Critical thinking/scenario practice

I'm a fairly recent graduate who would like to improve my critical thinking skills, particularly in analyzing situations and figuring out what to do. I don't find exercises with multiple choice answers helpful because that doesn't correspond well to real life (no such help is available). Does anyone have suggestions on how to practice this and/or possible resources? Related to this, I would also love to get ideas on how to practice grasping the "big picture", as I can get too focused on certain details. I want to get better at determining the salient details and recognizing the overall picture of what is going on.
Try working through case scenarios instead. You see these frequently in medical school review books and physicians' journals (usually in the format "Case of the Week" or something similar), and I don't know why we don't use them more often in nursing education. Perhaps because we associate them with PBDS-type testing, which has received such a mixed review over the years? Not sure...Here's one to get you started. Start from the "handoff report" and think about what the patient's key issues are, what the consequences are if they're not dealt with, and what you need to do for this patient as a result."You receive report from the off-going night-shift nurse about Mrs. A, a 72-year-old female who presented to the Emergency Department last night for mental status changes and right-sided weakness starting three hours prior to admission. She has a history of stable rate-controlled atrial fibrillation, for which she takes diltiazem and warfarin, and also of hypertension, for which she takes metoprolol and lisinopril. She does not remember the doses, and forgot to bring her medication list with her. She was worked up for CVA vs. TIA in the ED; a head CT came back negative, but her D-dimer was 655 and her INR was 1.4. Her other lab results are unremarkable. Given her history and symptoms, she was started on heparin IV drip in the ED and admitted to your unit for cardiac telemetry and neurological evaluation. As of handoff at 0700, her vitals were BP 165/95, HR 68, rhythm A-fib, RR 18, SpO2 97% on room air, temp 36.5, and 0/10 pain. She has a 20-gauge PIV in her left forearm infusing D5 1/2NS at 50 mL/hr, as well as heparin on a pump at 850 units/hr. She is alert and oriented to person, place and situation, is easily reoriented to time, moves all extremities and is calm and cooperative."* The admitting orders call for neurological checks q4h. What will you look for? What will warrant a call to the admitting physician vs. what can you manage on your own?* Are there any abnormal vitals you want to jump on? Why or why not?* Will you be implementing bleeding precautions, thrombosis precautions, neither or both? Why?Have fun!

You also have real live patients to practice with too, right?

Unfortunately, no, I don't have any patients to practice on right now, I'm looking for a job.

Quote from elizabethgrad09Unfortunately, no, I don't have any patients to practice on right now, I'm looking for a job.

murphyle,thanks for the scenario. i'm a recent graduate, so don't feel confident in my response to this complex scenario, but here goes.for each neuro check, i would look for changes in vs and loc/mental status, pupil response, facial drooping, grips/pushes. i would call the dr. if any of these changes were significant.re: abnormal vs, i would want to check her bp against recent values from the xfer orders and hx from h&p in deciding whether to notify the dr.i was not familiar with d-dimer so looked that up. that value is high (> 500) and the inr is low, so she could clot, however, she is also on a heparin drip, so i would think both kinds of precautions would be wise.note: i also looked up pbds testing, as i hadn't heard of that. here's a link for others who may be wondering:http://www.zimbio.com/nursing/articl...at+is+the+pbds

Thanks, Uptonogood RN. I thought of reviewing pathophysiology, but had not thought of your idea of mapping the info to previous patients; I like it!

Quote from elizabethgrad09murphyle,thanks for the scenario. i'm a recent graduate, so don't feel confident in my response to this complex scenario, but here goes.