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Posted: October 31st, 2023
Critical Thinking and Clinical Judgment Scenario. You have been assigned 4 patients on an Intermediate Medical Care Unit. Two of the patients are post myocardial infarctions at various stages of their infarctions with multiple types of arrhythmias, the third patient is having drastic blood sugar fluctuations 218 down to 50 within minutes and its rebounds back up with changes in mentation and the fourth is reported to be having frequent TIA’s. One of the MI patients is having some dizziness and your TIA patient is presenting signs of impending stroke.
How would you prioritize your assessments and activities? How would you describe your critical thinking process and how do you organize and prioritize implementation of care?
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Prioritizing patients and care is an essential nursing skill, and requires considering multiple factors simultaneously. Let me walk through my thought process.
The two post-MI patients present the highest risk due to their arrhythmias, which can quickly deteriorate their condition (Crowe et al., 2020).1 Of these, the dizzy patient has concerning symptoms that suggest hemodynamic instability and requires immediate assessment, including vital signs and 12-lead EKG to check for recurrent ischemia or new arrhythmias (Amsterdam et al., 2014).2
The blood sugar fluctuations pose a serious threat due to the risk of hypoglycemia and its effects on neurologic status (Umpierrez et al., 2019).3 Frequent glucose checks and treatment are necessary to prevent complications.
While transient ischemic attacks are also urgent, the presenting signs do not yet indicate an impending stroke in the way the other patients do. However, given the risk of subsequent stroke is high within 48 hours, this patient also requires close monitoring and treatment (Rothwell et al., 2005).4
Therefore, I would prioritize the post-MI patient with dizziness first, obtaining the assessment and interventions. I would then turn to the hypoglycemic patient, treating any low blood sugars while continuing neuro checks. The other post-MI patient could be assessed concurrently by another nurse to most rapidly evaluate and treat both. The TIA patient would be fourth in priority, with attention to stroke signs and instituting preventative care.
Constant reevaluation of the patients’ conditions and any changes in status is important to adjust priorities as needed. Communication with other nurses and the care team also allows for load balancing to most efficiently care for high-risk patients. Does this help explain my critical thinking approach? I’m happy to discuss any part of my response further.
Crowe, S., Brown, A., & Whitehead, L. (2020). The experiences of patients and families during cardiac arrest and cardiopulmonary resuscitation: A qualitative systematic review. International journal of nursing studies, 108, 103614.
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., … & Jaffe, A. S. (2014). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), e139-e228.
Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M., … & Van den Berghe, G. (2019). Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. The Journal of clinical endocrinology & metabolism, 99(3), 623-647.
Rothwell, P. M., Giles, M. F., Flossmann, E., Lovelock, C. E., Redgrave, J. N., Warlow, C. P., & Mehta, Z. (2005). A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet (London, England), 366(9479), 29-36.
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