analyzing complex situations in an emergency department or a department of surgery

Margot Phaneuf, PhD (Nurs) 1

Analyzing Complex Situationsin an Emergency Departmentor a Department of Surgery

Margot Phaneuf, Inf.,PhD.

Course prepared for training given at Coimbra Hospital in Portugal, September, 2003

Revised, nov.2012


What thought mechanisms are required to analyze a complex situation?


A complex situation requires complex thought, combining one’sintuition with thinking that is: . Inductive, . Systemic, . Dialectical and critical, . Hypothetical-deductive, and . Creative.


The nursing process remains the best strategy for dealing

with a complex situation, since it calls on several

types of thinking.


The nursing processThe nursing processData gathering

Analysis

Planning

Intervention

Evaluation

Evaluation

Clinical judgmentNursing diagnosis

6Margot Phaneuf, PhD (Nurs)

Hypotheses

Inductive thinking

Intuition

Systemic thinking

Hypothetical-deductive thinking

Dialectical and critical thinking

Clinical judgment

Contributions tothe formation of a clinical judgment

Choices


Inductive thinking:for collecting data

Intuition: for structuringa more targeted search

for data

Systemic thinking: for taking into account all

aspects of a situation

Hypothetic-deductivethinking: for identifying and analyzing hypotheses

Types of thinkingused in the overall care process

Dialectical and critical thinking:for selecting the hypothesis

or nursing diagnosis and evaluating the process

Creative thinking: for planning interventions


What to avoid in a complex situation

Simplistic reasoning that

moves directly from cause

to effect


Analysis of a complex situationAnalysis of a complex situationInductive thinking Systemic thinkingInductive thinking Systemic thinking

Critical thinking:Critical thinking: I look at both sides.

I look for other factors.

I reconsider what I know about the subject. I consider different aspects of the person.

Deductive reasoning

I confirm my intuitions.

I validate the facts and the symptoms. I analyze and integrate my observations.

(Dialectical thinking)

Choices Hypotheses

Inductive reasoning

Clinical judgment

Deductive Deductive thinkingthinking

I observe signs and facts; I have certain perceptions.

Intuitive thinkingIntuitive thinking I ask myself questions.


Various dimensions of a complex situation


The complexity of a situation may The complexity of a situation may result from a variety of factors.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


Observations and data to be gathered

Explanation of the CQAST model


Percussion

Inspection

Palpation

Auscul-tation

Ante-cedents

Currentproblems

Familyhistory

Examinationsand tests

Overview of data collection: Methods and types

Interview,questionnaire,

medical history1

Physical examination

2


Two main types Two main types of data collectionof data collection

Data related to independent role

Data relate tocooperative role


ConceptConcept ExplanationExplanation ExampleExample

CC CauseCause What causes the symptom to What causes the symptom to emerge? What makes it go emerge? What makes it go away?away?

How did the pain first appear? How did the pain first appear? Are you using an analgesic?Are you using an analgesic?

QQ Quality, Quality, quantity quantity

Description of the symptomDescription of the symptom

FrequencyFrequency

What does it feel like: a burning What does it feel like: a burning sensation, a pounding, etc.? How sensation, a pounding, etc.? How bad is it, on a scale of 1 to 10?bad is it, on a scale of 1 to 10?

AA Area affected Area affected by irradiationby irradiation

Area where the symptom is Area where the symptom is locatedlocated

Other affected areasOther affected areas

Tell me where it hurts, or point to Tell me where it hurts, or point to it with a finger. Does it hurt it with a finger. Does it hurt anywhere else? anywhere else?

SS Related Related symptomssymptoms

Other symptoms associated Other symptoms associated with the main symptomwith the main symptom

Do you have any other related Do you have any other related problems?problems?

TT Time, durationTime, duration When it appears, durationWhen it appears, duration How long have you had this How long have you had this problem? Is it constant or does it problem? Is it constant or does it come and go? How often in a come and go? How often in a week or a month? week or a month?

CQAST Model


Situation 1Physiological complexity


Situation 1: Serious abdominal injurySituation 1: Serious abdominal injury

Car accident, 50-year- oldsingle male

Significant bleeding,multipe fractures inthe thorax and thecervical spine


IssuesIssuesPhysiologyWhat 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?


IssuesIssues

General nursing planGeneral nursing planWhat are the patient’s emotional, psychological What are the patient’s emotional, psychological

and social needs?and social needs?What are the patient’s reactions, expectations, What are the patient’s reactions, expectations,

fears and complaints?fears and complaints?Are there family members who need to be Are there family members who need to be

contacted or who need support?contacted or who need support?What are my nursing diagnoses?What are my nursing diagnoses?What do I need to explain to or teach the patient?What do I need to explain to or teach the patient?What do I need to plan? What do I need to plan?


Anticipating physiological complications: hypovolemic shock

and cardiogenic shock


Situation 1. Potential complication: Situation 1. Potential complication: State of shockState of shock

Anxiety, prostration or agitation

Intense thirstCapillary recoloration time = 5 sec.

Blood pressure = 80mm Hg

If septic shock: shivers, fever, sharp rises in temperature or hypothermia

Skin mottling

Cold extremities, cyanosisOliguria:- 30 ml or anuria

Superficial polypnia

Tachycardia, weak pulse

Nausea, vomiting

Cold sweats


Severed spinal chord

Circulationobstacle

Drop in cardiac output, vascular trauma

Vasoplegia

Hypovolemic shock

Pneumothorax, cardiac tamponade

Cardiogenic shock

BleedingExternal-internal(liver, spleen, or retroperitoneal)

Cardiac failure

Circulatory distress mechanisms

Situation 1. ComplicationsSituation 1. Complications


IssuesIssuesPhysiologyPhysiologyWhat signs and symptoms have I seen?What signs and symptoms have I seen?(CQAST) What is the patient saying about it?(CQAST) What is the patient saying about it?Do I get the feeling that it’s serious?Do I get the feeling that it’s serious?Does it remind me of anything that I’ve already Does it remind me of anything that I’ve already

seen or learned about?seen or learned about?What do I know about this subject?What do I know about this subject?What should be checking or monitoring?What should be checking or monitoring?Is there an intervention model or protocol that Is there an intervention model or protocol that

would apply?would apply?What is the treatment? What do I need to plan?What is the treatment? What do I need to plan?


IssuesIssues




contacted or who need support?contacted or who need support?What are my nursing diagnoses?What are my nursing diagnoses?What do I need to explain to or teach the patient?What do I need to explain to or teach the patient?What do I need to plan? What do I need to plan?


Situation 2 Mixed complexity involving physiological risks and little

motivation to get better and live

Model for analyzing motivation


Situation 2. Suicide attempt: Situation 2. Suicide attempt: Antipsychotic poisoningAntipsychotic poisoning

30-year-old woman, mother of a young child

Difficult situation in terms of family support and living conditions


Model of relative motivation (McEwen)

Individual perceptions:

. Severity of the problem

. Subject’svulnerability

. Value of acting

Change factors:. Personal

circumstances: age, situation. Internal and

external obstacles to assistance

Prior knowledge

Motivation to change behaviour

Trigger


IssuesIssuesPhysiologyPhysiologyWhat signs and symptoms have I seen?What signs and symptoms have I seen?(CQAST)(CQAST)What is the patient saying about it? What are her What is the patient saying about it? What are her

problems?problems?What does my intuition tell me? What does my intuition tell me? Does it remind me of anything that I’ve already Does it remind me of anything that I’ve already

seen are learned about? seen are learned about? What should be checking or monitoring?What should be checking or monitoring?Is there an intervention model that would apply?Is there an intervention model that would apply?What is the treatment? What do I need to plan?What is the treatment? What do I need to plan?


IssuesIssues




contacted or who need support?contacted or who need support?What are my nursing diagnoses?What are my nursing diagnoses?What do I need to explain to or teach the patient?What do I need to explain to or teach the patient?What do I need to plan?What do I need to plan?


Issues Issues (continued)(continued)

PhysiologyPhysiologyIs the patient motivated to live, to get better?Is the patient motivated to live, to get better?Where does this motivation come from? Love Where does this motivation come from? Love

(spouse, children, family), personal interests (spouse, children, family), personal interests (nature, work, art), fear of having a serious (nature, work, art), fear of having a serious problem, fear of dying?problem, fear of dying?

What is getting in the way? Depression, problems What is getting in the way? Depression, problems in her love life, family or work, not having a job, in her love life, family or work, not having a job, other problems?other problems?

What are my nursing diagnoses?What are my nursing diagnoses?What do I need to plan? What do I need to plan?


Situation 3Mixed complexity

involving cultural issues

Transcultural analytical model


Situation 3. A miscarriage at 3 months, Situation 3. A miscarriage at 3 months, South American patientSouth American patient

Age: 38 yearsState of health: suffering from malnutrition

Support network:In-laws who are a bit hostile and very disappointed at losing the child.

Adapted from the transcultural models Adapted from the transcultural models of L. Purnell and M. Leiningerof L. Purnell and M. Leininger

Person

Family

Cultural community

Receiving society

Communication

Family

Spirituality

Maternity

Death rituals

Nutrition

Hygiene

Health-relatedhabits

Organizationof work

Authority andcommunityorganization

Biological differences

Risky behaviours

Values

Place of origin Education

LeasureReciprocal perceptions

Perceptions of the health system


Data collection: Data collection: A transcultural approach A transcultural approach

Cultural differences:

food, hygiene, etc.

Variations, biological

frailties

Communicationproblems:

language, mode

Concept of space

Concept of time

Socialorganization

structuresThe idea of

the family and theenvironment

Identify


IssuesIssues

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

apply?apply?What is the treatment? What is the treatment? What do I need to plan?What do I need to plan?


IssuesIssues






IssuesIssues CultureCulture . What cultural factors are interfering with care?. What cultural factors are interfering with care?. What are her eating habits?. What are her eating habits?. Ignorance of what the treatment involves? . Ignorance of what the treatment involves? . What authority do her husband’s and her in-laws’ . What authority do her husband’s and her in-laws’

exercise?exercise?. Do they have a different approach to personal . Do they have a different approach to personal

hygiene?hygiene?. What role do women play in their society?. What role do women play in their society?. What is the importance of a child and, above all, a . What is the importance of a child and, above all, a

male child, in this family?male child, in this family?. What are my nursing diagnoses?. What are my nursing diagnoses?


Situation 4 Mixed complexity

involving cultural, religious and family issues


Situation 4. Uterine bleeding Situation 4. Uterine bleeding in a Muslim womanin a Muslim woman

25 years old, motherof three children

Devout Muslim family, domineering husband.


IssuesIssues

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



IssuesIssuesGeneral nursing planGeneral nursing planWhat are the patient’s emotional, psychological What are the patient’s emotional, psychological


fears and complaints?fears and complaints?What is bothering her: sadness, despair, physical What is bothering her: sadness, despair, physical

pain?pain?Are there family members who need to be Are there family members who need to be



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


Situation 5 Mixed complexity with

physiological, psychological and social factors


cardiopathy

Individual:77-year-old man, Severe diabetes

Social background: Retired, poorFamily: Takes care of his wife, who has cancer


IssuesIssues

PhysiologyPhysiologyWhat signs and symptoms have I seen?What signs and symptoms have I seen?(CQAST) What is the patient saying about it?(CQAST) What is the patient saying about it?What does my intuition tell me is going on?What does my intuition tell me is going on?What do I know about the related problems?What do I know about the related problems?What should I be checking or monitoring?What should I be checking or monitoring?Is there an intervention model or protocol that would Is there an intervention model or protocol that would



IssuesIssues


or social needs?or social needs?What are the patient’s reactions, expectations, What are the patient’s reactions, expectations,

fears and complaints? What is bothering him?fears and complaints? What is bothering him?Are there family members who need to be Are there family members who need to be



IssuesIssuesPsychologyPsychology. What social and family factors are interfering with . What social and family factors are interfering with

care?care?. How has he reacted to the situation?. How has he reacted to the situation?. Responsibility of caring for his wife?. Responsibility of caring for his wife?. Economic constraints? . Economic constraints? . Absence of a support network?. Absence of a support network?. Ignorance of treatment methods? . Ignorance of treatment methods? . What are my nursing diagnoses?. What are my nursing diagnoses?. What do I need to plan?. What do I need to plan?


Situation 6Mixed complexity with physiological,

cultural, social and religious factors

Aggression curve and hallucination-related behaviour


Complication: Respiratory problems Complication: Respiratory problems Obstructed airwaysInhalation of foreign object

Contusion to the brainstem

Intracranial hypertensionCervical trauma

Thoracic pneumothorax

Quadriplegia

Hypoventilation

Respiratory arrest

Car accident,multiple fractures

17-year-old man,Hindu, delinquant, schizophrenic,aggressive and hallucinating


Trigger event

Refusal to

cooperate

Panic reaction

Attempt at

intimi-dation

Actingout:

agitation,aggression,

violenceRecovery

phaseStabili-zation

Curve of growing anxietyand aggression

Structure of an outburst


Signs of an attack

Disjointed speech

Raised voice

Refusal to cooperate

Mistrustful look

Rising anxiety

Agitation, excitement

Arrogant comments

Hostility, threats

Clenched teeth or fists

Hyperactivity

Rigid posture

Hallucination, disorientation

Delirious remarks

Pale or flushed face


IssuesIssues

PhysiologyPhysiologyWhat signs and symptoms have I seen?What signs and symptoms have I seen?(CQAST) What is the patient saying about it?(CQAST) What is the patient saying about it?What does my intuition tell me is going on?What does my intuition tell me is going on?What do I know about the related problems?What do I know about the related problems?What should I be checking or monitoring?What should I be checking or monitoring?Is there an intervention model or protocol that would Is there an intervention model or protocol that would



IssuesIssues



fears and complaints? What is bothering him?fears and complaints? What is bothering him?Are there family members who need to be Are there family members who need to be

contacted or who need support?contacted or who need support?What are my nursing diagnoses?What are my nursing diagnoses?What do I need to explain to or teach the patient?What do I need to explain to or teach the patient?Do I have reason to fear in his behaviour?Do I have reason to fear in his behaviour?What do I need to plan?What do I need to plan?


IssuesIssuesPsychologyPsychology. What factors stemming from his psychiatric problem . What factors stemming from his psychiatric problem

and his culture are interfering with care?and his culture are interfering with care?. His personality and his reaction to the situation?. His personality and his reaction to the situation?. Religious prescriptions or taboos?. Religious prescriptions or taboos?. Eating habits?. Eating habits?. Ignorance of treatment methods? . Ignorance of treatment methods? . Different approach to personal hygiene?. Different approach to personal hygiene?. What are my nursing diagnoses?. What are my nursing diagnoses?. What do I need to plan?. What do I need to plan?


Situation 7Mixed complexity

with physiological, cultural and legal factors

Gypsy woman injured in a criminal fire that she set


Family context:Single mother with 2 young children

Burns over 40% of her body

Pale, clammy skinTachycardia, tachypnea

State of

shock Loss of plasma

Cultural context: gypsy woman, Legal context: procedures foract of pyromania

Pressure when seated

Hypovolemic shock

Weakness, weak pulse

Anxiety,

Thirst

Urinary output

Symptoms

Otherfactors

Serious burn victim,30 years old


IssuesIssuesPhysiologyPhysiologyWhat signs and symptoms have I seen?What signs and symptoms have I seen?(CQAST) What is the patient saying about it?(CQAST) What is the patient saying about it?What does my intuition tell me is going on?What does my intuition tell me is going on?What do I know about the related problems?What do I know about the related problems?What should I be checking or monitoring?What should I be checking or monitoring?Is there an intervention model or protocol that would Is there an intervention model or protocol that would



IssuesIssuesThe nursing planThe nursing planWhat are the patient’s emotional, psychological What are the patient’s emotional, psychological


fears and complaints? What is bothering her?fears and complaints? What is bothering her?Are there family members who need to be Are there family members who need to be

contacted or who need support?contacted or who need support?How will the legal issues affect the situation?How will the legal issues affect the situation?What are my nursing diagnoses?What are my nursing diagnoses?What do I need to explain to or teach the patient?What do I need to explain to or teach the patient?What do I need to plan?What do I need to plan?


IssuesIssuesPsychologyPsychology. What factors stemming from her problem and her . What factors stemming from her problem and her

culture interfere with her care?culture interfere with her care?. Her personality and her reaction to the situation?. Her personality and her reaction to the situation?. Religious and social beliefs, understanding of rules . Religious and social beliefs, understanding of rules

and the law?and the law?. Eating habits?. Eating habits?. Ignorance of treatment methods? . Ignorance of treatment methods? . Different approach to personal hygiene?. Different approach to personal hygiene?. What are my nursing diagnoses?. What are my nursing diagnoses?. What do I need to plan?. What do I need to plan?


Situation 8Mixed complexity with

physiological, cultural, legal and ethical issues: a young man who has had an industrial accident and is in

a deep coma

Suggestions for analyzing the ethical issues


Neurological distress: Cerebral anoxiaNeurological distress: Cerebral anoxia

Young man, 22 years old,industrial accidentFather of 2 childrenVery devout catholic family

Very poor prognosis,coma


Intracranial bleedingor hematomaRespiratory distress

Circulatory arrest Increase in jugular-thoracic venous pressure

EdemaIntracranial

pressureCerebral anoxia

Neurological distress

Cranial fracture, significant compression


IssuesIssues

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



IssuesIssues

What decision will need to be made if there What decision will need to be made if there is respiratory arrest? is respiratory arrest?

What line of reasoning or principles can be What line of reasoning or principles can be used for this decision and its supporting used for this decision and its supporting arguments?arguments?

What does the family say?What does the family say?

What does the medical team think?What does the medical team think?


Suggestions for analyzing situations with ethical issues


ANALYZING A SITUATIONANALYZING A SITUATIONTHAT RAISES ETHICAL ISSUESTHAT RAISES ETHICAL ISSUES

What are the facts? What are the facts?

In physical, psychological and mental In physical, psychological and mental terms and in terms of the person’s future terms and in terms of the person’s future opportunities and quality of life?opportunities and quality of life?


ANALYZING A SITUATION THAT ANALYZING A SITUATION THAT RAISES ETHICAL ISSUES RAISES ETHICAL ISSUES

(page 2)(page 2)

What values are at play?What values are at play?

What are the values of:What are the values of:

. The patient (moral, cultural and. The patient (moral, cultural and

family values)?family values)?

. The family?. The family?

. The professionals (personal and. The professionals (personal and

professional)?professional)?


ANALYZING A SITUATIONANALYZING A SITUATIONTHAT RAISES ETHICAL ISSUES THAT RAISES ETHICAL ISSUES

(page 3)(page 3)

How has this problem come up?How has this problem come up?

Is there a conflict of values (a dilemma)? Is there a conflict of values (a dilemma)?

What are the possible solutions?What are the possible solutions?

. What legal issues may be involved?. What legal issues may be involved?

. What would be the consequences? . What would be the consequences?


ANALYZING A SITUATION THAT ANALYZING A SITUATION THAT RAISES ETHICAL ISSUES RAISES ETHICAL ISSUES

(page 4)(page 4)

For each alternative solution, what is the For each alternative solution, what is the most important value? most important value?

. How can priorities be determined?. How can priorities be determined?

. What decision should be made?. What decision should be made?

. What recommendations and justifications. What recommendations and justifications

can be made?can be made?


A dilemma?


Margot Phaneuf inf. PhD 34

DilemmaDilemma: : QualityQuality of life of life sacrednesssacredness of lifeof life

A A difficultdifficult situation situation wherewhere the the principleprincipleof of qualityquality of life (of life (sufferingsuffering, , discomfortdiscomfort, , immobilityimmobility, limitations of , limitations of manymany kindskinds, , worriesworries) ) confrontsconfronts the the principleprinciple thatthat life life isis an an absoluteabsolute value, value, sacredsacred and and untouchableuntouchable for for anyany reasonreason. .


The ethical dilemma: Some food for thought


QUESTIONS FOR QUESTIONS FOR ETHICAL REASONINGETHICAL REASONING

There are times when caregivers face ethical There are times when caregivers face ethical

dilemmas and must respond by making a dilemmas and must respond by making a decision to act, to express an opinion or to decision to act, to express an opinion or to voice their disagreement. Asking the following voice their disagreement. Asking the following questions can help you reach that decision. questions can help you reach that decision.

. What is the goal of this action or of not . What is the goal of this action or of not acting? Is it to bring an end to the person’s acting? Is it to bring an end to the person’s suffering? To hasten their death and end a life suffering? To hasten their death and end a life considered impossible? considered impossible?


QUESTIONS FOR ETHICAL QUESTIONS FOR ETHICAL REASONINGREASONING (1)(1)

- - Is it for the greater good of the patient?

- Is the underlying motive:

. One of compassion?

. An economic motive (such as the cost of

care)?

. A social motive (for example, because

organizational or family problems are

standing in the way of care delivery)?

- Does the patient suffer as a result?


QUESTIONS FOR ETHICAL QUESTIONS FOR ETHICAL

REASONINGREASONING (2)(2) .. Is the pain or the situation intolerable? Is the pain or the situation intolerable?

Intolerable for whom?Intolerable for whom?

- For the patient?- For the patient?

- For family and friends?- For family and friends?

- For the caregivers? - For the caregivers?

. Who lacks courage? . Who lacks courage?

- The patient?- The patient?

- Family and friends? - Family and friends?

- The caregivers?- The caregivers?


QUESTIONS FOR ETHICAL REASONING (3)

What rights do health professionals have over What rights do health professionals have over

patients? Parents over their children? patients? Parents over their children? Children over their parents (in terms of Children over their parents (in terms of making decisions for them)? making decisions for them)?

.. Does this act represent being faithful and Does this act represent being faithful and loyal to the person? loyal to the person?

. Is respect being shown for the patient’s . Is respect being shown for the patient’s independence, right to self-determination, independence, right to self-determination, integrity, privacy and dignity? integrity, privacy and dignity?


Illustrations of physiology inspired by:

Jean-Pierre Carpentier (2002),

Soins infirmiers aux urgences et en réanimation,

4th Ed., No 21, Paris, Masson.


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