Critical Thinking in The Nursing Process

1. Critical Thinking in The Nursing Process Separating the Professional from the Technical

2. Aspects of Critical Thinking • “the active, organized, cognitive process used to examine one’s own thinking and the thinking of others” • Using reflection, intuition, and previous experiences to make sound decisions • Requires a habit of asking questions, remaining well informed, a willingness to reconsider, and avoiding premature decision making

3. Components of Critical Thinking • Knowledge base • Theoretical • Experiential • Experience • Practice making decisions • Technical Skills & Competencies • Attitudes and behaviors

4. Critical Thinking Indicators R. Alfaro-LeFevre

5. Specific Critical Thinking in Nursing • The Nursing Process: a systematic problem solving approach consisting of; • Assessment • Diagnosis • Planning • Implementation • Evaluation • Nursing involves both thinking and doing • Nursing deals with complex issues

6. Synthesis of Critical Thinking & Nursing Process • Brings together • Critical thinking • Nursing process • Nursing knowledge • Patient situation

7. Step 1 of Nursing ProcessAssessment • Types of Assessment • Comprehensive • Focused • Special needs • Initial • Ongoing

8. Nursing Assessment • Types of Data • Subjective • Objective • Sources of Data • Primary data • Client • Secondary data • Family • Health Records • Health Team Members

9. Nursing Assessment • Methods of collection • Observation • Use all 5 senses • Physical assessment • Interview • Health history

10. Physical Assessment • Performed after nursing history • Collection of objective data • Ht., Wt., V.S. • General Survey • Head to toe exam • Inspection • Palpation • Percussion • Auscultation • Olfaction

11. Nursing Health History • Biographical Data • Reason for Seeking Health Care / Chief complaint • Client’s Expectations • History of Present Illness • Past Health History • Family History / social history • Medications • Review of body systems

12. Validating Data • To ensure data is • accurate • Complete • Factual • And you are not jumping to conclusions • When to validate • Subjective and objective data do not agree • Patient’s statements differ at different times • Data falls outside normal range

13. Organizing Data • Systematic • Usually controlled by agency forms • Body systems framework • Maslow’s Hierarchy of Needs • Gordon’s functional patterns • Orem’s Self care model • Roy Adaptation Model • NANDA nursing diagnosis Taxonomy II

14. Data Clustering • Organizing data into meaningful clusters • A set of signs or symptoms grouped together into logical order • Groupings of associations • Helps you recognize significant cues

15. Data Interpretation • Utilizes critical thinking to • Judge the value or significance of the data • Validate and verify assumptions with client and other health care team members

16. Step 2 of the Nursing ProcessNursing Diagnoses • Identify patterns in data and draw conclusions about client’s status • Describes client’s actual or potential response to a health problem • A statement of client health that nurses can identify, prevent, or treat independently • Stated in terms of unique human responses to diseases, injuries, or stressors • Must be accurate because it provides direction for nursing care

17. Types of Nursing Diagnoses • Actual (3-part statement) • Presently exists • Risk (2-part statement) • Likely to develop in vulnerable patient • Possible (2 or 3- part statement) • Suspect on intuition but don’t have enough data yet • Syndrome (1 part statement) • Collection of nursing diagnoses that occur together • Wellness (1-part statement) • Not a health problem, wants to move to higher level of wellness

18. Nursing Diagnosis Statement • Diagnostic Label (title or name) • Approved by NANDA • Related Factors • Etiology must be in nurses domain to intervene • Don’t use medical diagnoses • Defining Characteristics • Cues from assessment data • must support diagnosis • Eg. Impaired mobility R/T lack of peripheral sensation AEB inability to walk from bed to chair.

19. Sources of Diagnostic Error • Data collection • Omitted, incomplete, inaccurate, disorganized • Data analysis & interpretation • Inaccurate interpretation of cues, conflicting cues, incorrect judgments of inferences • Data clustering • Incorrectly clustered or not clustered at all • Diagnostic Statement • Problem & etiology must be in scope of nursing to treat

20. Avoiding Errors in Nursing Diagnoses • Identify client’s response not medical diagnosis • One symptom is insufficient for problem identification • Nursing interventions directed at correcting etiology of problem • Identify client response to equipment not the equipment itself • Client problems not nurse problems • Develop in cooperation with client

21. Medical Diagnosis vs. Nursing Diagnosis • Nursing diagnosis • Defines nursing needs of clients related to the medical diagnoses • Medical Diagnosis • Reflects specific disease, illness, or injury • Goal – prescribe treatment

22. Prioritizing Problems • Place in order of importance or urgency • Maslow’s Hierarchy of Human Needs • Physiological • Safety and security • Love and belonging • Self-esteem • Self-actualization • A,B,C’s • Nursing Process

23. Step 3 of the Nursing ProcessPlanning / Outcomes • Client centered goals / outcomes • Specific measurable objective • Are precise, descriptive, clearly stated • Reflects highest level of wellness • Should be realistic • Observable client behavior • Measurable criteria for each goal • Projected time frame for goal achievement • Provide a guide for selecting interventions • Short term goals • Achieve in hours or days, less than 1 week • Long term goals • Achieved over weeks or months

24. Properly Written Expected Outcomes • Subject • The client • Action verb • Action that will be performed by client • Performance criteria • Specific measurement to be evaluated • Target time • When action should be achieved • Special conditions • Amt. of assistance, what equipment, resources needed

25. 7 Guidelines for Writing Goals/Outcomes • Client centered… • Singular factors/ criteria… • Observable factors… • Measurable factors… • Time limited factors… • Mutual factors… • Realistic factors…

26. Purpose of Care Plans • Serves as Written guidelines for client care • Communicates care • Enhances continuity • Organizes information – promotes efficiency • Involves client and family • Meets requirements of accrediting agencies • Care plans help students learn problem solving, skills of written communication, organizational skills, and application of theory

27. Step 4 of the Nursing ProcessPlanning Nursing Interventions • AKA Nursing • Actions • Measures • Strategies • Activities • Actions based on clinical nursing judgment and knowledge that nurses perform to achieve client outcomes • Include activities of observation/assessment, prevention, treatment, & health promotion

28. 3 Types of Interventions • Independent • Nurse initiated interventions • In realm of independent nursing practice • No MD order required • Dependent • Physician initiated interventions • Require MD orders • Collaborative (interdependent) interventions • Coordination of multiple professionals

29. Interventions • Include activities of • Observation/assessment • Prevention • Therapeutic Treatments • Health promotion • Activities of daily living • Teaching • Discharge planning • Flow from Client goals/outcomes / orders • Individualize standardized interventions

30. Nursing Orders • Instructions on care plan describing implementation of interventions • Include • Date • Subject • Action verb • Times and limits • Signature • Standing Orders • Protocols • Critical Pathways • Evidence Based Practice

31. Errors in Writing Nursing Interventions • Nursing action nonspecific • Fail to indicate frequency • Fail to indicate quantity • Fail to indicate method • Fail to indicate person to perform

32. 5th step of Nursing ProcessImplementation & Evaluation • Implementation • The action phase of the nursing process • You will perform or delegate planned interventions • Implementation ends when you record the nursing actions on chart • Evolves into evaluation as you record resulting client responses

33. Preparing for Implementation • Check your knowledge and abilities • Organize your work • Prepare the patient • Implement the plan • Coordinate/collaborate • Delegate appropriately • Right task • Right circumstance • Right person • Right directions / communication • Right supervision

34. The final stepEvaluation • Planned • Ongoing • Does not end the nursing process • Systematic • Make judgments about • Client’s progress toward expected outcomes/goals • Effectiveness of nursing care plan • Quality of nursing care delivered

35. Types of Evaluation • Ongoing evaluation • At each contact with patient • Intermittent evaluation • At outcome evaluation specified times • Terminal evaluation • At time of discharge

36. Evaluating Patient Progress • Review Outcomes • Collect Reassessment Data • Judge Goal Achievement • Achieved (met) • Partially achieved (partially met) • Not achieved (unmet) • Record evaluative statement • Revise care plan if indicated • Begin with assessment data and go through entire nursing process

37. Documentation • Written evidence of interactions • Health professionals • Clients • Families • Health care organizations • Diagnostic tests • Treatments • Education • Client results/responses

38. Documentation Guidelines • Correct client record • Client name on each page • Document immediately • Date and time each entry • Sign each entry with name and professional credentials • No space between entries • Never change another’s entry • Use “quotes” for client statements • Chronological order

39. Elements of Documentation • Use appropriate vocabulary / terminology • Only approved abbreviations / symbols • Use organized and logical sequence • State only factual not inferences • Use correct spelling, legible writing • Protect client confidentiality by not releasing records to anyone without patient permission • Write neatly, legibly, & in ink • Use concrete specific terms • Follow agency guidelines

40. Documentation Methods • Source-Oriented Records • Separate sections for each discipline • Problem-Oriented Records • Consists of database, problem list, plan of care, & progress notes

41. Types of Charting • Narrative • SOAP • PIE • Focus • Charting by exception • Computerized