1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 15 Critical Thinking in Nursing Practice

2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Defined  Critical thinking is:  A continuous process characterized by open- mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant  Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions

3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study  Carla is a third year nursing student assigned to a surgical nursing unit. Mr. Javier Ramirez is a 55-year- old construction worker, admitted to the unit after falling off scaffolding on a construction site.  His x-ray films revealed a right fractured femur and right wrist fracture. An abdominal computed tomography (CT) scan shows bruising of the liver. Mr. Ramirez has not been hospitalized in the past. When he first meets Carla, he is very quiet and asks few questions.

4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Clinical Decisions in Nursing Practice  Clinical decision making requires critical thinking.  Clinical decision-making skills separate professional nurses from technical and ancillary staff.  Patients often have problems for which no textbook answers exist.  Nurses need to seek knowledge, act quickly, and make sound clinical decisions.

5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Skills InterpretationAnalysis InferenceEvaluation ExplanationSelf-regulation

6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Thinking and Learning  Learning is a lifelong process.  Intellectual and emotional growth involves learning new knowledge, as well as refining the ability to think, solve problems, and make judgments.  The science of nursing continues to grow. Nurses need to be flexible and open to new information.

7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Mr. Ramirez’s leg is in skeletal traction, and his right arm is in a soft cast. Carla decides that she needs to begin her care by assessing Mr. Ramirez and determining his health status.  She begins by reviewing his medical history. She learns that he has a history of smoking and was diagnosed with type 2 diabetes just 5 years ago.

8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Concepts for a Critical Thinker  Truth seeking  Open-mindedness  Analytic approach  Systematic approach  Self-confidence  Inquisitiveness  Maturity

9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Competencies Scientific methodProblem solving Decision making Diagnostic reasoning and inference Clinical decision making Nursing process as a competency

10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Five Components of Critical Thinking Knowledge base Experience Nursing process competencies Attitudes Standards

12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process  The nursing process is a five-step clinical decision-making approach: Assessment Diagnosis Planning Implementation Evaluation

13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Carla knows that Mr. Ramirez is likely to be in pain because he is reluctant to move and take part in any activity. Her options include conducting a thorough pain assessment and learning how Mr. Ramirez feels about his pain.  She must also be culturally sensitive and consider how Mr. Ramirez’s Hispanic heritage may influence his response to pain. Carla will then take what she learns and use pain control therapies that Mr. Ramirez will be likely to accept.

14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Attitudes a Nurse Needs Confidence Independence Fairness Responsibility Risk taking Discipline

15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Attitudes a Nurse Needs Perseverance Creativity Curiosity Integrity Humility

16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  When Carla notices that Mr. Ramirez is slow to respond to her questions, grimaces when shifting weight on his back, and is reluctant to have a bed bath, her critical thinking leads to the inference that Mr. Ramirez is in pain.  Carla decides to assess the situation more thoroughly by asking Mr. Ramirez specific questions about his comfort, such as, “Tell me if you are hurting,” “Show me where the pain is located,” and “Is this pain you have felt before?”

17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Before Carla begins her questions, she repositions Mr. Ramirez to make him more comfortable. As she does so, she observes an area of redness over his left heel. Redness could be due to inflammation or pressure on the skin. Carla palpates the area, noting that it is tender to touch and warm.  She asks Mr. Ramirez if he has been moving his leg much, and he says, “No, I haven’t. I am afraid I will hurt my other leg.” These initial findings imply that excess pressure is being applied to the heel.

18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 1. The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done A. Logically. B. Haphazardly. C. Independently. D. In a vacuum. Quick Quiz!

19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Carla gently applies pressure to the area with her finger and notes that after pressure is released, the area does not blanch or turn white, a key sign of excess pressure. She thinks about what she knows about normal skin integrity, the effect of immobility, and the effects of pressure on the skin. The information she collects leads her to determine that Mr. Ramirez has an early-stage pressure ulcer. The nursing diagnosis would be “Impaired skin integrity.”

20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Carla continues to gently encourage Mr. Ramirez to describe any symptoms or sensations that he is experiencing. He tells Carla that he does have pain in his stomach. Carla asks him to place his hand over the area of discomfort. Mr. Ramirez places his hand over the lower right quadrant of his abdomen.  On a scale of 0 to 10, Mr. Ramirez rates his pain at 7. Carla inspects the area more closely and palpates gently over the abdomen for the presence of tenderness. She notes that the abdomen feels very tight.

21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Developing Critical Thinking Skills Reflective Journaling: A tool used to clarify concepts through reflection by thinking back or recalling situations Concept Mapping: A visual representation of patient problems and interventions that illustrates an interrelationship

22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking and Delegation  Effective communication is needed between registered nurses (RNs) and nursing assistive personnel (NAP) for giving feedback and clarifying tasks and patient status.  When patients’ clinical conditions change, warranting attention by RNs, clear directions are necessary to avoid missed care.  Applying critical thinking can help an RN make the decision about when to appropriately delegate care.

23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Reflective Journaling The Circle of Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice. The Circle of Meaning model uses a series of questions to help you through a clinical experience and to find meaning.

24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Caring for Groups of Patients  Identify the nursing diagnoses and collaborative problems of each patient.  Decide which are most urgent.  Consider the time it will take to care for those patients.  Consider the resources that you have to manage each problem.  Consider how to involve the patients as participants in care.  Decide how to combine activities.  Decide which nursing care procedures to delegate.  Discuss complex cases with the health care team.

25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Meeting With Colleagues  When nurses have a formal means to discuss their experiences such as a staff meeting or a unit practice council, the dialogue allows for questions, differing viewpoints, and sharing of experiences.  When nurses are able to discuss their practices, the process validates good practice and offers challenges and constructive criticism.

26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Five-Step Nursing Process Model

27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Components of Critical Thinking in Nursing  I. Specific knowledge base in nursing  II. Experience  III. Critical thinking competencies  IV. Attitudes for critical thinking  V. Standards for critical thinking  A. Intellectual standards  B. Professional standards

28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 2. The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and A. Decision making. B. Problem solving. C. Intellectual standards. D. Critical thinking skills. Quick Quiz!

29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Synthesis of Critical Thinking With the Nursing Process Competency

30. 30Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Carla does what she can to position Mr. Ramirez more comfortably and makes sure his leg discomfort is under control. She knows that the increased pain and tightness he is experiencing suggest that something is causing pressure in the abdomen.  It could mean the patient is having bleeding from his bruised liver. Carla decides to call Mr. Ramirez’s physician immediately.

31. 31Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking Synthesis A reasoning process used to reflect on and analyze thoughts, actions, and knowledge Requires a desire to grow intellectually Requires the use of nursing process to make nursing care decisions