Critical Thinking Scenario – Nursing Essay
Critical thinking is an essential part of a nurse’s professional growth because it determines the quality of decisions made in the course of practice. In this case, there is a patient who is elderly, just retired, and is aged 60 years old. She is a female and has arthritis while also suffering from advanced liver failure. As such, she has been presented to the emergency department after being found by paramedics in her bathroom floor at her house. She lives in a flat with her husband. The husband was responsible for making the emergency call and on the call, the husband noted that the woman was hard to arouse. The woman also had shallow respirations. On the scene, there was a prescription bottle of temazepam and it was empty. It was a 30mg size, and it had been refilled a week before the incident, going by the date indicated on the bottle. When given painful stimuli by paramedics, the patient responded verbally indicating the need to die. The patient is also reported to have resisted medical attention. At the time, her consciousness diminished and her speech slurred but even as she was in the emergency department, she kept on insisting that she should be left to die. The nurses noted that her vital signs were temperature 37.2 degrees Celsius, her blood pressure was 80/40 and other indicators were P118, R 12, SPO2 92% on 2L/min via nasal cannula. The current issues at the emergency department is a discussion on what should be done for the patient. The present suggestion is for the patient to be put into intensive care unit where she can be monitored. The husband does not see the need and wants the woman to go home with him when her vital signs are normalized.
According to Kaddoura (2013), critical thinking has been in development as a practice within nursing for several years, and it is part of the nature of humankind. However, many nurses lack sufficient capacity to use critical thinking skills because of reliance on subjective, indefinite, limited and conventional or narrow-minded approaches when seeking solutions. With critical thinking skills, nurses have to analyze and appraise evaluations. It ensures that theoretical knowledge can be applied to clinical skills and employ reasonable judgments for ensuring that patient care is of the highest qualities.
A definition of the problem
One of the issues worth looking at on patients brought to the emergency department is their vital signs, to confirm their wellbeing from a physiological perspective. The vital signs collection and documentation is a general nursing practice serving as a measure of health and has been established as part of the clinical workflow. While using the workflow allows a nurse to identify the next course of action, thinking about the process should also lead to the identification of barriers and opportunities in the process for improving it and improving the outcome of the process or its efficacy (Yeung, Lapinsky, Granton, Doran, & Cafazzo, 2012). The documentation of the vital signs is a major reason for different prescription outcomes because nurses have to look at the signs and the context of the signs. If the situation is not explained thoroughly in an evidence-based perspective, it is easy to use the right vital signs but still make errors. Another challenge is in the timing of the documentation such that if there is a medical intervention needed urgently, it can be prescribed or administered to a patient. In this case, the patient got to the hospital without any administration of medical other than painful stimuli, which have not been adequately documented. Thus, while the vital signs will offer the right information regarding what should happen to the patient, they do not provide a complete narrative of the events and circumstances that affected the patient before her presentation to the emergency department.
The problem, in this case, is the documentation of the vital signs, which does not include other aspects of the patient’s condition and therefore cannot serve as a comprehensive basis of making clinical interventions.
Analysis of the problem
The use of vital signs for informing nursing decisions is crucial for nursing practice. It is also a consistent practice for nurses. It forms a central part of any nursing workflow when dealing with emergency department patients. The circumstances surrounding a patient’s situation are significant. The fundamental importance to the clinical outcomes of a patient starts with the way a situation is documented and the way vital signs are recognized and addressed.
A condition that was presented in the case involves monitoring of the patient in an intensive care unit to find out whether there are changes in vital signs and possibly verify the relevance of the indicators to the patient’s conditions. The move is useful for detecting patient deterioration. It shows that the vital signs are signposts. Also, nurses have to proceed carefully to seek restoration of health while at the same time, ensuring that no additional harm is presented to the patient (Mok, Wang, & Liaw, 2015). The vital signs are just a first indicator, and that is why the documentation of the workflow is important and should offer a better context for a patient intervention. The case offers background information about the problems at it emerged, but for a nurse responding to the emergency department, the details may not be apparent as paramedics handed over the patient to the department. Thus, there can be incomplete and infrequent monitoring of the patient, when a nurse only settles on the vital signs as indicators of what ought to happen next (James, Butler-Williams, Hunt, & Cox, 2010).
The early warning or scoring system and critical outreach teams that exist in today’s clinical situations in hospitals arise because of limitations in recognizing or acting on the deterioration of patients. When patients’ condition deteriorates when they are under care, it is possible that the mechanisms implemented for their care are ineffective (Odell, Victor, & Oliver, 2009). Finding out whether the systems are indeed ineffective may take time and would require different approaches for different patients. Nevertheless, responding to each patient case uniquely can be a way to ease the burden for nurses, allowing them to handle cases according to opportunities presented and according to the available information. Rather than affix a solution based on standard practice, there should be leeway in the way the nurse comes up with the solution, considering more than the vital signs. The nurse should look at the documentation of vital signs and the surrounding circumstances of the patient then make an informed decision. They have also to consider their experience and the additional protocols by their caregiving facility as well as patient’s family wishes (Johnstone, 2009). Care is provided in a holistic way, and a robotic response to vital signs does not offer sufficient avenue for addressing unique patient needs (De Meester, Bogaert, Clarke, & Bossaert, 2013).
When there is an increase in documentation regarding a patient’s conditions, experts are less likely to designate a case as potentially preventable. They make decisions according to the richness of the information present. Documentation ensures that they are making decisions and verdicts on health interventions from a more accurate perspective than when it is not present. Vital signs are part of the documentation, but they are not the complete source of information for useful decision making on patient outcome. They are static, while what is more important is a continuous narrative of weak performance to show improvement or deterioration. In fact, renewed attention to accurate recording, documentation, and interpretation of vital signs was identified at the right recommendation for practice in hospital nursing (De Meester, Bogaert, Clarke, & Bossaert, 2013). A weakness with this approach on relying on comprehensive documentation to make decisions is that the comprehensiveness may not be timely. For example, for the present case, the woman’s documentation could arise after she is taken to the intensive care unit. The arising information could show that she is deteriorating and upon inquiry, it may be revealed that she has had other medications and medical interventions that could have accelerated her emergency situation. The detail in the documentation of the information alongside the vital signs may cost her life or make the recovery incomplete. Thus, focusing only on a comprehensive documentation presents new weaknesses of timeliness to the nursing intervention (Jonsson, Jonsdottir, Moller, & Baldursdottir, 2011).
If one is documenting but does not understand the need for documentation other than to comply with policies and work procedures, there is the challenge of the data collected being ineffective. For example, just having vital signs as indicators of patient’s wellbeing offers limited information for addressing specific patient needs (Dahnke & Dreher, 2011). If the reaction of the patient is not taken into account, for example, then one loses the ability to think about conditions that would cause the patient to express verbally a wish to die (Dart, 2011). It is not a vital sign, but it is critical to the determination of the right approach to take for the patient, after the emergency department (Glembocki & Fitzpatrick, 2013). Thus, merely advocating for timely documentation as part of the nursing workflow leaves out a major area that would inform better nursing responses (Hardy, Titchen, Manley, & McCormack, 2009).
The handover structures at the emergency department may not be effective at ensuring that there is adequate continuity of nursing care. Many nurses in the department handling emergencies will see the handover as specific for patients they care about, and such handover happens at the bedside (Klim, Kelly, Kerr, Wood, & McCann, 2013). It is a structured process that will contain key patient elements like details, problem presentation, treatment, plan, observation by nurses and other relevant elements. However, timing the handover to make room for any additional intervention for the next nurse or physician is essential to improving patient outcomes (McKay, et al., 2013). Thus, to improve the documentation solutions presented in this case, there is a need to ensure that handover does not just happen at the transfer of the patient from paramedics to the emergency department (Holly, Salmond, & Saimbert, 2012). The documentation should be continuous from the first response so that successive nurse attendants to the patient have sufficient room to act and hinder further deterioration of the patient’s health. Early and timely comprehensive documentation also serves as learning resources for nurses to verifying whether the application of best practices for patient care is yielding preferred outcomes (Gerdtz, et al., 2013).
The recognition of the physiological changes that patients encounter, which are key factors leading to critical care admission, happens through nursing surveillance. Another notable factor is that patient experience deterioration rapidly, but 24 hours before that, they undergo a decline. During the decline phase, nursing surveillance plays the role of collecting, analyzing and interpreting information about the patient. The monitoring and evaluation process allows nurses to act on emerging indicators as the patient’s status changes. While this is the required approach, the adequacy of the surveillance will affect the outcomes. If there is a lack of information, then the outcomes from the surveillance will be inferior, and the recognition of the deteriorating vital signs might happen late (Fasolino & Verdin, 2015).
The proposed solution can be improved by having nurses and other caregivers and responders to emergency situations understand the importance of timely documentation. By knowing the role, they play for the completion of the care process for the patient; the responsible parties should have the right attitude for documenting patient conditions including vital signs in a timely way. They would not only consider what the basic threshold for reporting is, but also consider the unique insights of a case and include them in the documentation. In the case presented for this essay, the solution can be improved by querying details of the patient and including them to the report on vital signs to aid the response by other nurses in the intensive care unit when the patient will be transferred to (Melnyk & Fineout-Overholt, 2011).
In completing the assignment, there was a need to consider the situation based on the problem presented and then selected one aspect that is worth addressing. The case offers multiple problems, but the chosen problems appeared like one that would affect the individual case outcomes while also offering sustainable solutions that nurses could apply to future problems. In thinking critically, the possibility of more than one problem and solution emerged. Thus, prioritization based on the case, and on information already at hand became important. At the same time, it was apparent that thinking critically about the problem also raises other problems seeking solutions. For example, focusing on the documentation of vital signs as a matter in the main case, also presented a realization that the manner of looking at the problem could be a problem in itself. Also, the solution offered was not absolute, and it needed further modification to strengthen its sustainability.
When undertaking the same assignment in future, it would be necessary first to outline more than one problem and then allocate solutions to the problems before prioritizing them based on an ideal outcome given the cases’ circumstance. Although the case is concentrating on nursing perspectives, it may be necessary to bring up other medical perspectives and the societal issues affecting the case. The outcome would be a better understanding of the role that nurses play in patient outcomes both from a literature review perspective and from a pragmatic approach perspective. When reviewing the case in future, it would also be important to consider implications for the solution suggested to the case from a nurse who happens also to handle other similar cases (Levin & Feldman, 2012).
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