Critical Thinking in Nursing

1. Critical Thinking in Nursing Sheryl Abelew MSN RN

2. Chapter 4 Priority Setting

3. Priority Setting • Important step in the critical thinking process • Includes effective time management • Steve Covey (1989) states you should be “putting first things first”. There are three categories “must do, should do, and nice to do”. • Develop a time frame for priorities. ***Review box 4-2 Time Management Procedures

4. Prioritizing patient needs • Use Maslow’s hierarchy of needs • Five levels of needs • Physiologic needs • Sleep, food, water, movement, comfort • Psychological needs • Safety and security • Love and belonging • Affiliation, affection, intimacy • Self-esteem • Sense of self worth, self respect, dignity • Self-actualization • Recognition of potential growth, health, autonomy

5. Prioritizing Nursing Diagnosis • Place in level of priority High, Medium, and Low • High • Life threatening, threats to pt safety, pain, and anxiety, unstable or changes in condition • Medium • Problems that could result in unhealthy consequences, like emotional or physical impairment, but no threat on life • Low • Problems that can be resolved with minimal intervention and have little potential to cause dysfunction

6. Priority Activities • Four levels of priority according to Rubenfeld and Scheffer (1999) • Life Threatening Issues • ABC’s • Safety • Protecting the patient from injury, practicing within scope of nursing, doing no harm • Patient Priorities • Plan of care based on patient activities and condition • Nursing Priorities • Examine all the patients strengths and health concerns, moral and ethical and Maslow’s hierarchy of needs

7. Multitasking • Setting priorities is not linear • Addresses multiple concerns at the same time • Learning to take charge and make efficient use of time is key in time management • Making a to do list will help with multitasking

8. Prioritizing within the nursing process • Assessment • Obtain complete information and sort and ID problems • Analysis • Prepare list of needs and diagnosis • Outcome Identification • Have measureable goals based on Maslow, and prioritize diagnosis • Plan • Select diagnosis and activities • Implementation • Perform immediate actions to prevent harm first. Highest priority to lowest priority • Evaluation • May require reevaluation and/or adjustments

9. Pitfalls in priority setting • Priorities may change • Inadequate assessment of clients needs • Failure to differentiate priority and non priority tasks • Accepting others priorities without seeing the big picture • Performing tasks that were identified first vs. those that are a priority • Completing the easiest task first instead of the priority

10. Chapter 5 Nursing Process Applications

11. Nursing process • “Nursing Process is considered to be a specialized form of systematic inquiry or problem solving process used in drawing conclusions about the patient’s problems and the corresponding nursing actions to resolve problems.” Saucier, Stevens * Williams (2002).

12. Role of Nursing Process • Allows for a consistent use of standards and standardized language providing for a way to measure and quantify the effects of nursing care and interventions • In order to keep terms consistent, ANA recognizes NANDA as the official language of nursing diagnosis, NIC for interventions classification, and NOC for outcomes classifications

13. Steps of the nursing process • Assessment • Analysis (Diagnosis) • Outcome Identification • Plan • Implementation • Evaluation

14. Assessment • Collect data • Identify pertinent data • Recognize deviations from normal • Validate data • Sort and Organize data in a logical order • Identify patterns in the data

15. Analysis • Examine for unmet needs and strengths and health concerns • Focus on problems the nurse can change • Develop diagnosis based on facts • Validate the diagnosis • Establish priorities

16. Outcome Identification • Establish outcomes • Realistic • Achievable • Measureable • Collaborate to review goals to meet needs

17. Plan • How to develop your strategies for meeting nursing interventions • Use NIC for nursing interventions • Write plan of care using standardized language • Collaborate for planning delivery of care

18. Implementation • Initiate actions to accomplish goals • Manage care in order of priority • Delegate care based on caregiver, acuity, needs and plan of care • Intervene as necessary • Document interventions and response

19. Evaluation • Compare actual vs. expected outcomes • Communicate findings • Record attainment of goal • Review and modify POC based on needs

20. Care Plan • Written documentation of the nursing process • See Box 5-3 for care plan formation • See Table 5-5 for sample care plan scenario

21. Chapter 6 Delegation

22. Delegation • Transferring tasks to a competent individual • Used most commonly with a skill mix based on scope of practice • Consider job description when delegating

23. 5 Rights of delegation • Right Task • Right Circumstance • Right Person • Right Direction and Communication • Right Supervision and Evaluation

24. Obstacles of delegation • Delegator reluctant to take the risk and give up control • Subordinate fails to take responsibility • Workplace issues

25. Delegation Procedure • Assessment • List patients need and assessment findings • Analysis • Level of care and acuity • Outcome identification • Establish priorities • Plan • Nurse specifies nature of tasks and skill required • Implementation • Delegation of tasks • Evaluation • Compare outcomes with the POC

26. Chapter 7 Communication

27. Levels of Communication • Three levels of Communication • Social • Interactions for building relationships • Therapeutic • Nurse listens to patient problems and focuses on needs • Collegial • Enhancing relationships with colleagues, improved pt care, and better documentation

28. Collaboration • Nursing Personnel • Delegating • Report • Interdisciplinary • Conflict resolution • Physician notification • Receiving phone calls

29. Written Communication • Documentation • One way to validate critical thinking • Keep confidential • Accurate and objective • Performed promptly

30. Chapter 8 Patient Teaching

31. Applying the nursing Process • Goal directed based on rationale thought processes • Involves critical thinking • Approached analytically

32. Learning needs assessment • 4 areas must be assessed • What the patient needs to learn • Characteristics of the patient • Patients preferred learning style • Whether patient is ready/willing to learn • Conduct a learning needs assessment • Assess cultural background • Developmental stage consideration • Literacy

33. Processes • Analyzing needs • Validate with the patient • Outcome identification • ID goals, clear objectives • Planning the lesson • Instructional methods • Traditional i.e. lecture, discussion • Non traditional i.e. role-playing, simulations, etc • Implementing educational session • Evaluating the educational process

34. Chapter 9 Applying clinical reasoning to various practice settings

35. Reasoning • When processing data, continually evaluate reasoning • Examine the evidence to determine what else is needed • Obtain and clarify data • Examine logic and give reasons for conclusions • Review the consequences of possible actions and draw conclusions if desired outcome can be obtained

36. Guidelines for decision making • Use professional standards as guidelines to decision making when evaluating patient circumstances, and then consider the textbook data, current diagnostic test findings, and assessments of the nurse • Nurses need to follow the regulations set forth according to scope of practice and standards of practice as well as the code of ethics for nurses when making decisions • Review box 9-2 pg 199

37. Application of cognitive skills • Nurse collects information and uses skill of interpretation to define what the patient is presenting as • Nurse establishes expected outcomes for interventions to determine if the problem will be resolved • After implementation, nurse will evaluate on an ongoing basis progress towards goals • After recognizing effects from intervention, nurse will offer rationale for the result • Lastly, nurse will reexamine thinking

38. Clinical Reasoning applications • Quality implies evaluation • Evaluation requires standards which define the acceptable levels of care • Nurse must evaluate actions to the professional practice standards from the ANA

39. Evaluating the workload • Indicators that identify impossible workload • Failure to monitor when indicated by patients condition • Inadequate treatment for circumstances • Excessive delay of treatments • Failure to provide ongoing care and treatments • Lack of time to provide patient teaching

40. Monitoring patient condition • Use clinical reasoning to monitor patients change of condition and respond with the appropriate intervention • Two examples of monitoring the patients condition • Calling the physician • When there is a change in condition • Pain without ordered meds that manage the pain • Acute elimination problems • Lab values that require orders • Risk to safety • Interpreting lab values • Are the findings abnormal and expected • Are the findings abnormal and unexpected • Are the findings normal

41. Pitfalls in clinical reasoning • Failure to use appropriate decision making skills • Failing to assess, report, or omissions • Failure to assess for changing of condition • Nurse fails to perform duties appropriately results in negligence

42. Chapter 10 Ethical decision making

43. Ethics • Ethics deals with the principles of right and wrong • Foundation of ethics is standards of conduct and moral judgment • Nurses must be aware of their own value system

44. Model of ethics • Choosing • Allows for free choice identifying alternatives and selecting alternatives • Prizing • Individual satisfaction with choice of verbalization to others • Acting (Internalization and repetition)

45. Ethical Guides Ethical Principles • Autonomy • Right to self-determination • Nonmaleficence • Directs the nurse does no harm • Beneficence • Doing good on the patients behalf • Justice • Moral obligation to treat people fairly and equally • Fidelity • Keeping your word and acting in the patient’s best interest • Veracity • Telling the truth

46. American Nurses code of ethics • ANA as developed a code of ethics • Nine statements define this code • Review pg 233 Box 10-3

47. Ethical decision making process • Assessment • Analysis • Outcome Identification • Plan • Implementation • Evaluation **

48. Assessment • Gather information to determine the facts that will have the most affect on the situation • Develop sensitivity to recognize ethical situation and its essence to nursing • Identify risks to the patients

49. analysis • Determine the values in conflict • Become aware of the relevant information • Values clarification • Generate multiple alternatives and rank in order of what is right and wrong • Explore emotional, social and physical risks to patient and staff

50. Outcome identification • Providing safe nursing care • Expected outcome should serve as a guide in making decisions • Use clearly stated outcomes for success to be measureable