Presentation on theme: "Chapter 15: Critical Thinking in Nursing Practice"— Presentation transcript:
1 Chapter 15: Critical Thinking in Nursing Practice
Bonnie M. Wivell, MS, RN, CNS
2 CRITICAL THINKINGCritical 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 existsAnalyzing information about the issueEvaluating informationMaking conclusions
3 Critical Thinking Requires…
Cognitive skillsAsk questionsRemain well-informedBe honest in facing personal biasesBe willing to reconsider and think clearly about issues
4 Attributes of a Critical Thinker
Asks pertinent questionsIs able to admit a lack of understanding or informationIs interested in finding new solutionsListens carefully to others and is able to give feedbackExamines problems closely
5 Critical Thinking Can Lead To…
Sound clinical decisionsUsing the Nursing Process to guide patient careEvidence-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 meaningConcept mapping – see other power point
8 Chapter 16: Nursing Assessment
9 Nursing Process (ADPIE)
11 AssessmentThe 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 dataPrimary source = patientSecondary source = family, medical recordAnalysis of data
12 Data Collection Subjective Objective Patient states
Observations or MeasurementsVitalsInspection of a wound
13 Methods of Data Collection
InterviewHelps clients relate their own interpretation and understanding of their conditionThree phasesOrientationBegin a relationshipUnderstand client’s primary needsWorkingGather information about the client’s health statusTermination
14 Methods of Data Collection Cont’d.
Nursing Health HistoryBiographical informationReason for seeking health careClient expectationsPresent illness or health concernsHealth historyFamily historyEnvironmental history (work, home, exposure)Psychosocial history (support system, coping skills)Spiritual healthReview of systemsDocumentation of findings
15 Putting It All Together
Physical examObserve client behaviorDiagnostic and laboratory dataInterpreting assessment data and making nursing judgmentsValidate data, ensure it isn’t an inferenceHolistic perspective for better clinical decision makingLeads to nursing diagnosis
16 Chapter 17: Nursing Diagnosis
17 Nursing DiagnosisClassifies health problems within the domain of nursingDOMAINA TERRITORY GOVERNED BY A SINGLE RULERA 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 fallsAtrial Fibrillation (A-fib)Pain
21 Establishing Priorities
Helps nurses to anticipate and sequence nursing interventionsClassification of priorities:High = if untreated may result in harmIntermediate = non-life threatening needsLow = not always directly related to specific illness or prognosis; affects the client’s future well-being
22 Potentials for Nursing Diagnosis
SafetyConfusionHistory of fallsSkin integrityImmobilityPainFractured hip
23 Building A Nursing Diagnosis
1. PROBLEM2. ETIOLOGY3. SYMPTOMS
24 PES P – At risk for impaired skin integrity E – Immobilization
PROBLEMP – At risk for impaired skin integrityRELATED TO (R/T)E – ImmobilizationAS 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 goalsMay 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
PATIENT CENTEREDOBSERVABLETIME LIMITEDREALISTIC
31 Establishing Goals and Expected Outcomes
A broad statement that describes the desired change in a client’s condition or behaviorExpected OutcomeMeasurable 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 Short-term Long-term
A specific and measurable behavior or response; “PATIENT WILL”Short-termAn objective behavior or response expected within hours to a weekLong-termAn objective behavior or response expected within days, weeks, or months
33 Goal StatementPATIENT’S SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION.
34 Goal Client Centered Observable? Time Limited Realistic?
Skin will remain intactObservable?YesTime LimitedDuring hospitalizationRealistic?
35 NIC/NOC Nursing Outcomes Classification
Published by the Iowa Intervention ProjectLinked to NANDA International nursing diagnosesNursing Interventions ClassificationThree levelsDomains: use broad terms to organize the more specific classes and interventionsClasses: 30 which offer useful clinical categories to refer to when selecting interventionsInterventions: 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 outcomesDirect = tx performed through interactions with clientIndirect = tx performed away from the client but on behalf of the client
38 Types of Interventions
Nurse InitiatedIndependentPhysician InitiatedDependentCollaborativeInterdependent
39 Planning Nursing CareDECIDE ON AN INTERVENTION TO PREVENT SKIN BREAKDOWN
40 Interventions Nursing Orders MD Orders Collaborative Orders
Reposition every two hoursSkin care to all boney prominences with repositioningRN skin assessment every shiftMD OrdersSpecific dressings/ointments to woundsCollaborative OrdersWound care consult
41 RationaleWhy did we choose maintaining skin integrity as a priority goal?Anticipate and prevent complicationsPrevent infectionResearch evidence in support of nursing interventionsCitationPotter, P.A. and Perry, A.G. (2009) p. 1279
42 Chapter 20: Evaluation
43 EvaluationYou conduct evaluative measures to determine if you met expected outcomes, not if nursing interventions were completedDid 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 progressesBased 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:InitialOngoingDischarge Planning
46 Chapter 24: Communication
47 Communication and Nursing Practice
Communication is a lifelong learning processFunctioning as a client advocate, nurses need to be assertiveThe intimate moment of connection that makes all the difference in the quality of care and meaning for the client and the nurseEffective 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 participantsEvery 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 individualInterpersonal = One-to-one interactionTranspersonal = Occurs within a person’s spiritual domain; prayer, meditation, guided reflection, religious ritualsSmall-Group = Occurs when a small number of persons meet togetherPublic = Interaction with an audience
50 Basic Elements of the Communication Process
Referent = refers to, object of conversationSender and Receiver = encodes and decodesMessages = content of the communicationChannels = means of conveying and receiving messages through sensesFeedback = the message the receiver returnsInterpersonal Variables = factors that influence communication; perceptionEnvironment = the setting for the interaction; needs to meet participant needs
51 Nonverbal Communication
Personal appearancePosture and gaitFacial expressionsEye contactGesturesSoundsTerritoriality and Personal space
52 Professional Nursing Relationships
Nurse-Client Helping RelationshipsNurse-Family RelationshipsNurse-Health Care Team RelationshipsNurse-Community Relationships
53 Elements of Professional Communication
Courtesy = hello, knockUse of names = convey respectTrustworthiness = without doubt or questionAutonomy and responsibility = self-directed and independentAssertiveness = express feelings and ideas without judging or hurting others
55 Communicating Clearly
Using SBAR facilitates accurate communication between:NURSES AND PHYSICIANSNURSES AND COLLEAGUESRecommended 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 medicationsMental 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 listeningSharing observationsSharing empathySharing hopeSharing humorSharing feelingsUsing touchUsing silenceClarifyingFocusingParaphrasingAsking relevant questionsSummarizingSelf disclosureConfrontation
62 Non-Therapeutic Communication
Asking personal questionsGiving personal opinionsChanging the subjectAutomatic responsesFalse reassuranceSympathyApproval or disapprovalDefensive responsesPassive or aggressive responsesArguing
63 Why Does Communication Break Down?
COMMUNICATION STYLESHIGH LEVEL OF ACTIVITYFREQUENT INTERUPTIONSINATTENTION
64 Privacy HIPPA PHI Healthcare Insurance Privacy and Portability Act
US Dept. of Health and Human ServicesPHIProtected Health Information
Presentation on theme: "Chapter 15 Critical Thinking in Nursing Practice"— Presentation transcript:
1 Chapter 15 Critical Thinking in Nursing Practice
Critical thinking is not a simple step-by-step linear process that is learned in a short period of time. Critical thinking is acquired through experience, commitment, and active curiosity. You will soon learn that critical thinking and the nursing process are interwoven. One does not exist without the other. When caring for clients and their family members, nurses need to think smart in order to make sensible judgments so the client can receive appropriate nursing care.
2 Clinical Decision in Nursing Practice
Clinical decision-making skills separate professional nurses from technical and ancillary staff.Clients have problems for which no textbook answers exist.Nurses need to seek knowledge, act quickly, and make sound clinical decisions.Critical thinking challenges you to think creatively, search for the answer, collect data, make inferences, and draw conclusions.
3 Critical Thinking Defined
Chaffee (2002)An active, organized, cognitive process used to carefully examine one’s thinking and the thinking of othersSettersten and Lauer (2004)Recognizing an issue exists, analyzing information, evaluating information, and making conclusionsThinking and learning are related processes. Nurses will use observations and judgments to make choices.You will always want to ask “why” and “how” when caring for clients.The use of evidence-based knowledge (Chapter 5) helps you become a critical thinker.Table 15-1 further discusses critical thinking skills.
4 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.In Chapter 1 we talked about the attributes of a profession. One of them was having a knowledge base. The science of nursing continues to grow. Nurses need to be flexible and open to new information.
5 Levels of Critical Thinking
Kataoka-Yahiro and Saylor (1994) Critical Thinking ModelBasic critical thinkingComplex critical thinkingCommitmentAt the basic level, students think concretely on the basis of a set of rules or principles, following a step-by-step process without deviation from the plan.Complex critical thinking analyzes and examines choices independently. Students learn to think beyond and synthesize knowledge.Commitment is the third level of critical thinking. Students (soon to be future nurses) anticipate needs and make choices without assistance from others.
6 Critical Thinking Competencies
Scientific methodProblem solvingDecision makingDiagnostic reasoning and inferenceClinical decision makingNursing process as a competencyThese critical thinking competencies are cognitive processes. Critical thinking processes are not unique to nursing, but are used in everyday life in many situations. These include scientific method, problem solving, and decision making.Specifically in nursing we use diagnostic reasoning and inference, clinical decision making, and nursing processes.
7 Critical Thinking Model for Decision Making
Models serve to explain concepts and help nurses make decisions and judgments about patients.Kataoka-Yahiro and Saylor (1994)Define the outcome of critical thinking as nursing judgment that is relevant to nursing problems in a variety of settings.
8 Five Components of Critical Thinking
Knowledge baseExperienceNursing process competenciesAttitudesStandardsBox 15-2 presents the components of critical thinking.A nurse’s knowledge base is drawn from nursing school education as well as from knowledge obtained from basic sciences, humanities, and behavioral science.Experience is obtained from clinical situations, actually working with clients and their families.The nursing process will be discussed specifically in the following chaptersChapter 16: AssessmentChapter 17: Nursing DiagnosisChapter 18: Planning for Nursing CareChapter 19: Implementing Nursing CareChapter 20: EvaluationThere are 11 attitudes a new nurse needs when thinking critically. Table 15-3 discusses these attitudes.Finally, there are two standards to consider when thinking critically: intellectual and professional. An intellectual standard is a guideline or principle for rationale thought. Professional standards refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility.
9 Critical Thinking Attitudes
Independence of thoughtFair-mindednessInsightIntellectual humility and suspension of judgmentCourageIntegrityPerseveranceConfidence in reasonInterest in explorationCuriosity
10 Developing Critical Thinking Skills
Reflective journalingA tool used to clarify concepts through reflection by thinking back or recalling situationsConcept mappingA visual representation of client problems and interventions that illustrates an interrelationshipWhen you use critical thinking, you need to connect knowledge and theory. This can be done through reflective journaling and concept mapping.
11 Critical Thinking Synthesis
A reasoning process used to reflect on and analyze thoughts, actions, and knowledgeRequires a desire to grow intellectuallyRequires the use of nursing process to make nursing care decisionsCritical thinking and the nursing process are inseparable. As a new nurse, you will rely on the nursing process to guide your practice. The next five chapters thoroughly discuss nursing process and application to client care.