Analyzing Complex Situations in an Emergency Department or a Department of Surgery

1. Analyzing Complex Situations in an Emergency Department or a Department of Surgery Course prepared for training given at Coimbra Hospital in Portugal By Margot Phaneuf, R.N., Ph.D.

2. Which steps of the critical thinking process are required to analyze a complex situation?

3. A complex situation requires complex tought, combining one’s intuition with thinking that is: . Inductive, . Systematic, . Dialectical and critical, . Hypothetical-deductive, and . Creative.

4. The care process remains the best strategy for dealing with a complex situation, since it calls on several aspects of critical thinking.

5. The nursing process Data gathering Clinical judgment Nursing diagnosis Analysis Planning Intervention Evaluation Evaluation

6. Inductive thinking Contributions to the formation of a clinical judgment Intuition Systematic thinking Dialectical and critical thinking Hypotheses Choices Hypothetical-deductive thinking Clinical judgment

7. Inductive thinking: for collecting data Types of thinking used in the overall nursing process Intuition: for structuring a more targeted search for data Systematic thinking: for taking into account all aspects of a situation Creative thinking: for planning interventions Hypothetic-deductive thinking: for identifying and analyzing hypotheses Dialectical and critical thinking: for selecting the hypothesis or nursing diagnosis and evaluating the process

8. Simplistic reasoning that moves directly from cause to effect What to avoid in a complex situation

9. Analysis of a complex situation I look for other factors. I reconsider what I know about the subject. I consider different aspects of the person. Inductive thinking Systemic thinking I observe signs and facts; I have certain perceptions. Intuitive thinking I ask myself questions. I confirm my intuitions. I validate the facts and the symptoms. I analyze and integrate my observations. (Dialectical thinking) Choices Hypotheses Critical thinking: I look at both sides. Deductive thinking Inductive reasoning Deductive reasoning Clinical judgment

10. Various dimensions of a complex situation

11. The complexity of a situation may result from a variety of factors. • Factors: • Physiological, • Psychological (discouragement, depression, lack of motivation, suicidal thoughts), • Social (family socio-economic status), • Cultural (habits, hygiene), • Religious (values, taboos), • Linguistic (barriers to communication), • Moral and ethical, • Legal

12. Observations and data to be gathered Explanation of the CQAST model

14. Two main types of data collection Data related to independent role Data relate to cooperative role

15. CQAST Model Source: Mario Brûlé et Lyne Cloutier L’examen clinique, Erpi 2001.

16. Situation 1 Physiological complexity

17. Situation 1: Serious abdominal injury Car accident, 50-year- old single male Significant bleeding, multipe fractures in the thorax and the cervical spine

18. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? Do I get the feeling that it’s serious? Does it remind me of anything that I’ve already seen or learned about? What do I know about this subject? What should be checking or monitoring? Is there an intervention model or protocol that would apply? What is the treatment? What do I need to plan?

19. Issues General nursing plan What are the patient’s emotional, psychological and social needs? What are the patient’s reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

20. Anticipating physiological complications: hypovolemic shock and cardiogenic shock

21. Situation 1. Potential complication: State of shock Anxiety, prostration or agitation Cold sweats Intense thirst Nausea, vomiting capillary refill time = 5 sec. Tachycardia, weak pulse Blood pressure = 80mm Hg Tachypnea If septic shock: shivers, fever, sharp rises in temperature or hypothermia Skin mottling Oliguria:- 30 ml or anuria Cold extremities, cyanosis

22. Situation 1. Complications Vasogenic (distributive)shock Cardiac failure Obstructive shock Severed spinal chord Bleeding External-internal (liver, spleen, or retroperitoneal) Pneumothorax, cardiac tamponade Drop in cardiac output, vascular trauma Hypovolemic shock Cardiogenic shock Circulatory distress mechanisms

23. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? Do I get the feeling that it’s serious? Does it remind me of anything that I’ve already seen or learned about? What do I know about this subject? What should be checking or monitoring? Is there an intervention model or protocol that would apply? What is the treatment? What do I need to plan?

24. Issues General nursing plan What are the patient’s emotional, psychological and social needs? What are the patient’s reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

25. Situation 2 Mixed complexity involving physiological risks and little motivation to get better andlive Model for analyzing motivation

26. Situation 2. Suicide attempt: Antipsychotic poisoning Difficult situation in terms of family support and living conditions 30-year-old woman, mother of a young child

27. Model of relative motivation (McEwen) Individual perceptions: . Severity of the problem . Subject’s vulnerability . Value of acting Change factors: . Personal circumstances: age, situation . Internal and external obstacles to assistance Prior knowledge Motivation to change behaviour Trigger

28. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? What are her problems? What does my intuition tell me? Does it remind me of anything that I’ve already seen are learned about? What should be checking or monitoring? Is there an intervention model that would apply? What is the treatment? What do I need to plan?

29. Issues General nursing plan What are the patient’s emotional, psychological and social needs? What are the patient’s reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

30. Issues Physiology • Is the patient motivated to live, to get better? • Where does this motivation come from? Love (spouse, children, family), personal interests (nature, work, art), fear of having a serious problem, fear of dying? • What is getting in the way? Depression, problems in her love life, family or work, not having a job, other problems? • What are my nursing diagnoses? • What do I need to plan?

31. Situation 3 Mixed complexity involving cultural issues Transcultural analytical model

32. Situation 3. A miscarriage at 3 months, South American patient Support network: In-laws who are a bit hostile and very disappointed at losing the child. Age: 38 years State of health: suffering from malnutrition

33. Adapted from the transcultural models of L. Purnell and M. Leininger Reciprocal perceptions Communication Leasure Receiving society Nutrition Family Hygiene Values Cultural community Health-related habits Family Spirituality Person Maternity Organization of work Death rituals Authority and community organization Biological differences Place of origin Education Risky behaviours Perceptions of the health system

34. Data collection: A transcultural approach Communication problems: language, mode Identify Cultural differences: food, hygiene, etc. Concept of space Concept of time Variations, biological frailties Social organization structures The idea of the family and the environment

35. Issues Physiology What signs and symptoms have I seen? (CQAST) What is the patient saying about it? What does my intuition tell me is going on? What do I know in this area? What should be checking or monitoring? Is there an intervention model or protocol that would apply? What is the treatment? What do I need to plan?

36. Issues General nursing plan What are the patient’s emotional, psychological and social needs? What are the patient’s reactions, expectations, fears and complaints? Are there family members who need to be contacted or who need support? What are my nursing diagnoses? What do I need to explain to or teach the patient? What do I need to plan?

37. Issues Culture • What cultural factors are interfering with care? • What are her eating habits? • Ignorance of what the treatment involves? • What authority do her husband’s and her in-laws’ exercise? • Do they have a different approach to personal hygiene? • What role do women play in their society? • What is the importance of a child and, above all, a male child, in this family? • What are my nursing diagnoses?

38. Situation 4 Mixed complexity involving cultural, religious and family issues

39. Situation 4. Uterine bleeding in a Muslim woman Devout Muslim family, domineering husband. 25 years old, mother of three children

40. Issues Physiology • What signs and symptoms have I seen? • (CQAST) What is the patient saying about it? • What does my intuition tell me is going on? • What do I know in this area? • What should be checking or monitoring? • Is there an intervention model or protocol that would apply? • What is the treatment? • What do I need to plan?

41. Issues General nursing plan • What are the patient’s emotional, psychological and social needs? • What are the patient’s reactions, expectations, fears and complaints? • What is bothering her: sadness, despair, physical pain? • Are there family members who need to be contacted or who need support? • What are my nursing diagnoses? • What do I need to explain to or teach the patient? • What do I need to plan?

42. Issues Culture and religion What specific factors apply to this situation? • Religious taboos? • Need to preserve modesty? • Eating habits? • Ignorance of treatment methods? • Husband’s authority? • Different approach to personal hygiene? • The role of women in this society? • What are my nursing diagnoses? • What should I do?

43. Situation 5 Mixed complexity with physiological, psychological and social factors

44. cardiomyopathy Individual: 77-year-old man, Severe diabetes Social background: Retired, poor Family: Takes care of his wife, who has cancer

45. Issues Physiology • What signs and symptoms have I seen? • (CQAST) What is the patient saying about it? • What does my intuition tell me is going on? • What do I know about the related problems? • What should I be checking or monitoring? • Is there an intervention model or protocol that would apply? • What is the treatment? • What do I need to plan?

46. Issues General nursing plan • What are the patient’s emotional, psychological or social needs? • What are the patient’s reactions, expectations, fears and complaints? What is bothering him? • Are there family members who need to be contacted or who need support? • What are my nursing diagnoses? • What do I need to explain to or teach the patient? • What do I need to plan?

47. Issues Psychology • What social and family factors are interfering with care? • How has he reacted to the situation? • Responsibility of caring for his wife? • Economic constraints? • Absence of a support network? • Ignorance of treatment methods? • What are my nursing diagnoses? • What do I need to plan?

48. Situation 6 Mixed complexity with physiological, cultural, social and religious factors Aggression curve and hallucination-related behaviour

49. Complication: Respiratory problems Contusion to the brainstem Obstructed airways Intracranial hypertension Inhalation of foreign object Cervical trauma Thoracic pneumothorax Hypoventilation Quadriplegia Respiratory arrest Car accident, multiple fractures 17-year-old man, Hindu, delinquent, schizophrenic, aggressive and hallucinating

50. Curve of growing anxiety and aggression Acting out: agitation, aggression, violence Attempt at intimi- dation Panic reaction Recovery phase Refusal to cooperate Trigger event Stabili- zation Structure of an outburst