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Chapter 15: Critical Thinking in Nursing Practice
Bonnie M. Wivell, MS, RN, CNS
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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
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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
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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
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Critical Thinking Can Lead To…
Sound clinical decisions Using the Nursing Process to guide patient care Evidence-Based Practice (EBP)
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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
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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
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Chapter 16: Nursing Assessment
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Nursing Process (ADPIE)
Assessment Nursing Diagnosis Planning Implementation/Intervention Evaluation
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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
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Data Collection Subjective Objective Patient states
Observations or Measurements Vitals Inspection of a wound
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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
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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
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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
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Chapter 17: Nursing Diagnosis
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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
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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)
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Problem List Fractured hip – In traction Confusion Hypertension (HTN)
Insulin Dependent Diabetes (IDDM) History of falls Atrial Fibrillation (A-fib) Pain
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TRACTION
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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
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Potentials for Nursing Diagnosis
Safety Confusion History of falls Skin integrity Immobility Pain Fractured hip
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Building A Nursing Diagnosis
1. PROBLEM 2. ETIOLOGY 3. SYMPTOMS
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PES P – At risk for impaired skin integrity E – Immobilization
PROBLEM P – At risk for impaired skin integrity RELATED TO (R/T) E – Immobilization AS EVIDENCED BY (AEB) S – Bedrest and traction
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Nursing Diagnosis Statement
POTENTIAL FOR SKIN BREAKDOWN RELATED TO IMMOBILITY AS EVIDENCED BY BEDREST AND TRACTION
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Nursing Diagnosis Statement
ANOTHER NURSING DIAGNOSIS STATEMENT: PAIN RELATED TO FRACTURED HIP AS EVIDENCED BY PATIENT STATES PAIN LEVEL 8/10
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Chapter 18: Planning Nursing Care
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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
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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?
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Guidelines for Writing Goals
PATIENT CENTERED OBSERVABLE TIME LIMITED REALISTIC
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Establishing Goals and Expected Outcomes
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
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Goals Client-Centered Short-term Long-term
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
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Goal Statement PATIENT’S SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION.
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Goal Client Centered Observable? Time Limited Realistic?
Skin will remain intact Observable? Yes Time Limited During hospitalization Realistic?
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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
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Chapter 19: Implementing Nursing Care
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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
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Types of Interventions
Nurse Initiated Independent Physician Initiated Dependent Collaborative Interdependent
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Planning Nursing Care DECIDE ON AN INTERVENTION TO PREVENT SKIN BREAKDOWN
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Interventions Nursing Orders MD Orders Collaborative 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
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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
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Chapter 20: Evaluation
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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
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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
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Time Factor in Setting Priorities
The planning of nursing care occurs in three phases: Initial Ongoing Discharge Planning
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Chapter 24: Communication
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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
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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
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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
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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
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Nonverbal Communication
Personal appearance Posture and gait Facial expressions Eye contact Gestures Sounds Territoriality and Personal space
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Professional Nursing Relationships
Nurse-Client Helping Relationships Nurse-Family Relationships Nurse-Health Care Team Relationships Nurse-Community Relationships
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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
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SBAR Situation Background Assessment Recommendations
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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)
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Situation Identify self Where are you calling from?
What is the patient’s name? What is the problem?
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Background Diagnosis Pertinent information: Vital signs/Pulse oximetry
Current medications Mental status
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Assessment Nurse’s assessment of the situation Could be …….
Might be …….. I have no idea what is going on!
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Recommendation Could I have an order for .…?
Would you like to change ….? I have tries XYZ without results Could I ….?
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Therapeutic Communication
Specific responses that encourage the expression of feelings and ideas and convey acceptance and respect
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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
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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
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Why Does Communication Break Down?
COMMUNICATION STYLES HIGH LEVEL OF ACTIVITY FREQUENT INTERUPTIONS INATTENTION
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Privacy HIPPA PHI Healthcare Insurance Privacy and Portability Act
US Dept. of Health and Human Services PHI Protected Health Information
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