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Thinking Like a Nurse

Monica Thomas
Auburn University Montgomery

Thinking like a Nurse

I have only been a nurse for a year and a half but I have learned so much during that short
amount of time. About six months ago a patient with a myocardial infarction in the intensive care
unit stood out to me and I have not been able to forget this experience. This situation taught me
so much. It has helped me become the nurse I am today and to always remember patient
advocacy is a huge priority in the nursing world. One thing I will always remember is to follow
my gut feeling because normally it will always be right. This patient with an active myocardial
infarction has taught me to be proactive and be the best patient advocate for the safety and wellbeing of the patient.
I just recently began working in the intensive care unit (ICU). I had previously worked on
a cardiac stepdown unit. My co-workers always joked with me saying, you have a black cloud
over you because it seemed if anything would happen it would always be when I was working
and with one of my patients. I even began to wonder why I was doing this stressful job because I
never could catch a break. However, looking back now I feel that God put me in those places and
those times for me to have the opportunity to learn and better my critical thinking skills as a
nurse. What better way to use critical thinking skills than in emergency situation when you do
not have a choice and can reflect back on experiences to help in future situations. According to
Nunnery (2012), critical thinking is viewed as engaging in a purposeful cognitive activity
directed toward establishing a belief or map of action. (p. 129). I have always been an
adrenaline junky and enjoyed learning new aspects of nursing. I have always been the person to
jump in to do something new so if it ever happened to me again I would feel more comfortable if
I did not have any help or experienced nurses around me. I absolutely love my job and I am so
thankful I have been able to experience some of the things I have so far. I have done things that

some of our nurses that have been there for years have never done before. This specific situation
is one of those experiences I have endured that many nurses in ICU do not do often.
It was an ordinary night when I arrived to work. There were a total of five patients in our
six bed ICU. I was working with an excellent experienced nurse and I took two patients which
meant I would get the first admission. All of a sudden we heard CODE 5 over head to the
medical surgical unit. I began getting nervous because I knew I would receive this patient shortly
after it was called. The patient had passed out going to the bathroom on the med surge unit after
her heart rhythm went into a cardiac dysrhythmia called torsades de pointes. My patient was a
71 year old white female brought to ICU at 0400 with an active myocardial infarction but
thankfully had become responsive again prior to arriving. The patient was having excruciating
chest pain rating a seven out of ten on the numerical pain scale. The patient had been given two
sublingual nitroglycerin tablets prior to arriving to ICU and it was time for the third to be
administered. . I immediately gave the third nitroglycerin and the patient still had no relief of
the chest pain. The emergency department (ED) physician was still present and gave a verbal
order to repeat an electrocardiogram (EKG) at 0430. I was notified by the laboratory of a critical
troponin level of 0.61. The ED physician was notified at 0420 of the critical troponin level and
that the patient continued to have chest pain. I received new orders for two milligrams morphine,
four milligrams Zofran and a 500cc bolus of normal saline. Around 0430 the second EKG was
completed and showed an inferior injury, probable early acute infarct. The Morphine, Zofran
and normal saline bolus was administered right after the EKG was completed. The ED physician
was made aware of the EKG results and the patient continued to have chest pain, I received an
order to administer 60 milligrams of Lovenox subcutaneously as well as repeat cardiac enzymes
and an EKG at 0600.

The ED physician had spoken with the on call cardiologist after the patient arrived to
ICU but I felt that I needed to call the cardiologist and make him more aware of the patients
status and current changes. At this time the cardiologist was made aware of the patients critical
troponin, abnormal EKG results, and chest pain. As I was speaking to the cardiologist I asked
do I need to have the supervisor call the heart catheterization team in? and he said No. My
heart dropped, I knew this patient needed to go for an emergent heart catheterization but who
am I to question a physician when I am a new nurse. Something in my gut still did not feel right
and I asked what can we do if we cannot take her to the heart catheterization lab because
something needs to be done, the patient is in a lot of distress. The patient had an elevated
troponin, abnormal EKG and chest pain and I inferred the patient must go to the catheterization
lab however, I now know there are other steps to take if the catheterization lab is not available to
maintain the patient until further intervention can be provided. I finally received orders to
administer TNKase per the hospitals weight base protocol. Of course, I had never given this
medication and normally we do not give this medication in ICU. The nursing supervisor was
called and made aware of the TNKase order so she could bring the medication to the unit. The
ED physician was informed of the TNKase order and asked if the Lovenox order should be
discontinued which he agreed to discontinue. I quickly started completing the TNKase
questionnaire and explaining all of the risk of administering this medication. The patient started
expressing fear due to her husbands history of a brain bleed after a cardiac event. More
education was provided to the patient and her husband and they both asked to have time to
discuss what they needed to do. During the TNKase questionnaire the husband stated the patient
had fallen at some point but could not remember how long ago maybe six months ago but I
cannot remember he stated. Any type of trauma, CPR, or fall was a contraindication for

administering TNKase. I was nervous about administering this medication because both the
patient and her husband were not great historians. I called and spoke with the cardiologist again
and explained my hesitancy and he stated go ahead and administer the TNKase. One of the
protocols for administering TNKase is to obtain more than one peripheral IV access due to the
risk of bleeding once the TNKase is administered. The other registered nurse and I quickly
started working together to get more peripheral IV access to be ready if the patient agreed to
receive the TNKase so we would not waste any more time.
Even though we had been working diligently to improve the status of this patient nothing
seemed to be helping at this time. The patient did not look well at all, she was diaphoretic and
her color looked awful. The patient kept looking at me and asked Am I going to die? I am so
scared. The only thing that come to mind was maam I am going to take really good care of
you and do everything I can to get you better. The patient was in a lot of distress and kept
asking for her son. Her husband was frantically trying to get in touch with their son but was
having a hard time reaching him. Finally, he was able to reach his son and his son was an hour
and a half away but was on his way to the hospital. As the nurse, I did everything possible to
make the patient more comfortable. According to Florence Nightingale it is important to focus
on the care of the patient rather than the nursing process (Petiprin, 2015). Each patient and
situation is different and as a nurse I have to learn to adapt and meet the environmental needs for
each patient. I tried to maintain a calm and quiet environment to help decrease any fear or
anxiety the patient was having due to the current situation.
After calling the cardiologist about the patient having a history of a fall I also found out
our interventionist for heart catheterizations was unavailable and this is the reason she was
unable to go to the catheterization lab, so the next option was to administer the TNKase. It was

very frustrating before receiving the order for the TNKase because it seemed like forever to get
the order or to get anything done for my patient. I learned from this experience how important it
is to advocate for the patient and do everything in my power to get the orders I need to provide
the adequate care. I look back on this experience and wonder why did it take so long to get
anything done? Was it a misunderstanding or poor communication on my part? Did I not
make it clear enough to the cardiologist how critical the patient was or was he holding back
because he knew he did not have a backup interventionist? I still question if maybe I had given
more information or said something differently maybe the patient would have received the
adequate care in a timelier manner. I will from now on, be persistent if I feel something is not
right and nothing is being done for the patient. I still feel that I was honest, respectful and the
patient and I developed a trusting relationship during this experience with the patient. Although, I
feel I could have probably done more I continued to stick with my beliefs on providing the
utmost care to the best of my ability with the resources I had available.
The cardiologist finally arrived at the hospital and began questioning why the TNKase
had not been administered and I quickly explained to him, a consent must be obtained and the
patient was unsure if she wanted to go through with this treatment plan. The patient finally
consented with the cardiologist in the room and he spoke with her about transferring to another
hospital. The cardiologist stated he would get her transported quickly to another hospital so she
could be taken down to their heart catheterization lab. I administered the TNKase immediately
after the consent was obtained. I was so nervous about pushing this medication because I knew
the risks of what could happen. I remember shaking as I began pushing the medicine into her IV.
I was flooded with many emotions but then I thought to myself yes, this could harm her but at
this point this is the only thing that will save her life. Something inside me gave me the strength

to continue pushing the TNKase and I felt more at ease. The patient began feeling much better
and had some relief of pain. I felt relieved that something was finally helping my patient. I do not
like to see a patient in so much distress and it is even worse when I cannot do anything to make it
better.
As I was getting ready to leave that morning I was still waiting on the phone call from the
hospital stating they would accept the patient. I never received a phone call before I left that
morning so I passed off in report all of the incidents that happened to the oncoming nurse. At one
time the patient and her family asked me do I need to ask for another cardiologist and as a
nurse I was left in an ethical dilemma on how I felt and what was the right thing to say. I felt that
the cardiologist that was on call during the night did not react or have a backup interventionist as
he should and the patient did not receive the prompt treatment I wanted her to have. The hospital
has another cardiologist that practices in a different group and is able to perform heart
catheterization and intervene. At times I wanted to say to them please ask for the other
cardiologist but I know as a professional nurse I cannot say this to a patient. This was a hard
situation when I knew another cardiologist could be called only if the patient requested to change
physicians. I encouraged them at this point to go ahead and transfer to the other hospital as soon
as the hospital accepted her, which I was under the impression this would not take long at all.
Little did I know the transfer did not take place until later that afternoon. Had I known this would
happen, I put myself back in this position and I wonder should I have just risked it for the
patients life and told her to ask for the other cardiologist?
I was fortunate to hear from this patient a few weeks later and found out everything went
well once she was transferred and had the heart catheterization. The patient received two stents
and was doing well. I was relieved that the patient had a good outcome after the slow process of

getting her to the hospital to receive the treatment she needed. I prayed more over this patient
during the couple of hours she was under my care than I believe I have for anything in my life. I
truly believe in the power of prayer and I know God was watching over my patient and me as
well. With everything that was going on with the patient, I do not believe she would be here
today and be able to live a fairly healthy lifestyle without God being on our side that night.
According to Nunnery (2012), reflective thinking is active, persistent, and careful consideration
of any belief or supposed form of knowledge in the light of the grounds that support it (p. 129).
I reflect back on this experience and realize how important critically reflecting on prior
knowledge would have been a huge factor if I had only been a little more knowledgeable and
persistent. I truly believe I had enough grounds to support my belief the patient needed
emergent intervention from the elevated troponin, abnormal EKG and chest pain. I believed I had
a valid reason to assume a heart catheterization was the best option for the patient but also
thankful we could do something in the meantime to stabilize the patient. I have learned even
when one is nervous or scared about confronting a physician about a situation to always
remember it is about the patient and I must advocate to provide the utmost care.

References
Nunnery, R.K. (2012). Advancing your career: Concepts of professional nursing. Philadelphia,
PA: F.A. Davis Company
Petiprin, A. (2015). Nursing theory: Environmental theory. Retrieved from http://www.nursingtheory.org/theories-and-models/nightingale-environment-theory.php