Nurse Critical Thinking Scenarios
Critical thinking can seem like such an abstract term that you don’t practically use. However, this could not be farther from the truth. Critical thinking is frequently used in nursing. Let me give you a few examples from my career in which critical thinking helped me take better care of my patient.
The truth is, that as nurses we can’t escape critical thinking . . . I know you hate the word . . . but let me show you how it actually works!
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Critical Thinking in Nursing: Example 1
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 to 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 90’s 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.. 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.
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Critical Thinking in Nursing: Example 2
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. The 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 a 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 was 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.
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.
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Date Published - Sep 30, 2016
Date Modified - Jun 12, 2017
Written by Jon Haws RN
Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.
*Note: This post is the third in a series.
In the second post in this series on active learning strategies in nursing, I shared one nursing instructor’s way to set realistic expectations of her students beginning with the first time they step into the classroom. Now in this third post, let’s look at the ultimate question I hear everywhere I go: “How do I get my students to think critically?”
I attended an all-day conference by a nationally known speaker on this very topic. It was called, “How To Get Students to Think Critically.” I was pretty excited and looking forward to the day. It became pretty clear within the first hour of the day what the answer was. It was this: Involve your students. The speaker lectured to us for eight hours about how important it was to involve learners actively in the process. I found this amazing. We were not ourselves involved as learners once in that day. We were lectured to. We were lectured at, but we were never involved. I wanted to know how to involve my learners. That day ended without me gaining that knowledge.
I don’t blame the speaker. Her content was good. After all, she was doing what so many who teach nursing do - she was lecturing. To many people who teach, that’s all they have seen modeled. They are familiar with it. They can come in and do a “content dump” and feel they have done their job well. But who knows the content at the end of that lecture? The educator who give it knows it. The bad news is, he/she may be the only person retaining and understands that knowledge. Many educators have discovered that if they want to teach their students to think critically, they must create opportunities for their students to think critically. It’s like putting in a catheter. Can a student catheterize someone by hearing a lecture on it? No, one masters it by gathering the knowledge, watching a demo, getting the right supplies, and practicing on a manikin until feeling competent enough to get checked off by the teacher. The same is true for critical thinking.
So, how do you do that? I like to start off the thinking at the very beginning of class with something that looks fun or simple to start the brain thinking. Many of these activities can be found by putting these words into a search engine, “Brain puzzle of thinking puzzle.” Here is one example I put on a PowerPoint slide and ask the students: “Based on the pattern established below, where do the 0, 7, and 9 go?”
Complete the series:
8, 5, 4, __, 1, __, 6, 10, 3, 2, __.
Where do 0, 7 and 9 go?
See if you can figure this problem out without reading further yourself. Have you solved it?
After two minutes I poll the group and ask why people made the selections. I then show them the completed list so they can check whether or not they were right. Also, check yourself:
Complete the series:
8, 5, 4, 9, 1, 7, 6, 10, 3, 2, 0.
Did you solve the pattern this way? You may be asking why is this the right answer. Well, if you write the numbers out, you can see the list is an alphabetical one. Eight, Five, Four, Nine, One, Seven, Six, Ten, Three, Two, Zero. What point does this make? Nursing is all about recognizing patterns. What do we expect to see in a patient with CHF? What would be normal and what would not? What are the expected effects of a diuretic? What is an alarming effect? One must know the patterns to problem solve and act appropriately for the patient.
One could also use a short patient scenario or NCLEX-style question at the beginning of class as the “problem of the day.” Present this and ask each learner to record what he or she thinks the answer to the question before you lecture. Then stop every 20 minutes or so and ask your learners to individually think and write down if they have changed their initial choice. If so, write down why. What principles or information have you learned that has changed your answer or caused you to know your choice is correct? In the last segment of the class, have the learners share and discuss the answers they have and the correct answer with rationales. This makes it safe to make mistakes of judgment on paper, not on people. The only way one learns is to be involved in making situational choices. The number pattern and/or the patient scenario offer learner practice in critical thinking.
Might you use one or both of these ideas? What do you think of these teaching strategies? Are they useful to you? Which strategies do you currently use that gives you great learner results?
Michele Deck presents nationally and internationally on innovative teaching methods in the field of health care education and training. She is co-founder and chief executive officer of G.A.M.E.S., a company that specializes in seminars on adult learning and interactive training methods, and Tool Thyme for Trainers, a company which supplies innovative and creative presentation tools for educators worldwide. Honors include ANPD’s prestigious Belinda E. Puetz Award, election to Sigma Theta Tau National Nursing Honor Society, Business Woman of the Year by the National Business Council, and Best Over All Trainer by Creative Training Techniques Companies. She serves on ANPD’s Education committee and was a member of the Editorial board of the Journal for 8 years.