Kelsi Baron
CRITICAL THINKING EXERCISES
Purpose:
Critical thinking skills and strategies are needed to decrease patient mortality and morbidity rates and
decrease failure to rescue rates. Nurses are the surveillance system for early detection of problems and
intervention to prevent adverse patient outcomes. It is the intent of these exercises that cognitive
strategies used by nurses are practiced within the clinical setting. The student is allowed to think about
how nurses think and why nurses need to think skeptically in order to make the thinking clearer, more
accurate, and defensible. Students will continue to be assigned direct patient care as usual, being
these exercises are not intended as a replacement for it. After students complete these critical
thinking exercises, they will present them during post conference on the day assigned by their clinical
instructor.
Critical Thinking – MEDICATION (CTM)
Specific course outcomes met by these exercises and evaluated by your clinical instructor:
1. Identify appropriate nursing care reflective of individual patient differences, modifying care
appropriately. (Generalist Nursing Practice)
2. Explain rationale for nursing interventions reflective of current best evidence for practice. (Scholarship
for Practice)
3. Recognize the importance of using the nursing process in the design and implementation of health
promotion based nursing care. (Health Care Environment)
Directions:
Based on the specific medication classification(s) presented in theory for current or previous weeks, you
will be assigned a patient taking medications in that classification (i.e. cardiac: patients taking beta
blockers, calcium channel blockers, etc.). Please note that content coverage for these exercises might be
altered by the clinical instructor if patient census dictates.
On a separate sheet of paper, gather the following data for your patient:
Patient’s medical diagnosis, age, gender, & other pertinent demographic information (allergies, PMH,
chronic conditions)
Diagnosis: with congestive heart failure
Age: 77
Gender: Male
Allergies: NKA
Other: History of coronary artery disease, prostate cancer, bladder cancer, HTN, hyperlipidemia,
Type 2 diabetes. Surgical history of cardiac stenting, cholecystectomy, transurethral resection of prostate,
bladder biopsy and cystoscopy. Quit smoking 20 years ago.
Medication: classification, dosage, route (IV compatibility? Can it be crushed? Given with food?)
Ceftriaxone (Rocephin): Antibiotic. 200 ml/hr every 24 hours via IV
Docusate-senna (Duculax): Stool softener. 1 tablet twice a day. Take with full glass of water or
juice in the evening, do not administer within 2 hours of other laxatives.
Furosemide (Lasix): Loop diuretic. 4ml daily via IV.
Insulin (Novolog): Insulin. Administered daily ac/hs/0200, via injection. Given after meals.
Metoprolol (Lopresor): Beta blocker/antihypertensive. 1 tablet daily. Take with meals or directly
after eating. Extended release tablets should not broke, crushed, or chewed.
Multivitamin: Vitamin. 1 tablet daily. Chewable forms should be crushed or chewed fully before
swallowing. Liquid preparations should shook completely before administered and may be taken with
juice. Do not take with milk.
Potassium-Chloride: Corrects low levels of potassium. 1 tablet taken twice a day. Take with
food or just after a meal. Do not crush, chew or break the pill.
Rivaroxaban (Xarelto): Anticoagulant. 1 tablet daily with dinner. Do not take with grapefruit juice
or with other medications containing aspirins or NSAIDs.
Simvastatin (Zocor): Lipid lowering agent. 2 tablets at bedtime. Do not take with grapefruit juice
and may be taken without food.
Acetaminophen (Tylenol): Pain reliever. 2 tablets as needed. Take will full glass of water and
with or without food.
Indications for use (from the book)
Ceftriaxone: Antibiotic from the 3rd generation Cephalosporin, which act on gram negative and
have a longer duration of action and are resistant to beta-lactamase.
Docusate-senna: Stool softener/surfactant which causes more water and fat to be absorbed into
the stools. Most often to help with prevention of constipation.
Furosemide: Loop diuretic which blocks the reabsorption of Na+ and Cl- and when given IV it
has the ability to cause large amounts of fluid to be excreted by the kidneys.
Insulin: Type 1/2 diabetes mellitus.
Metoprolol: Acts by reducing sympathetic stimulation of the heart, thus decreasing cardiac
workload.
Multivitamin: Provides essential substances needed to maintain optimal wellness.
Potassium-Chloride: Prevents and treats hypokalemia.
Rivaroxaban: Prolong bleeding time and prevent blood clots.
Simvastatin: Management of hypercholesterolemia and prevention of MI, stroke, and
cardiovascular mortality in patients with coronary heart disease.
Acetaminophen: Reduces fever and relieves pain.
Why is this patient taking the medication?
Ceftriaxone:
Docusate-senna: Prevent constipation from the different drugs he is on.
Furosemide: To remove any fluid retention in excess amounts from the CHF.
Insulin: His Type 2 diabetes.
Metoprolol: For CHF and helps reduce long term consequences of the disease.
Multivitamin: To keep his nutritional intake good and can benefit his chronic disease which can
deplete his system.
Potassium-Chloride: Prevent hypokalemia from depletion from the diuretic.
Rivaroxaban: Prevention of blood clots which can increase problems with CHF.
Simvastatin: Management and prevention of cardiovascular mortality with his coronary heart
disease.
Acetaminophen: Pain reliever.
Contraindications (from the book)
Ceftriaxone: Hypersensitivity to cephalosporins, hepatic and renal impairment and Hx of GI
disease.
Docusate-senna: Abdominal pain, nausea, or vomiting and caution in excessive use.
Furosemide: Hypersensitivity to furosemide or sulfonamides, anuria, hepatic coma, and severe
fluid or electrolyte depletion.
Insulin: Pregnancy, renal impairment or failure, fever, and thyroid disease.
Metoprolol: Patients with asthma, cardiogenic shock, sinus bradycardia, heart block greater than
first degree and overt cardiac failure.
Multivitamin: Too much can result in it being toxic to the body.
Potassium-Chloride: Patients with hyperkalemia, chronic renal failure, systemic acidosis, severe
dehydration, and adrenal insufficiency.
Rivaroxaban: Patients with active bleeding, severe renal impairment, & prosthetic heart valves.
Simvastatin: Active liver disease, pregnancy and caution in Hx of liver disease.
Acetaminophen: Chronic alcoholism or liver disease.
Contraindications this specific patient has
Ceftriaxone: None.
Docusate-senna: None.
Furosemide: None.
Insulin: None.
Metoprolol: None.
Multivitamin: None.
Potassium-Chloride: None.
Rivaroxaban: None.
Simvastatin: None.
Acetaminophen: None.
Other prescribed medications that relate to this medication and affect the administration of this medication
(list all medications; star and indicate the affect a medication may have if any)
No other or additional prescribed medications in which will affect the current.
Expected therapeutic effects (from the book)
Ceftriaxone: Decreased incidence of infection and resolution of signs and symptoms.
Docusate-senna: Soft formed BM within 24-48 hours.
Furosemide: Reducing edema associated with the CHF.
Insulin: Decrease hyperglycemia and manage symptoms related to hyperglycemia.
Metoprolol: Decrease BP, increase activity tolerance and prevent MI.
Multivitamin: Maintenance of normal metabolic processes.
Potassium-Chloride: Prophylaxis of hypokalemia.
Rivaroxaban: Prevention of blood clots and pulmonary emboli.
Simvastatin: Decrease LDLs and total cholesterol levels, as well as slowing progression of
coronary artery disease.
Acetaminophen: Decrease fever and help relieve pain.
Side effects to consider (from the book)
Ceftriaxone: Rashes, c. diff, urticaria, diarrhea, and superinfection.
Docusate-senna: Throat irritation, mild cramps, diarrhea and rashes.
Furosemide: Dehydration or electrolyte depletion.
Insulin: Overtreatment, thus resulting in hypoglycemia.
Metoprolol: Slowing heart rate, and hypotension.
Multivitamin: Hypervitaminosis.
Potassium-Chloride: Nausea, vomiting, and reduced renal function.
Rivaroxaban: Blisters, syncope, extremity pain and wound secretion.
Simvastatin: Amnesia, confusion, abdominal cramps, rashes, constipation and pancreatitis.
Acetaminophen: Liver damage, gastric irritation, and toxicity.
When was the last time this medication was administered?
Ceftriaxone 3/24/14 at 0900
Docusate-senna 3/24/14 at 2119
Furosemide 3/24/14 at 0814
Insulin 3/24/14 at 2121, 1 unit
Metoprolol 3/24/14 at 0814
Multivitamin 3/24/14 at 0814
Potassium-Chloride 3/24/14 at 2119
Rivaroxaban 3/24/14 at 1739
Simvastatin 3/24/14 at 2119
Acetaminophen 3/23/14 at 0900
What were the effects last time it was administered?
Ceftriaxone:
Docusate-senna: Ease of a BM.
Furosemide: Increased urine output with no negative effects.
Insulin: Maintenance of blood glucose, it decreased blood sugar from 285.
Metoprolol: No physical signs.
Multivitamin: No physical signs.
Potassium-Chloride: No physical signs.
Rivaroxaban: No physical signs.
Simvastatin: No physical signs.
Acetaminophen: Relief from his headache.
What pertinent assessment needs to be made prior to administration of this medication? Review the
documentation; is it there? (Physical assessment? Health history? What lab values need to be checked
prior to administration?)
Monitor vital signs (especially heart rate and blood pressure), labs (K+, Na+, Cl-, Ca+, and WBC)
blood glucose, pain, edema, and lung sounds and heart sounds. A complete health history should be
obtained to ensure that no previous complications of illnesses will affect how a drug is absorbed or used
for.
What evaluation data needs to be collected after administration? When? Review the documentation; is it
there?
Reassessment of vitals, pain, labs, and monitor for any adverse effects of the medications. You
should check your patient within 15-30 minutes for symptoms and then for pain reassessment. Ensure to
document all results prior to and after the medications.
Review the care plan. If no health promotion diagnosis exists, what diagnosis would you recommend for
this patient population? Explain.
I would recommend for the patient to monitor his diet and activity level. He should maintain a
good nutritional diet that is low in sodium. He should also try and maintain some level of activity to help
decrease symptoms, improve his heart function and improve his overall sense of well-being. Although he
will have to start out slow with physical activity but it will really benefit him in the long run.
Post conference:
Compare and contrast the patient’s medication, classification, use, and other characteristics (age,
financial resources, level of education, ethnic background, etc.) to your peer group in post conference. Be
sure to also address the following questions:
1. What would you be on alert for with these types of patients? –Increased shortness of breath,
increased edema, more fatigue, confusion or impaired thinking, increase heart rate, and changes in
electrolytes.
2. What are important assessments to make? –Weight gain, changes in lung or heart sounds, new
swelling in other areas, frequent dry cough, nausea, vomiting, heart rate or blood pressure changes, and
signs of toxicity.
3. What complications may occur? - Kidney damage or failure, heart valve problems, liver damage,
and stroke. What could go wrong? –Worsening of CHF, increase of symptoms and worsening of
symptoms or death.
4. What interventions will prevent complications? –Close monitoring of labs and vitals.
5. Discuss specific health promotion nursing diagnoses that would be appropriate for this patient
population along with outcomes and interventions. –Decrease sodium consumption in diet. Fluid
restrictions to decrease fluid retention. Increased activity tolerance through mild exercise.
Personal reflection:
1. This critical thinking activity showed my growth because it has allowed me to be able to explain how
these medications work, interact, and it shows that I have an understanding of the disease and some
medications that help.
2. As a result of this critical thinking activity, I have learned how to better research the medications that
this patient is taking. It has allowed me not to only better understand them but I can see how they are
used for more than one disease process. I can also see how they all work together and what benefits they
provide for the patient. I have a better understanding of the medications.
Critical Thinking – PATHOPHYSIOLOGY (CTP)
Specific course outcomes met by these exercises and evaluated by your clinical instructor:
1. Identify appropriate nursing care reflective of individual patient differences, modifying care
appropriately. (Generalist Nursing Practice)
2. Explain rationale for nursing interventions reflective of current best evidence for practice. (Scholarship
for Practice)
3. Recognize the importance of using the nursing process in the design and implementation of health
promotion based nursing care. (Health Care Environment)
Directions:
Based on the pathophysiology topic presented in theory for current or previous weeks, you will be
assigned a patient with medical diagnoses reflecting that focus (i.e. Cardiac: patients with heart failure,
MI, etc. Your clinical instructor will help you determine the best medical diagnosis to gather information on
and use for this exercise.). Please note that content coverage for these exercises might be altered by the
clinical instructor if patient census dictates.
Example data (there may be more as directed by your clinical instructor):
General survey, two-minute focused physical assessment, prior shift/admission assessments, diet, I & O,
oxygen, blood glucose monitoring, activity level, treatment/procedures, medications (only list them) as
well as care plan.
On a separate sheet of paper, gather the following data for your patient:
Patient’s medical diagnosis, age, gender, & other pertinent demographic information (allergies, PMH,
chronic conditions)
Diagnosis: with congestive heart failure
Age: 77
Gender: Male
Allergies: NKA
Other: History of coronary artery disease, prostate cancer, bladder cancer, HTN, hyperlipidemia,
Type 2 diabetes. Surgical history of cardiac stenting, cholecystectomy, transurethral resection of prostate,
bladder biopsy and cystoscopy. Quit smoking 20 years ago.
Describe pathophysiology of medical diagnosis (from the book)
Is an inadequacy of heart pumping, which causes the heart fails to maintain the circulation of
blood. Due to the restricted forward movement of blood it results in congested and edema in pulmonary
or peripheral tissues. Cardiac reserve is expended during rest in those with CHF. Simple tasks become
harder.
Etiology (from the book)
CHF can be caused from damage of the heart muscle like coronary artery disease, a heart
attack, cardiomyopathy or conditions that over work the heart. As well as impaired left ventricular
pumping, valvaular disorders, stenosis, or cor pulmonale.
Etiology for the patient
Coronary artery disease and cardiac stenting.
Clinical manifestations (from the book)
Congestion in peripheral tissues decreased cardiac output, pulmonary congestion, and fluid
congestion, shortness of breath, coughing, crackles in lungs, exercise intolerance, poor urinary output
and fluid and sodium retention.
Clinical manifestations exhibited by patient (from your assessment and assessments you reviewed)
Difficulty breathing, coughing, left sided chest pain, left neck pain, bloating in stomach & swelling
in legs.
Lab/diagnostic tests expected with this diagnosis (from the book)
Chest radiography, two dimensional echocardiography tests, ECG, and cardiac catheterization.
Patient history and physical exams help show the presence of clinical manifestations. CBC, serum
creatinine, BUN, BNP, serum albumin, lipid panels, liver function tests, electrolytes and PT/PTT.
Lab/diagnostic test results for the patient
Labs: Na+ 136
BNP 273
K+ 4.8
WBC 10.3
Cl 95
Hgb 16
CO2 35
Platelet 242
Cr 1.1
Ca 8.8
Diagnostic: DR Chest 2 view; frontal & lateral
Stable mild dilation & calcification of thoracic aorta. Stable mild cardiomegaly
without pulmonary vascular congestion. No pleural effusions and no evidence of acute disease in chest.
Current nursing diagnosis
At risk for falls
Review the care plan. If no health promotion diagnosis exists, what diagnosis would you recommend for
this patient population? Explain.
The patient has decreased cardiac output so I would recommend that the patient get adequate
sleep and bed rest to help with activity tolerance. Along with encouraging the patient to take rest periods
during activity to help get him through the activity and not over work his heart.
Also with the fluid retention that is common with this disease, I would advise him to weigh
himself daily. This will allow us to see if he is gaining weight due to fluid retention or because of a different
reason. This way he can keep track of his weight and know ways to maintain his weight and what to look
for.
Post conference:
Compare and contrast the patient’s pathophysiology and other characteristics (age, financial resources,
level of education, ethnic background, etc.) to your peer group in post conference. Be sure to also
address the following questions:
1. What would you be on alert for with these types of patients? –Increased shortness of breath,
increased edema, more fatigue, confusion or impaired thinking, increase heart rate, and changes in
electrolytes, along with underlying respiratory infections.
2. What are important assessments to make? –Weight gain, changes in lung or heart sounds, new
swelling in other areas, frequent dry cough, nausea, vomiting, heart rate or blood pressure changes, and
signs of toxicity.
3. What complications may occur?- Kidney damage or failure, heart valve problems, liver damage, and
stroke. What could go wrong? –Worsening of CHF and symptoms or death or reoccurring infections of
the respiratory system and treatments no longer working.
4. What interventions will prevent complications? – Close monitoring of the patients symptoms,
vitals, labs, and increasing the patients understanding of the disease.
5. Discuss specific health promotion nursing diagnoses that would be appropriate for this patient
population along with outcomes and interventions. –Decrease sodium consumption in diet, fluid
restrictions to decrease fluid retention, increased activity tolerance through mild exercise, and the
importance of bed rest and adequate sleep.
Personal reflection:
1. This critical thinking activity showed my growth because I was able to show understanding of the
disease and what things can cause the disease. I was able to break down the disease and put together
the symptoms and medical history of the patient to show how he got the disease.
2. As a result of this critical thinking activity, I have learned how to understand the importance of a full
physical assessment because many different clinical manifestations can make up one or more diseases.
It is important to keep track of everything because it can tell you ahead of time if symptoms are worsening
or perhaps heading towards a new illness. Not only all of these reasons but I know understand congestive
heart failure on a better level and that it can be right or left sided and what their symptoms can manifest
as.