
Your example illustrates why critical thinking is different from problem solving or decision making. The charge nurse was trying to solve a problem by making the decision to just monitor the resident and place him in Isolation.
You used divergent thinking, reasoning about the source of his discomfort, reflection, and the basic support of your years spent working in the ER. These tools allowed you to see the situation from more than just a COVID perspective. You were able to analyze the information, use reasoning and logic, and come to a conclusion about the resident’s health status. This allowed you to address the root cause of the resident’s discomfort in a timely manner, and to get him the help he needed.

[Jay-Ann]

Critical thinking as a nurse is always At the start of my shift one day working in LTC. I was doing the med pass, when I reached the doorway of one of the residents’ room. I noticed he was eagerly trying to wheel himself into the washroom. I asked if wanted to use the washroom, but he said no he “wanted some water to drink” and was trying to get to the faucet. I told him I had water on the med cart could give him, but he was still trying to wheel himself to the faucet. The resident became very upset when I tried redirecting him. I gave him some water and he kept asking for more. After about seven cups of water, he still wanted more. The resident was not currently on any hyperglycemic medication and was not diabetic to my knowledge and it was not stated in his medical diagnoses. I found this very unusual behaviour for him, so I checked his blood sugar, seeing that this is a symptom of hyperglycemia. The resident’s blood sugar reading read “HI” with no value. I notified the charge nurse and gave the resident some more water as he was alert and oriented.
The charge nurse notified the doctor, and he asked what caused me to check the resident’s blood sugar. So, I explained that the resident was showing signs of increased thirst. The doctor ordered STAT insulin, 90 minutes after administration I was still not able to get a blood sugar value. The resident CBG was still reading “HI”. After three STAT doses, I was able to get a blood sugar value in the high 20s.
The resident is now on scheduled hyperglycemic medication. Thinking critically aided in managing the outcome.

[Loretta]

Critical thinking and the knowledge we have as nurses is very important. This allowed you to recognize the symptoms and act quickly to get a diagnosis for the patient. Luckily a trip to the ER was avoided if symptoms became more severe.

[Maria]

Hi Jay-Ann

Great job catching hyperglycemia on a resident. Critical thinking is very crucial in our everyday nursing practice. By observing his behavior you were able to use critical thinking and make appropriate decisions on what steps to take.

[Rebecca]

This is a very good example of critical thinking, thank your for sharing it. I worked as a PSW in LTC after my first year of nursing and always tried to inform the nurses if I noticed any behavior or significant changes. Being able to recognize and implement the appropriate actions like how you described is the perfect example of how using critical thinking and the nursing process is important.

[Loretta]

Critical thinking is a vital part of everyday nursing. About 2 weeks ago I had a patient come in to the clinic requesting a dressing change as he had a toenail removed and was not given any information as to how often dressing changes should be done. He stated that a referral was supposed to have been sent to home care but he had not heard from them. I started to remove the dressing but realized that there was jelonet or another type of similar dressing on top the the nail bed. I knew we do not usually keep those types of dressings in the clinic. We don’t usually get many people come in for dressings and we only have simple dressing supplies. I decided to keep the dressing in place and went to talk to the Doctor. I told her the situation and that I did not remove the dressing because we did not have the correct dressing supplies to to the dressing change. She agreed that home care would be a better fit. Our organization has a home care department, which she did a referral for him. I explained the situation to the patient and since his dressing was not visibly soiled he would be fine to wait for the home care nurses to come to his home. I let him know we would be sending the referral and they would contact him to set up a time to come in and do his dressing changes.

[Johanna]

In my role, a common problem encountered is a resident who speaks in a threatening manner to his co-residents. This is identified as the problem that needs to be resolved.
I could make a decision that his behavior is unacceptable and poses a risk to others. I could solve the problem by giving him a PRN dose of risperidone. This very well may or may not resolve the problematic behavior.
However, the use of critical thinking encourages using tools such as divergent thinking, reflection, and basic support. I could then take a look at the overall situation. By talking to the staff and the resident, I might identify that the resident has been walking all morning, and is complaining of back pain. I might also notice that he is wearing his slippers, not his running shoes. My experience tells me that he might also be tired, in addition to in pain.
Therefore, I could provide his PRN Dilaudid dose and ask the PSWs to change his shoes and encourage him to lie down on his bed to rest. I could also start pain monitoring documentation to capture any recent trends and to provide data to give to his practitioner supporting a possible medication change.
This provides a better solution for the resident; one that truly addresses his needs and possible root causes of the undesirable behavior.

[Blair]

When I worked more on the floor in LTC I was always amazed by the shift before me or psw that would say. Just give the their PRN before we get any problems. We do it all the time makes our night easier.

My instant reaction is to check and see if this is true and then but in referral to BSO for behaviour tracking and a note on the dr board for a medication review once the behaviour tracking is complete.

That is not quality resident care. Use that crustal thinking and find the root cause.

Great example

[Blair]

While working as a withdrawal management nurse. I had to use critical thinking regularly. This program was volunteer and the client often suffered from mental health issues along with addiction. Many times I had clients that would come to me and state they needed to go and this wasn’t right for them. I always made sure to do a welfare fare check before departing. During their stay clients would see physiatrist and get put back in their medication. I often had to inform clients I was not able to give them the medication on discharge due to them being unstable and the danger of overdose.
After many incidents the organization put in a policy that you could no longer have more then a week supply on hand of a clients medication

[Jessica]

We had a patient we felt was going bad on the floor. I addressed my concerns with the internal medicine doctor and the concerns were not fully addressed. As the patient became in further distress, I made the decision to skip over the internal medicine doctor and call our CCOT team. Although they were not convinced the patient required their intervention either, they did agree to assess the patient. Once the CCOT nurse and doctor assessed the patient it was clear to them she was in heart failure and immediately took over care. I believe the patient would not have survived the night if I didn’t make my assessments and look towards what I felt her outcome would be if I didn’t call the CCOT team.

[Jay-Ann]

Hi Jessica,
There would definitely be a different outcome if you had not used your critical thinking skills and acted promptly. As nurses we think critically but we also follow our gut instinct as well, if we feel something is wrong it usually is.

[Rebecca]

Critical thinking is the basis for how nurses make decisions. When using the nursing process to make decisions, nurses have to use critical thinking. The process to determine what actions are need, or if any action is even needed comes from critical thinking. When performing any assessments or taking vitals we have to assess the information in relation to the patients on a regular basis. In response to emergencies or a change in patient status or health requires gathering information and using critical thinking and the nursing process to best determine how to best to proceed. When I was in pre-grad I had a very valuable learning experience. I was fortunate to work with a group of nurses that worked very well as a team. I had a patient with hypertension and a medication to help manage it. The order had parameters, so I went to take the BP before administering the medication and his BP was very low. The whole team came to help. We rechecked his BP and went through the nursing process to make sure all the appropriate steps to help the patient were taken. After implementing interventions to bring up his BP, his medication was modified, and I continued to monitor his BP. This was the most urgent patient experience I had as a student. This experience was valuable to me as it showed me how important critical thinking is and how to use it in a more urgent setting. It wasn’t just making quick decisions, it was getting all the information needed and looking at the patient’s specific needs but still taking appropriate actions as necessary.

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