Chapter 15: Critical Thinking in Nursing Practice

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

11. 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

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

13. 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

14. 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

15. 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

16. Chapter 17: Nursing Diagnosis

17. 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

18. 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)

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

20. TRACTION

21. 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

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

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

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

25. Nursing Diagnosis Statement POTENTIAL FOR SKIN BREAKDOWN RELATED TO IMMOBILITY AS EVIDENCED BY BEDREST AND TRACTION

26. Nursing Diagnosis Statement ANOTHER NURSING DIAGNOSIS STATEMENT: PAIN RELATED TO FRACTURED HIP AS EVIDENCED BY PATIENT STATES PAIN LEVEL 8/10

27. Chapter 18: Planning Nursing Care

28. 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

29. 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?

30. Guidelines for Writing Goals

31. 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

32. 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 Statement PATIENT�S SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION.

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

35. 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

36. Chapter 19: Implementing Nursing Care

37. 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

38. Types of Interventions Nurse Initiated Independent Physician Initiated Dependent Collaborative Interdependent

39. Planning Nursing Care DECIDE ON AN INTERVENTION TO PREVENT SKIN BREAKDOWN

40. 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

41. 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

42. Chapter 20: Evaluation

43. 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

44. 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

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

46. Chapter 24: Communication

47. 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

48. 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

49. 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

50. 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

51. Nonverbal Communication Personal appearance Posture and gait Facial expressions Eye contact Gestures Sounds Territoriality and Personal space

52. Professional Nursing Relationships Nurse-Client Helping Relationships Nurse-Family Relationships Nurse-Health Care Team Relationships Nurse-Community Relationships

53. Elements of Professional Communication Courtesy = hello, knock Use of names = convey respect Trustworthiness = without doubt or question Autonomy and responsibility = self-directed and independent Assertiveness = express feelings and ideas without judging or hurting others

54. SBAR Situation Background Assessment Recommendations

55. Communicating Clearly Using SBAR facilitates accurate communication between: NURSES AND PHYSICIANS NURSES AND COLLEAGUES Recommended by Joint Commission (JCAHO) and the Institute for Healthcare Improvement (IHI)

56. Situation Identify self Where are you calling from? What is the patient�s name? What is the problem?

57. Background Diagnosis Pertinent information: Vital signs/Pulse oximetry Current medications Mental status

58. Assessment Nurse�s assessment of the situation Could be ��. Might be ��.. I have no idea what is going on!

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

60. Therapeutic Communication Specific responses that encourage the expression of feelings and ideas and convey acceptance and respect

61. Components of Therapeutic Communication Active listening Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Using touch Using silence Clarifying Focusing Paraphrasing Asking relevant questions Summarizing Self disclosure Confrontation

62. Non-Therapeutic Communication Asking personal questions Giving personal opinions Changing the subject Automatic responses False reassurance Sympathy Approval or disapproval Defensive responses Passive or aggressive responses Arguing

63. Why Does Communication Break Down? COMMUNICATION STYLES HIGH LEVEL OF ACTIVITY FREQUENT INTERUPTIONS INATTENTION

64. Privacy HIPPA Healthcare Insurance Privacy and Portability Act US Dept. of Health and Human Services PHI Protected Health Information