Applying Critical Thinking Skills Involved In Clinical Reasoning

1. Applying Critical Thinking Skills Involved In Clinical Reasoning Whei Ming Su, MA, RN, CCRN Associate Professor Purdue University North Central

2. Learning Objectives 1. Describe the nature of critical thinking. 2. Identify the relationship between critical thinking and nursing process. 3. Examine selected critical thinking skills involved in clinical decision making and implications for learning/teaching in nursing practice. 4. Given a case study, apply selected critical thinking skills.

3. Critical Thinking Skills Involved in Clinical ReasoningIntroduction What is difference between thinking and critical thinking? Why focus on critical thinking? What are differences between novice thinking and expert thinking?

4. Why Focus on Critical Thinking? The nurses are expected to accept more responsibilities, collaborate with diverse individuals, and make more independent decisions. Nurses are often involved in complex situations that require in-depth thinking. We must view ourselves as knowledge workers, who are thought-oriented rather than task orientated. CT is the key to prevent and resolving problems.

5. If we can�t think critically, we become part of problem!

6. Novice Thinking Compared with Expert Thinking Novice Nurse Expert Nurse Knowledge is stored Knowledge is highly separate facts. organized and structured. Focus much on actions. Thinking through things before acting. Need clear-cut rules. Know when to bend the rules.

7. Novice Thinking Compared with Expert Thinking (Continued) Novice Nurse Expert Nurse Are unaware of resources. Are aware of resources. Anxious & lack of confidence. Confident and focus. Focus more on procedure. Focus on both parts. Know than client responses. when to skip steps or do 2 steps together. Collect data more superficially. Collect more relevant & in depth data. Tend to follow policies by rote. Analyze policies & ways to improve them.

8. Definitions Of Critical Thinking It is thinking that defines its purposes and goals well; thinking that frames a question or problem precisely; thinking that carefully checks information for its completeness and relevance; thinking that is sensitive to ideas and concepts; thinking that can trace implications and consequences; thinking a that can appreciate multiple perspectives and ways of looking the things. It is, in short, thinking done in such a way as to be disciplined and self-correcting. (Paul, 1995)

9. What is Implication for Teaching-learning? Teach/learn how to think instead of just teach/learn what to think.

10. The Nature Of Critical ThinkingCharacteristics Critical Thinking is Rational. Critical Thinking is Reflective. Critical Thinking is inquisitive. Critical Thinking is Autonomous.

11. Critical Thinking Attitude Fair-mindedness Intellectual humility Intellectual integrity Intellectual perseverance Intellectual empathy Intellectual courage Intellectual curiosity

12. Critical Thinking And Nursing Process Critical thinking is the thought process underlying judgments and decisions made throughout the nursing process.

13. Critical Thinking And Nursing Process Nursing Process Critical Thinking Cognitive Skills Assessment * Identifying an organized and comprehensive approach to discovery * Identifying cues and making inferences * Validating data * Clustering data Diagnosis * Identifying patterns * Drawing diagnostic conclusions

14. Critical Thinking And Nursing Process Nursing Process Critical Thinking Cognitive Skills Planning * Setting priorities * Establishing evaluative criteria * Generating solutions Implementation * Testing hypotheses Evaluation * Making criterion-based evaluations

15. Thinking Map for Diagnostic Reasoning Collect Data ? ? Find Cues and Make Inferences I ? Fill in Data gaps ? ? Validate Data I ? I Cluster Data I ? Fill in Data Gaps ? ? Identify Pattern of Functioning ? Choose All Possible Nursing Dx and CP

16. Choose All Possible Nursing Dx and CP ? Fill in Data Gaps ? ? Compare Clusters with the Defining Characteristics ? of the Chosen ND/CP ? Fill in Data Gaps ? ? Re-examine Both Supporting and Conflicting Evidence ? ? Fill in Data Gaps ? ? ? ?? Accept or Reject ? ? ? ? ? Determine Causative and Related Factors No Problems / Poss. ? other Dx ? Formulate the Nursing Diagnosis or Collaborative Problem Statement

17. Identifying An Organized And Comprehensive Approach To Discovery Choosing a systematic approach that enhances ability to discover all the information needed to fully understand the client's health status. How you organize your assessment depends on the patient�s health status and your own preference.

18. GuidelinesHow to assess systematically and comprehensively If the person is acutely ill If the person has a specific problem If the person is generally healthy

19. Identifying An Organized And Comprehensive Approach To DiscoveryQuestions To Check Your Thinking Is the approach relevant to the client's situation? What else should I be looking for?

20. Identifying Cues And Making Inferences Cues are data that prompt you to suspect a problem. Inferences are judgments made from the cues; they are mini-conclusions. Questions To Check Your Thinking Is the data relevant? Is the data within normal limit? What are some possible assumptions?

21. Factors That Affect Inference Making Ability Observational skills Prior Knowledge Clinical Experience Values and beliefs

22. Practice Exercise: Making Inferences Cues Corresponding Inferences Frowning O2 Oximetry reading 79% A client insists to go home against medical advice.

23. Rule: Making Inferences More than one cue, more likely it�s true Avoid making inferences based on only one cue. Once you make an inference, verify whether it�s correct by gathering more information and looking for additional cues.

24. Validating Data Verify information to determine if it's correct. Why? When? - Subj. data do not match obj. data. - The data seem extremely abnormal or unsual. - Data that someone else observed

25. Techniques For Validating Data Re-check your own data. Look for factors. Ask someone else. Always double-check information. Compare your subjective and objective data. Clarify patient and family statement.

26. Validating DataQuestions To Check Your Thinking Do the objective data support the subjective data? What factors may alter the accuracy of the data? Is the data consistent with the perspectives of the client and family? Is there any personal bias that might influence data collection and interpretation? Do I have enough data? What other data might I need?

27. Practice ExerciseIdentifying Cues And Making InferencesValidating Data Mrs. Lee had a colon resection and a colostomy done. On the 1ST postoperative day, shift report reveals the following: Vital signs: BP 80/64, P 82, R 18 Lab values: Glucose 112, BUN 26, Cr. 0.8, Na138, K 3.8 Cl 102 Emotional status: She has been crying off and on. Practice exercise: Make inferences from the scenario with supporting data (cues). How do you validate the supporting data? What are the missing data?

28. Organizing (Clustering) Data A data cluster is two or more pieces of information that fit together and have more meaning together than they do examined separately. Determining What Fit Together Prior Knowledge and experience Available tools 1. Functional Health Pattern (Gordon) 2. Nine Human Responses Patterns of the Unitary Person (NANDA) 3. Human Needs (Maslow) 4. Body System

29. Identifying PatternsDrawing Diagnostic Conclusions Identifying Patterns Interpreting what possible patterns of functioning are suggested by the data you have clustered together. Drawing Diagnostic Conclusions (Identifying Problems) Making the final judgment about the meaning of the cue clusters; providing the evidence that led to your conclusions. Questions To Check Your Thinking Which data fit into clusters? What are the relationships among the data (part-whole or cause-effect ) in each cluster? What data are missing in each cluster to rule in/out the first impression of possible patterns of functioning? What are the possible diagnoses that fit each possible pattern of functioning? What data are missing to rule in/out each diagnosis?

30. An Example Of Clustering Data,Identifying Pattern, AndDrawing Diagnostic Conclusion ClusterData Poss. Pattern Poss. DX Data Gaps No appetite since Nutional/Matabolic Fluid volume deficit having cold; has or or not eaten today; Elimination Urinary retention last fluid at noon; oral temp. 39.4C; skin hot & flushed; decreased urinary frequency & amt.

31. Practice Exercise: Clustering Data, Identifying Pattern, AndDrawing Diagnostic Conclusions Larry, a 76 year old man, was admitted for ventricular arrhythmia. He is on Xylocaine 4 mg/min IV infusion. His health history includes hypertension, DM, and CHF. He is allergic to sulfa drugs. You are assigned to take care of Larry. When you assess him, you find that his speech is slurred. He is alert and orientated Practice Exercise: Examine the given data and identify the possible relationships among data. Group the related data into clusters. Examine the clusters and identify the possible patterns. Formulate possible diagnoses under each possible pattern. Compare the data clusters with the defining characteristics of each diagnosis and identify the missing data in the clusters to support or reject the diagnosis. Cluster Possible Pattern Poss. DX Missing Data

32. An Example Data Grouping Poss. Pattern Poss. Diagnosis Data Gaps Slurred speech Activity/Exercise PC; Lido Toxidity Are other High dose of Lido signs of MI Lido toxicity? Hx: HTN, CHF Advanced age Are admission lab results (renal & liver function) WNL?

33. An Example (Continued) Data Grouping Poss. Pattern Poss. Diagnosis Data Gaps Slurred speech Cognitive/ PC: Stroke Are there MI Perceptual other Hx: HTN, CHF neurological signs of stroke? Is CT of head needed?

34. An Example (Continued) Data Grouping Poss. Pattern Poss. DX Data Gaps Slurred speech Role/Relationship Nursing Dx Does the client Advanced age Impaired use dentures? Communication Is the slurred speech a pre-existing condition?

35. Setting Priorities The process of differentiating between problems needing immediate attention and those requiring subsequent action. Questions To Check Your Thinking What are the most important problems we need to solve? What criteria should be considered for ranking? What factors may influence the criteria?

36. Criteria for Setting Priorities Preservation of life Maslow�s Hierarchy Client preference

37. Guidelines for Determining Priorities Assign a high priority to problems that contribute to other problems. Ask yourself negative questions. Negative questions begin with, �What could happen if I don�t�� Understand: - the client�s perception of priority. - the whole picture of problems at hand. - the client�s overall health status and expected discharge outcome - the expected length of stay. - whether there are standard plans that apply.