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Chapter 15: Critical Thinking in Nursing Practice

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Chapter 15: Critical Thinking in Nursing Practice Bonnie M. Wivell, MS, RN, CNS Critical Thinking Requires Cognitive skills Ask questions Remain well-informed Be ... – PowerPoint PPT presentation

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Title: 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
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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
PATIENT CENTERED
OBSERVABLE
TIME LIMITED
REALISTIC
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
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