Critical Thinking Critical Thinking in Nursingin Nursing

Lipe, S. K. & Beasley, S., (2004). Lipe, S. K. & Beasley, S., (2004). Critical Thinking in Nursing: A cognitive skills Critical Thinking in Nursing: A cognitive skills workbook.workbook. Lippincott. Philadelphia, PA. Lippincott. Philadelphia, PA.

Critical ThinkingProblem Solving

Decision Making

Priority SettingClinical Reasoning

OBJECTIVESOBJECTIVES

Utilize critical thinking to develop Utilize critical thinking to develop treatment plan in both simulated treatment plan in both simulated and clinical situations.and clinical situations.

Discuss the process of critically Discuss the process of critically thinking.thinking.

Identify common errors in utilizing Identify common errors in utilizing the critical thinking process.the critical thinking process.

OBJECTIVESOBJECTIVES

Discuss the characteristics of a critical Discuss the characteristics of a critical thinker and standards commonly applied thinker and standards commonly applied when critically thinking.when critically thinking.

Explain how time management, client Explain how time management, client care needs/activities, multitasking, and care needs/activities, multitasking, and nursing diagnoses are integral to the nursing diagnoses are integral to the prioritizing processes. prioritizing processes.

OBJECTIVESOBJECTIVES

Prioritize nursing diagnoses using patient Prioritize nursing diagnoses using patient condition as the basis for decisions.condition as the basis for decisions.

Formulate priorities for management and Formulate priorities for management and delivery of nursing care in various delivery of nursing care in various settings.settings.

Apply critical thinking and prioritizing to Apply critical thinking and prioritizing to client scenarios and NCLEX-style client scenarios and NCLEX-style questions.questions.

CRITICAL THINKINGCRITICAL THINKING

Ennis – ‘reasonable, reflective Ennis – ‘reasonable, reflective thinking that is focused on deciding thinking that is focused on deciding what to believe or do’what to believe or do’

[Lipe & Beasley (Nosich, 2001, p.2)][Lipe & Beasley (Nosich, 2001, p.2)]

‘‘Critical Thinking is goal directed; it Critical Thinking is goal directed; it is thinking with a purpose.’ (Lipe & is thinking with a purpose.’ (Lipe & Beasley, 2004, p. 3)Beasley, 2004, p. 3)

Problem SolvingProblem Solving

Systematic Systematic approach approach resulting in resulting in formation of formation of solutionssolutions

Decision MakingDecision Making

Involves Involves choosing from choosing from optionsoptions

It is a step in It is a step in the problem the problem solving solving processprocess

Characteristics of a Critical Characteristics of a Critical ThinkerThinker

Independent thinkerIndependent thinker QuestioningQuestioning Recognizes biases & Recognizes biases &

assumptionsassumptions ObservantObservant Organize/cluster Organize/cluster

datadata PrioritizesPrioritizes Open mindedOpen minded Open to new ideasOpen to new ideas

Flexible-willing to Flexible-willing to changechange

Innovative, Innovative, creativecreative

AnalyticalAnalytical CommunicatorCommunicator AssertiveAssertive KnowledgeableKnowledgeable ResourcefulResourceful IntuitiveIntuitive ““Out of the boxOut of the box” ”

thinkerthinker

Process of Critically Process of Critically ThinkingThinking

http://www.criticalthinking.org/CTmodel/CTModel1.cfm#

6 Essential Cognitive Skills of 6 Essential Cognitive Skills of Critical ThinkingCritical Thinking

Interpretation Interpretation – ability to explain the meaning of – ability to explain the meaning of informationinformation

AnalysisAnalysis – examine subjective and objective, – examine subjective and objective, advantages, disadvantages, and consequencesadvantages, disadvantages, and consequences

EvaluationEvaluation – Is info source credible? Any bias? Is – Is info source credible? Any bias? Is info relevant?info relevant?

InferenceInference – draw a conclusion based on info – draw a conclusion based on info

Explanation Explanation – ability to explain one’s conclusions– ability to explain one’s conclusions

Self-regulationSelf-regulation – reflecting on our own thinking; – reflecting on our own thinking; Did I have all the facts? Are my assumptions Did I have all the facts? Are my assumptions correct/ incorrect?correct/ incorrect?

Pitfalls in Critical ThinkingPitfalls in Critical Thinking

Illogical ProcessIllogical Process

BiasBias

Closed-Closed-

mindednessmindedness

SCENARIOSCENARIO

Situation: Frank Fellow, a 72-year-old patient Situation: Frank Fellow, a 72-year-old patient admitted for acute confusion presented in the admitted for acute confusion presented in the emergency department (ED) with a history of emergency department (ED) with a history of hypertension, diabetes type 1, and arthritis. He lives hypertension, diabetes type 1, and arthritis. He lives in a single-family home with his wife.in a single-family home with his wife.

The client is slightly confused and has an unsteady The client is slightly confused and has an unsteady gait. He frequently forgets to use his walker and fails gait. He frequently forgets to use his walker and fails to call for assistance from the nursing staff when to call for assistance from the nursing staff when ambulating to the bathroom. ambulating to the bathroom.

Interpretation - clarifyingInterpretation - clarifying Analysis - questioningAnalysis - questioning Outcomes – what do you expect?Outcomes – what do you expect? Inference - conclusionInference - conclusion Self Regulation – what else?Self Regulation – what else?

INFLUENCING FACTORSINFLUENCING FACTORS

EmotionsEmotions

ValuesValues

PerceptionsPerceptions

Social climateSocial climate

Characteristics of an Effective Characteristics of an Effective Decision MakerDecision Maker

Self ConfidentSelf Confident AssertiveAssertive ProactiveProactive FlexibilityFlexibility KnowledgeableKnowledgeable Ability to accept responsibilityAbility to accept responsibility Ability to focusAbility to focus

Priorities firstPriorities first

Are these characteristics similar to the critical thinker?Are these characteristics similar to the critical thinker?

PrioritizingPrioritizingTime ManagementTime ManagementMaslow Hierarchy Maslow Hierarchy

of Needsof NeedsPrioritizing Prioritizing

Nursing DiagnosesNursing DiagnosesPriority ActivitiesPriority ActivitiesMultitaskingMultitaskingNursing ProcessNursing Process

Self-Act

Self-esteem

Love and Belonging

Safety and Security

Physiologic Needs

The 34 yr. patient with cirrhosis is admitted for The 34 yr. patient with cirrhosis is admitted for dehydration and needs a central line for high dehydration and needs a central line for high volume fluid replacement. Vital signs upon volume fluid replacement. Vital signs upon arrival on the unit at 2 pm were temp 99, pulse arrival on the unit at 2 pm were temp 99, pulse 102, r 24, b/p 90/60. The nurse has finished 102, r 24, b/p 90/60. The nurse has finished report and the physician is on the way to the report and the physician is on the way to the unit to place a central line. Which nursing unit to place a central line. Which nursing activity is the highest priority?activity is the highest priority?

A. Ensure consent signedA. Ensure consent signed B. Take the patient’s vital signsB. Take the patient’s vital signs C. Notify the familyC. Notify the family D. Listen to breath soundsD. Listen to breath sounds E. Assess urinary outputE. Assess urinary output

16-year-old boy transported to the emergency 16-year-old boy transported to the emergency department by ambulance following a MVA. department by ambulance following a MVA. Witnesses report his car slid on ice, and the vehicle Witnesses report his car slid on ice, and the vehicle became airborne, throwing the adolescent from his became airborne, throwing the adolescent from his car. Initial assessment reveals that the patient has a car. Initial assessment reveals that the patient has a patent airway, is responsive to painful stimuli, has a patent airway, is responsive to painful stimuli, has a laceration to his left thigh that is covered with a laceration to his left thigh that is covered with a dressing, and has contusions to the left flank area. dressing, and has contusions to the left flank area. Place the following activities in order of priority.Place the following activities in order of priority.

___Call the parents for consent to treat___Call the parents for consent to treat

___Immobilize head and neck___Immobilize head and neck

___Assess level of consciousness and neurologic deficits___Assess level of consciousness and neurologic deficits

___Assess left thigh and apply clean pressure dressing___Assess left thigh and apply clean pressure dressing

PITFALLS IN PRIORITY SETTINGPITFALLS IN PRIORITY SETTING

Inadequate Assessment and Inadequate Assessment and Evaluation of Client NeedsEvaluation of Client Needs

Failure to Differentiate Between Failure to Differentiate Between Priority and Non-priority TasksPriority and Non-priority Tasks

Acceptance of Others’ Priorities Acceptance of Others’ Priorities Without Assessing All the VariablesWithout Assessing All the Variables

Performance of Tasks with a “First Performance of Tasks with a “First Identified, First Completed” ApproachIdentified, First Completed” Approach

Completion of the Easiest Tasks FirstCompletion of the Easiest Tasks First

The patient is resting quietly, breath The patient is resting quietly, breath sounds clear, respirations easy and sounds clear, respirations easy and

unlabored, skin color pink. O2 @ 3 Liters, unlabored, skin color pink. O2 @ 3 Liters, and O2 sat is 98%. After eating dinner , and O2 sat is 98%. After eating dinner , the patient rings the nurse. The nurse’s the patient rings the nurse. The nurse’s assessment reveals respirations are 30 assessment reveals respirations are 30 breaths/min and labored, crackles are breaths/min and labored, crackles are

auscultated bilaterally, skin color dusky, auscultated bilaterally, skin color dusky, and the SpO2 82%. and the SpO2 82%.

What are you the nurse going to What are you the nurse going to do?do?

The nurse intervenes by The nurse intervenes by Elevating the head of the bedElevating the head of the bedApplying prescried O2 through a Applying prescried O2 through a

nonrebreathernonrebreatherNotify PhysicianNotify Physician

………………

CALLING THE PHYSICIANCALLING THE PHYSICIAN

Change in statusChange in statusPain w/o ordered mgmt strategiesPain w/o ordered mgmt strategiesLack of treatment ordersLack of treatment ordersLab valuesLab valuesRisk to safetyRisk to safety

LAB VALUESLAB VALUES

Do not consider lab values in Do not consider lab values in isolationisolation

Evaluate data and compared to Evaluate data and compared to patient’s clinical statuspatient’s clinical status

Compare to age, medical diagnosis, Compare to age, medical diagnosis, assessment data, physical status, assessment data, physical status, physical orders, current treatment, physical orders, current treatment, previous labsprevious labs

Failure to assess, monitor, and Failure to assess, monitor, and report…report…

negligencenegligence

13. Which patient should the nurse see first?13. Which patient should the nurse see first? A. a 40 yo 7 day postpartum female with bright A. a 40 yo 7 day postpartum female with bright

red vaginal bleeding and a hgb of 7.0 g/dL.red vaginal bleeding and a hgb of 7.0 g/dL. B. A diabetic patient with a blood sugar of 400 B. A diabetic patient with a blood sugar of 400

mg/dL and no orders for insulin coverage.mg/dL and no orders for insulin coverage. C. A 46 yo ESRD patient who had an AV fistula C. A 46 yo ESRD patient who had an AV fistula

placement 2 days ago. No thrill or bruit noted.placement 2 days ago. No thrill or bruit noted. D. A 50 yo woman, 2 days after knee D. A 50 yo woman, 2 days after knee

replacement. She refuses to use CPM machine replacement. She refuses to use CPM machine due to paindue to pain

Client

Care