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 ones
  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 patients 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

10
(No Transcript)
11
Assessment

• The deliberate and systematic collection of data
  to determine a clients current and past health
  status and functional status and to determine the
  clients 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 clients primary needs
• Working
• Gather information about the clients health
  status
• Termination

14
Methods of Data Collection Contd.

• 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 isnt 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 Contd.

• 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 clients 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 (gtone
  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 clients condition or behavior
• Expected Outcome
• Measurable criteria to evaluate goal achievement
  a specific measurable change in a clients 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

• PATIENTS 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 persons
  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 patients name?
• What is the problem?

57
Background

• Diagnosis
• Pertinent information
• Vital signs/Pulse oximetry
• Current medications
• Mental status

58
Assessment

• Nurses 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