Chapter 15: Critical Chapter 15: Critical Thinking in Nursing Thinking in Nursing

PracticePractice

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

CRITICAL THINKINGCRITICAL THINKING

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

Critical Thinking Requires…Critical Thinking Requires…

Cognitive skillsCognitive skills Ask questionsAsk questions Remain well-informedRemain well-informed Be honest in facing personal biasesBe honest in facing personal biases Be willing to reconsider and think Be willing to reconsider and think

clearly about issuesclearly about issues

Attributes of a Critical Attributes of a Critical ThinkerThinker

Asks pertinent questionsAsks pertinent questions Is able to admit a lack of Is able to admit a lack of

understanding or informationunderstanding or information Is interested in finding new solutionsIs interested in finding new solutions Listens carefully to others and is able Listens carefully to others and is able

to give feedbackto give feedback Examines problems closelyExamines problems closely

Critical Thinking Can Lead Critical Thinking Can Lead To…To…

Sound clinical decisionsSound clinical decisions

Using the Nursing Process to guide Using the Nursing Process to guide patient carepatient care

Evidence-Based Practice (EBP)Evidence-Based Practice (EBP)

Nursing ProcessNursing Process

DefinitionDefinition The act of reviewing the patient’s The act of reviewing the patient’s

situation in order to obtain information situation in order to obtain information of past history, present status, and to of past history, present status, and to identify patient current and potential identify patient current and potential problems and needsproblems and needs

Developing Critical Thinking Developing Critical Thinking SkillsSkills

Reflection = the process of Reflection = the process of purposefully thinking back or purposefully thinking back or recalling a situation to discover its recalling a situation to discover its purpose or meaningpurpose or meaning

Concept mapping – see other power Concept mapping – see other power pointpoint

Chapter 16: Nursing Chapter 16: Nursing AssessmentAssessment

Nursing Process (ADPIE)Nursing Process (ADPIE) AAssessmentssessment

Nursing Nursing DDiagnosisiagnosis

PPlanninglanning

IImplementation/Interventionmplementation/Intervention

EEvaluationvaluation

AssessmentAssessment The deliberate and systematic collection The deliberate and systematic collection

of data to determine a client’s current of data to determine a client’s current and past health status and functional and past health status and functional status and to determine the client’s status and to determine the client’s present and past coping patterns.present and past coping patterns. Collection and verification of dataCollection and verification of data

Primary source = patientPrimary source = patient Secondary source = family, medical recordSecondary source = family, medical record

Analysis of dataAnalysis of data

Data CollectionData Collection

SubjectiveSubjective Patient statesPatient states

ObjectiveObjective Observations or MeasurementsObservations or Measurements

VitalsVitals Inspection of a woundInspection of a wound

Methods of Data CollectionMethods of Data Collection InterviewInterview

Helps clients relate their own interpretation Helps clients relate their own interpretation and understanding of their conditionand understanding of their condition

Three phasesThree phases Orientation Orientation

Begin a relationshipBegin a relationship Understand client’s primary needsUnderstand client’s primary needs

WorkingWorking Gather information about the client’s health statusGather information about the client’s health status

TerminationTermination

Methods of Data Collection Methods of Data Collection Cont’d.Cont’d.

Nursing Health HistoryNursing Health History Biographical informationBiographical information Reason for seeking health careReason for seeking health care Client expectationsClient expectations Present illness or health concernsPresent illness or health concerns Health historyHealth history Family historyFamily history Environmental history (work, home, exposure)Environmental history (work, home, exposure) Psychosocial history (support system, coping Psychosocial history (support system, coping

skills)skills) Spiritual healthSpiritual health Review of systemsReview of systems Documentation of findingsDocumentation of findings

Putting It All TogetherPutting It All Together Physical examPhysical exam Observe client behaviorObserve client behavior Diagnostic and laboratory dataDiagnostic and laboratory data Interpreting assessment data and making Interpreting assessment data and making

nursing judgmentsnursing judgments Validate data, ensure it isn’t an inferenceValidate data, ensure it isn’t an inference Holistic perspective for better clinical Holistic perspective for better clinical

decision makingdecision making Leads to nursing diagnosisLeads to nursing diagnosis

Chapter 17: Nursing Chapter 17: Nursing DiagnosisDiagnosis

Nursing DiagnosisNursing Diagnosis

Classifies health problems within the Classifies health problems within the domain of nursingdomain of nursing DOMAINDOMAIN

A TERRITORY GOVERNED BY A SINGLE A TERRITORY GOVERNED BY A SINGLE RULERRULER

A REALM OR RANGE OF PERSONAL A REALM OR RANGE OF PERSONAL KNOWLEDGE AND RESPONSIBILITYKNOWLEDGE AND RESPONSIBILITY

Nursing Diagnosis Cont’d.Nursing Diagnosis Cont’d.

A nursing diagnosis is a clinical A nursing diagnosis is a clinical judgment about individuals, families, judgment about individuals, families, or communities and their responses or communities and their responses to actual and/or potential health to actual and/or potential health problems or life processes (problems or life processes (Pg. 248)Pg. 248)

(NANDA International, 2007)(NANDA International, 2007)

Problem List Problem List

Fractured hip – In tractionFractured hip – In traction ConfusionConfusion Hypertension (HTN)Hypertension (HTN) Insulin Dependent Diabetes (IDDM)Insulin Dependent Diabetes (IDDM) History of fallsHistory of falls Atrial Fibrillation (A-fib)Atrial Fibrillation (A-fib) PainPain

TRACTIONTRACTION

Establishing PrioritiesEstablishing Priorities

Helps nurses to anticipate and Helps nurses to anticipate and sequence nursing interventions sequence nursing interventions

Classification of priorities:Classification of priorities: High = if untreated may result in harmHigh = if untreated may result in harm Intermediate = non-life threatening Intermediate = non-life threatening

needsneeds Low = not always directly related to Low = not always directly related to

specific illness or prognosis; affects the specific illness or prognosis; affects the client’s future well-beingclient’s future well-being

Potentials for Nursing Potentials for Nursing DiagnosisDiagnosis

SafetySafety ConfusionConfusion History of fallsHistory of falls

Skin integritySkin integrity ImmobilityImmobility

PainPain Fractured hipFractured hip

Building A Nursing DiagnosisBuilding A Nursing Diagnosis

11. . PROBLEMPROBLEM

2. 2. ETIOLOGYETIOLOGY

3. 3. SYMPTOMSSYMPTOMS

PESPES

PROBLEMPROBLEM

P –P – At risk for impaired skin integrityAt risk for impaired skin integrity

RELATED TO (R/T) RELATED TO (R/T)

E –E – ImmobilizationImmobilization

AS EVIDENCED BY (AEB)AS EVIDENCED BY (AEB)

S –S – Bedrest and tractionBedrest and traction

Nursing Diagnosis Nursing Diagnosis StatementStatement

POTENTIAL FOR SKIN BREAKDOWN POTENTIAL FOR SKIN BREAKDOWN RELATED TO IMMOBILITY AS RELATED TO IMMOBILITY AS EVIDENCED BY BEDREST AND EVIDENCED BY BEDREST AND TRACTIONTRACTION

Nursing Diagnosis Nursing Diagnosis StatementStatement

ANOTHER NURSING DIAGNOSIS ANOTHER NURSING DIAGNOSIS STATEMENT:STATEMENT:

PAIN RELATED TO FRACTURED HIP PAIN RELATED TO FRACTURED HIP AS EVIDENCED BY PATIENT STATES AS EVIDENCED BY PATIENT STATES PAIN LEVEL 8/10PAIN LEVEL 8/10

Chapter 18: Planning Chapter 18: Planning Nursing CareNursing Care

Goals and Outcomes Goals and Outcomes

States in terms of States in terms of PATIENTPATIENT goals and goals and outcomesoutcomes Not Not NURSINGNURSING goals goals

May be short, intermediate or long May be short, intermediate or long term (>one week)term (>one week)

Written using “S-M-A-R-T” acronymWritten using “S-M-A-R-T” acronym

S-M-A-R-TS-M-A-R-T Specific: Specific: What needs to be What needs to be

accomplished?accomplished? Measurable: Measurable: How will we know when How will we know when

the goal has been met?the goal has been met? Attainable: Attainable: Possible to meet goal with Possible to meet goal with

available resources.available resources. Realistic: Realistic: Patient must have the Patient must have the

capacity to meet the goal.capacity to meet the goal. Time-specific: Time-specific: When will the goal be When will the goal be

achieved?achieved?

Guidelines for Writing GoalsGuidelines for Writing Goals

PATIENT CENTEREDPATIENT CENTERED

OBSERVABLEOBSERVABLE

TIME LIMITEDTIME LIMITED

REALISTICREALISTIC

Establishing Goals and Establishing Goals and Expected OutcomesExpected Outcomes

GoalGoal A broad statement that describes the A broad statement that describes the

desired change in a client’s condition or desired change in a client’s condition or behaviorbehavior

Expected OutcomeExpected Outcome Measurable criteria to evaluate goal Measurable criteria to evaluate goal

achievement; a specific measurable achievement; a specific measurable change in a client’s status that you change in a client’s status that you expect to occur in response to nursing expect to occur in response to nursing carecare

GoalsGoals

Client-CenteredClient-Centered A specific and measurable behavior or A specific and measurable behavior or

response; “PATIENT WILL”response; “PATIENT WILL” Short-termShort-term

An objective behavior or response expected An objective behavior or response expected within hours to a weekwithin hours to a week

Long-termLong-term An objective behavior or response expected An objective behavior or response expected

within days, weeks, or monthswithin days, weeks, or months

Goal StatementGoal Statement

PATIENT’S SKIN WILL REMAIN INTACT PATIENT’S SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION. THROUGHOUT HOSPITALIZATION.

GoalGoal Client CenteredClient Centered

Skin will remain Skin will remain intactintact

Observable?Observable? YesYes

Time Limited Time Limited During During

hospitalizationhospitalization Realistic?Realistic?

YesYes

NIC/NOCNIC/NOC Nursing Outcomes ClassificationNursing Outcomes Classification

Published by the Iowa Intervention ProjectPublished by the Iowa Intervention Project Linked to NANDA International nursing Linked to NANDA International nursing

diagnosesdiagnoses Nursing Interventions ClassificationNursing Interventions Classification

Three levelsThree levels Domains: use broad terms to organize the more Domains: use broad terms to organize the more

specific classes and interventionsspecific classes and interventions Classes: 30 which offer useful clinical categories to Classes: 30 which offer useful clinical categories to

refer to when selecting interventionsrefer to when selecting interventions Interventions: 542 treatments based upon clinical Interventions: 542 treatments based upon clinical

judgment and knowledge that a nurse performs to judgment and knowledge that a nurse performs to enhance outcomesenhance outcomes

Chapter 19: Implementing Chapter 19: Implementing Nursing CareNursing Care

Nursing InterventionsNursing Interventions

Any treatment, based upon clinical Any treatment, based upon clinical judgment and knowledge, that a judgment and knowledge, that a nurse performs to enhance client nurse performs to enhance client outcomesoutcomes Direct = tx performed through Direct = tx performed through

interactions with clientinteractions with client Indirect = tx performed away from the Indirect = tx performed away from the

client but on behalf of the clientclient but on behalf of the client

Types of InterventionsTypes of Interventions

Nurse InitiatedNurse Initiated IndependentIndependent

Physician InitiatedPhysician Initiated DependentDependent

CollaborativeCollaborative InterdependentInterdependent

Planning Nursing CarePlanning Nursing Care

DECIDE ON AN INTERVENTION TO DECIDE ON AN INTERVENTION TO PREVENT SKIN BREAKDOWNPREVENT SKIN BREAKDOWN

InterventionsInterventions

Nursing OrdersNursing Orders Reposition every two hoursReposition every two hours Skin care to all boney prominences with Skin care to all boney prominences with

repositioningrepositioning RN skin assessment every shiftRN skin assessment every shift

MD OrdersMD Orders Specific dressings/ointments to woundsSpecific dressings/ointments to wounds

Collaborative OrdersCollaborative Orders Wound care consultWound care consult

RationaleRationale

Why did we choose maintaining skin Why did we choose maintaining skin integrity as a priority goal?integrity as a priority goal? Anticipate and prevent complicationsAnticipate and prevent complications Prevent infectionPrevent infection

Research evidence in support of Research evidence in support of nursing interventionsnursing interventions

CitationCitation Potter, P.A. and Perry, A.G. (2009) p. Potter, P.A. and Perry, A.G. (2009) p.

12791279

Chapter 20: EvaluationChapter 20: Evaluation

EvaluationEvaluation

You conduct evaluative measures to You conduct evaluative measures to determine if you met expected determine if you met expected outcomes, not if nursing outcomes, not if nursing interventions were completedinterventions were completed

Did you meet the expected Did you meet the expected goal/outcome?goal/outcome?

Evaluation is ongoing, as is the Evaluation is ongoing, as is the nursing processnursing process

The Nursing Process in The Nursing Process in Ongoing CareOngoing Care

Each care plan must evolve as the Each care plan must evolve as the patient progressespatient progresses

Based on evaluation (assessment), Based on evaluation (assessment), the nursing diagnoses, priorities, and the nursing diagnoses, priorities, and interventions will changeinterventions will change

Time Factor in Setting PrioritiesTime Factor in Setting Priorities

The planning of nursing care occurs The planning of nursing care occurs in three phases:in three phases: InitialInitial OngoingOngoing Discharge PlanningDischarge Planning

Chapter 24: Chapter 24: CommunicationCommunication

Communication and Nursing Communication and Nursing PracticePractice

Communication is a lifelong learning processCommunication is a lifelong learning process Functioning as a client advocate, nurses need Functioning as a client advocate, nurses need

to be assertiveto be assertive The intimate moment of connection that The intimate moment of connection that

makes all the difference in the quality of care makes all the difference in the quality of care and meaning for the client and the nurseand meaning for the client and the nurse

Effective communication helps maintain Effective communication helps maintain effective relationships and helps meet legal, effective relationships and helps meet legal, ethical, and clinical standards of careethical, and clinical standards of care

Communication and Communication and Interpersonal RelationshipsInterpersonal Relationships

Requires a sense of mutuality and a Requires a sense of mutuality and a belief that the nurse-client belief that the nurse-client relationship is a partnership and both relationship is a partnership and both are equal participantsare equal participants

Every nuance of posture, every small Every nuance of posture, every small expression and gesture, every word expression and gesture, every word chosen, and every attitude held all chosen, and every attitude held all have the potential to hurt or healhave the potential to hurt or heal

Levels of CommunicationLevels of Communication

Intrapersonal = Occurs within an individualIntrapersonal = Occurs within an individual Interpersonal = One-to-one interactionInterpersonal = One-to-one interaction Transpersonal = Occurs within a person’s Transpersonal = Occurs within a person’s

spiritual domain; prayer, meditation, spiritual domain; prayer, meditation, guided reflection, religious ritualsguided reflection, religious rituals

Small-Group = Occurs when a small Small-Group = Occurs when a small number of persons meet togethernumber of persons meet together

Public = Interaction with an audiencePublic = Interaction with an audience

Basic Elements of the Basic Elements of the Communication ProcessCommunication Process

Referent = refers to, object of conversationReferent = refers to, object of conversation Sender and Receiver = encodes and decodesSender and Receiver = encodes and decodes Messages = content of the communicationMessages = content of the communication Channels = means of conveying and Channels = means of conveying and

receiving messages through sensesreceiving messages through senses Feedback = the message the receiver Feedback = the message the receiver

returnsreturns Interpersonal Variables = factors that Interpersonal Variables = factors that

influence communication; perceptioninfluence communication; perception Environment = the setting for the Environment = the setting for the

interaction; needs to meet participant needsinteraction; needs to meet participant needs

Nonverbal CommunicationNonverbal Communication

Personal appearancePersonal appearance Posture and gaitPosture and gait Facial expressionsFacial expressions Eye contactEye contact GesturesGestures SoundsSounds Territoriality and Personal spaceTerritoriality and Personal space

Professional Nursing Professional Nursing RelationshipsRelationships

Nurse-Client Helping RelationshipsNurse-Client Helping Relationships Nurse-Family RelationshipsNurse-Family Relationships Nurse-Health Care Team Nurse-Health Care Team

RelationshipsRelationships Nurse-Community RelationshipsNurse-Community Relationships

Elements of Professional Elements of Professional CommunicationCommunication

Courtesy = hello, knockCourtesy = hello, knock Use of names = convey respectUse of names = convey respect Trustworthiness = without doubt or Trustworthiness = without doubt or

questionquestion Autonomy and responsibility = self-Autonomy and responsibility = self-

directed and independentdirected and independent Assertiveness = express feelings and Assertiveness = express feelings and

ideas without judging or hurting othersideas without judging or hurting others

SBARSBAR

SSituationituation BBackgroundackground AAssessmentssessment RRecommendationsecommendations

Communicating ClearlyCommunicating Clearly

Using SBAR facilitates accurate Using SBAR facilitates accurate communication between:communication between: NURSES AND PHYSICIANSNURSES AND PHYSICIANS NURSES AND COLLEAGUESNURSES AND COLLEAGUES

Recommended by Joint Commission Recommended by Joint Commission (JCAHO) and the Institute for (JCAHO) and the Institute for Healthcare Improvement (IHI)Healthcare Improvement (IHI)

SSituationituation

Identify selfIdentify self Where are you calling from?Where are you calling from? What is the patient’s name?What is the patient’s name? What is the problem?What is the problem?

BBackgroundackground

DiagnosisDiagnosis Pertinent information:Pertinent information:

Vital signs/Pulse oximetryVital signs/Pulse oximetry Current medicationsCurrent medications Mental statusMental status

AAssessmentssessment

Nurse’s assessment of the situationNurse’s assessment of the situation Could be …….Could be ……. Might be ……..Might be …….. I have no idea what is going on!I have no idea what is going on!

RRecommendationecommendation

Could I have an order for .…?Could I have an order for .…? Would you like to change ….?Would you like to change ….? I have tries XYZ without results. I have tries XYZ without results.

Could I ….?Could I ….?

Therapeutic CommunicationTherapeutic Communication

Specific responses that Specific responses that encourage the expression of encourage the expression of feelings and ideas and feelings and ideas and convey acceptance and convey acceptance and respectrespect

Components of Therapeutic Components of Therapeutic CommunicationCommunication

Active listeningActive listening Sharing Sharing

observationsobservations Sharing empathySharing empathy Sharing hopeSharing hope Sharing humorSharing humor Sharing feelingsSharing feelings Using touchUsing touch Using silenceUsing silence

ClarifyingClarifying FocusingFocusing ParaphrasingParaphrasing Asking relevant Asking relevant

questionsquestions SummarizingSummarizing Self disclosureSelf disclosure ConfrontationConfrontation

Non-Therapeutic Non-Therapeutic CommunicationCommunication

Asking personal Asking personal questionsquestions

Giving personal Giving personal opinionsopinions

Changing the Changing the subjectsubject

Automatic Automatic responsesresponses

False reassuranceFalse reassurance

SympathySympathy Approval or Approval or

disapprovaldisapproval Defensive Defensive

responsesresponses Passive or Passive or

aggressive aggressive responsesresponses

ArguingArguing

Why Does Communication Why Does Communication Break Down?Break Down?

COMMUNICATION STYLESCOMMUNICATION STYLES HIGH LEVEL OF ACTIVITYHIGH LEVEL OF ACTIVITY FREQUENT INTERUPTIONSFREQUENT INTERUPTIONS INATTENTION INATTENTION

PrivacyPrivacy

HIPPAHIPPA Healthcare Insurance Privacy and Healthcare Insurance Privacy and

Portability ActPortability Act US Dept. of Health and Human ServicesUS Dept. of Health and Human Services

PHI PHI Protected Health InformationProtected Health Information