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Chapter 15: Critical Thinking in Nursing Practice

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  1. Chapter 15: Critical Thinking in Nursing Practice Bonnie M. Wivell, MS, RN, CNS

  2. CRITICAL THINKING Critical thinking is an active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others (Pg. 216) Recognize that an issue exists Analyzing information about the issue Evaluating information Making conclusions

  3. Critical Thinking Requires… • Cognitive skills • Ask questions • Remain well-informed • Be honest in facing personal biases • Be willing to reconsider and think clearly about issues

  4. Attributes of a Critical Thinker • Asks pertinent questions • Is able to admit a lack of understanding or information • Is interested in finding new solutions • Listens carefully to others and is able to give feedback • Examines problems closely

  5. Critical Thinking Can Lead To… • Sound clinical decisions • Using the Nursing Process to guide patient care • Evidence-Based Practice (EBP)

  6. Nursing Process • Definition • The act of reviewing the patient’s situation in order to obtain information of past history, present status, and to identify patient current and potential problems and needs

  7. Developing Critical Thinking Skills • Reflection = the process of purposefully thinking back or recalling a situation to discover its purpose or meaning • Concept mapping – see other power point

  8. Chapter 16: Nursing Assessment

  9. Nursing Process (ADPIE) • Assessment • Nursing Diagnosis • Planning • Implementation/Intervention • Evaluation

  10. Assessment • The deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and past coping patterns. • Collection and verification of data • Primary source = patient • Secondary source = family, medical record • Analysis of data

  11. Data Collection • Subjective • Patient states • Objective • Observations or Measurements • Vitals • Inspection of a wound

  12. Methods of Data Collection • Interview • Helps clients relate their own interpretation and understanding of their condition • Three phases • Orientation • Begin a relationship • Understand client’s primary needs • Working • Gather information about the client’s health status • Termination

  13. Methods of Data Collection Cont’d. • Nursing Health History • Biographical information • Reason for seeking health care • Client expectations • Present illness or health concerns • Health history • Family history • Environmental history (work, home, exposure) • Psychosocial history (support system, coping skills) • Spiritual health • Review of systems • Documentation of findings

  14. Putting It All Together • Physical exam • Observe client behavior • Diagnostic and laboratory data • Interpreting assessment data and making nursing judgments • Validate data, ensure it isn’t an inference • Holistic perspective for better clinical decision making • Leads to nursing diagnosis

  15. Chapter 17: Nursing Diagnosis

  16. Nursing Diagnosis • Classifies health problems within the domain of nursing • DOMAIN • A TERRITORY GOVERNED BY A SINGLE RULER • A REALM OR RANGE OF PERSONAL KNOWLEDGE AND RESPONSIBILITY

  17. Nursing Diagnosis Cont’d. A nursing diagnosis is a clinical judgment about individuals, families, or communities and their responses to actual and/or potential health problems or life processes (Pg. 248) (NANDA International, 2007)

  18. Problem List Fractured hip – In traction Confusion Hypertension (HTN) Insulin Dependent Diabetes (IDDM) History of falls Atrial Fibrillation (A-fib) Pain


  20. Establishing Priorities Helps nurses to anticipate and sequence nursing interventions Classification of priorities: High = if untreated may result in harm Intermediate = non-life threatening needs Low = not always directly related to specific illness or prognosis; affects the client’s future well-being

  21. Potentials for Nursing Diagnosis Safety Confusion History of falls Skin integrity Immobility Pain Fractured hip

  22. Building A Nursing Diagnosis 1. PROBLEM 2. ETIOLOGY 3. SYMPTOMS

  23. PES PROBLEM P –At risk for impaired skin integrity RELATED TO (R/T) E –Immobilization AS EVIDENCED BY (AEB) S –Bedrest and traction



  26. Chapter 18: Planning Nursing Care

  27. Goals and Outcomes States in terms of PATIENT goals and outcomes Not NURSING goals May be short, intermediate or long term (>one week) Written using “S-M-A-R-T” acronym

  28. S-M-A-R-T Specific: What needs to be accomplished? Measurable: How will we know when the goal has been met? Attainable: Possible to meet goal with available resources. Realistic: Patient must have the capacity to meet the goal. Time-specific: When will the goal be achieved?

  29. Guidelines for Writing Goals

  30. Establishing Goals and Expected Outcomes Goal A broad statement that describes the desired change in a client’s condition or behavior Expected Outcome Measurable criteria to evaluate goal achievement; a specific measurable change in a client’s status that you expect to occur in response to nursing care

  31. Goals • Client-Centered • A specific and measurable behavior or response; “PATIENT WILL” • Short-term • An objective behavior or response expected within hours to a week • Long-term • An objective behavior or response expected within days, weeks, or months


  33. Goal • Client Centered • Skin will remain intact • Observable? • Yes • Time Limited • During hospitalization • Realistic? • Yes

  34. NIC/NOC • Nursing Outcomes Classification • Published by the Iowa Intervention Project • Linked to NANDA International nursing diagnoses • Nursing Interventions Classification • Three levels • Domains: use broad terms to organize the more specific classes and interventions • Classes: 30 which offer useful clinical categories to refer to when selecting interventions • Interventions: 542 treatments based upon clinical judgment and knowledge that a nurse performs to enhance outcomes

  35. Chapter 19: Implementing Nursing Care

  36. Nursing Interventions • Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes • Direct = tx performed through interactions with client • Indirect = tx performed away from the client but on behalf of the client

  37. Types of Interventions • Nurse Initiated • Independent • Physician Initiated • Dependent • Collaborative • Interdependent


  39. Interventions • Nursing Orders • Reposition every two hours • Skin care to all boney prominences with repositioning • RN skin assessment every shift • MD Orders • Specific dressings/ointments to wounds • Collaborative Orders • Wound care consult

  40. Rationale • Why did we choose maintaining skin integrity as a priority goal? • Anticipate and prevent complications • Prevent infection • Research evidence in support of nursing interventions • Citation • Potter, P.A. and Perry, A.G. (2009) p. 1279

  41. Chapter 20: Evaluation

  42. Evaluation • You conduct evaluative measures to determine if you met expected outcomes, not if nursing interventions were completed • Did you meet the expected goal/outcome? • Evaluation is ongoing, as is the nursing process

  43. The Nursing Process in Ongoing Care Each care plan must evolve as the patient progresses Based on evaluation (assessment), the nursing diagnoses, priorities, and interventions will change

  44. Time Factor in Setting Priorities The planning of nursing care occurs in three phases: Initial Ongoing Discharge Planning

  45. Chapter 24: Communication

  46. Communication and Nursing Practice • Communication is a lifelong learning process • Functioning as a client advocate, nurses need to be assertive • The intimate moment of connection that makes all the difference in the quality of care and meaning for the client and the nurse • Effective communication helps maintain effective relationships and helps meet legal, ethical, and clinical standards of care

  47. Communication and Interpersonal Relationships • Requires a sense of mutuality and a belief that the nurse-client relationship is a partnership and both are equal participants • Every nuance of posture, every small expression and gesture, every word chosen, and every attitude held all have the potential to hurt or heal

  48. Levels of Communication • Intrapersonal = Occurs within an individual • Interpersonal = One-to-one interaction • Transpersonal = Occurs within a person’s spiritual domain; prayer, meditation, guided reflection, religious rituals • Small-Group = Occurs when a small number of persons meet together • Public = Interaction with an audience

  49. Basic Elements of the Communication Process • Referent = refers to, object of conversation • Sender and Receiver = encodes and decodes • Messages = content of the communication • Channels = means of conveying and receiving messages through senses • Feedback = the message the receiver returns • Interpersonal Variables = factors that influence communication; perception • Environment = the setting for the interaction; needs to meet participant needs