October 29, 2018

Worst-Case Scenario Mindset (PEC System)

My husband always says, "You go straight to the worst case scenario. You are a special kind of weirdo, haha." As a nurse, I usually need to be two steps ahead of something going wrong. Sometimes I can't control the forces in play, but oftentimes, I can. I manage medical problems for a living and umm, it's awesome! My entire shift centers on scanning the road ahead, seeing obstacles and working toward removing them before we approach an upcoming path. Here is how I approach any nursing intervention that takes place. I feel new nurses can use this advice to help them prevent (most) inopportune outcomes from transpiring.

PEC SYSTEM: Purpose / Expected Outcomes / Could Happen

What is the purpose of the intervention?
I ask myself this question BEFORE I perform an intervention. This will explain the action's goal. If I'm giving to give furosemide, 40MG IVP, for example, I need to know the reason. And if I don't, I ask the provider who ordered it to clarify the order. You'd be surprised how many times I've been told, "Oh, don't give that drug. I'm sorry, I entered that in for the wrong patient." You are a nursing professional, you can discern what seems out of place or what doesn't jive with your patient's medical plan. I don't mind looking stupid, as long as my patient remains safe. Yeah, a provider repeating an order seems unnecessary, but oftentimes I learn more about the game plan this way. Let's go back to the furosemide example. Usually, a provider will explain their medical plan to me in its entirety. I won't merely get the drug's purpose, I get the entire medical management layout. Most providers WANT nurses to know the game plan, so we are all on the same page. Healthcare is a team effort, you are an integral part!

What are the expected outcomes? The goals?
So, we gave the furosemide, now what? What are the expected outcomes? Diuresis? Hypotension? Hypokalemia? What will this intervention initiate or cause? If you understand the pharmacological mechanisms of loop diuretics, you are on the right track. Administering a nursing intervention isn't the end of your job. You must monitor for the outcomes. You must asses that the response was successful. You don't get to walk away and "hope" it went as expected. You must ADPIE, and you need to properly evaluate your intervention. You performed this action, no one else. Why is this important? Because I've seen provider ask nurses, "Okay, you gave the medication and what was the response? Did the patient urinate? Did their potassium drop? What was the result? I don't know if you don't tell me or document it in real-time." I know, sounds crazy but it's true. If you don't say anything, most providers assume it's all good, and everything went as expected. If it didn't, it's up to you to inform the parties involved and move to other interventions. You have no idea the power your hold and just how much providers look to nurses to update them on situations. You are with this patient for many hours versus a provider who rounds on multiple patients throughout their shift. They have brief moments in time, you have hours and the ability to see the full story. Use your superpowers for good, haha.

What could go wrong? Side effects / potential dangers?
Now that you've evaluated the intervention, what are the possible adverse effects that could occur (immediately following the intervention up until the end of your shift)? Let's take it back to the furosemide example. We could have dizziness, weakness, or hypotension. So, the appropriate nursing interventions should involve proper safety measures, I/O surveillance and monitoring the patient's vital signs for changes. Have you ever clocked in, received bedside report and saw a blood pressure of 90/40. You ask the outgoing nurse what happened and he or she has no idea. You then look at the patient's record and see a beta-blocker was administered about an hour ago. It's not rocket science, the beta blocker is linked to the hypotension. But too often, nurses will call a provider about hypotension and NOT explain the context correctly. You administered a drug that caused hypotension, then you start correcting the issue with MORE drugs. Before I call a provider about a change in vital signs or a change in patient condition, I try to investigate and find out if I (or a medication) might have caused the problem. In other words, could what I administered during my shift have contributed or caused this current problem? Because without this information, providers will create differential diagnoses based on incomplete data. Medications can fix one thing and yet, cause issues in other areas. You must see the full pharmacological profile. The same goes for general nursing interventions. If you insert an NGT, what could go wrong? What should you do?

PEC System - All Together Now
That is it, the goal should be for you to see the full story and have the ability to see what is to come. I work 12-hour shifts, I love stories. I want the beginning, middle, and end of events in order to prepare myself for the potential problems. I'm weird that way. Hypotension means nothing to me if I don't know the trends or patterns. Some patients have a baseline SBP in the 90s. Hypertension means nothing to me if I don't know the context. If a patient has diabetes, PVD, and CAD, hypertension isn't a surprise, and long-term management will be required. This is a chronic issue versus an acute issue of unknown origin. See that difference? When you use the PEC System, your viewpoint will be expanded in a way. The point is to take control of the situation and not simply randomly float around doing tasks with no true direction. You got this, don't over think it!

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