chapter 15: critical thinking in nursing practice bonnie m. wivell, ms, rn, cns
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Chapter 15: Critical Chapter 15: Critical Thinking in Nursing Thinking in Nursing
PracticePractice
Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS
CRITICAL THINKINGCRITICAL THINKING
Critical thinking is an active, Critical thinking is an active, organized, cognitive process used to organized, cognitive process used to carefully examine one’s thinking and carefully examine one’s thinking and the thinking of others (Pg. 216)the thinking of others (Pg. 216) Recognize that an issue existsRecognize that an issue exists Analyzing information about the issueAnalyzing information about the issue Evaluating information Evaluating information Making conclusionsMaking conclusions
Critical Thinking Requires…Critical Thinking Requires…
Cognitive skillsCognitive skills Ask questionsAsk questions Remain well-informedRemain well-informed Be honest in facing personal biasesBe honest in facing personal biases Be willing to reconsider and think Be willing to reconsider and think
clearly about issuesclearly about issues
Attributes of a Critical Attributes of a Critical ThinkerThinker
Asks pertinent questionsAsks pertinent questions Is able to admit a lack of Is able to admit a lack of
understanding or informationunderstanding or information Is interested in finding new solutionsIs interested in finding new solutions Listens carefully to others and is able Listens carefully to others and is able
to give feedbackto give feedback Examines problems closelyExamines problems closely
Critical Thinking Can Lead Critical Thinking Can Lead To…To…
Sound clinical decisionsSound clinical decisions
Using the Nursing Process to guide Using the Nursing Process to guide patient carepatient care
Evidence-Based Practice (EBP)Evidence-Based Practice (EBP)
Nursing ProcessNursing Process
DefinitionDefinition The act of reviewing the patient’s The act of reviewing the patient’s
situation in order to obtain information situation in order to obtain information of past history, present status, and to of past history, present status, and to identify patient current and potential identify patient current and potential problems and needsproblems and needs
Developing Critical Thinking Developing Critical Thinking SkillsSkills
Reflection = the process of Reflection = the process of purposefully thinking back or purposefully thinking back or recalling a situation to discover its recalling a situation to discover its purpose or meaningpurpose or meaning
Concept mapping – see other power Concept mapping – see other power pointpoint
Chapter 16: Nursing Chapter 16: Nursing AssessmentAssessment
Nursing Process (ADPIE)Nursing Process (ADPIE) AAssessmentssessment
Nursing Nursing DDiagnosisiagnosis
PPlanninglanning
IImplementation/Interventionmplementation/Intervention
EEvaluationvaluation
AssessmentAssessment The deliberate and systematic collection The deliberate and systematic collection
of data to determine a client’s current of data to determine a client’s current and past health status and functional and past health status and functional status and to determine the client’s status and to determine the client’s present and past coping patterns.present and past coping patterns. Collection and verification of dataCollection and verification of data
Primary source = patientPrimary source = patient Secondary source = family, medical recordSecondary source = family, medical record
Analysis of dataAnalysis of data
Data CollectionData Collection
SubjectiveSubjective Patient statesPatient states
ObjectiveObjective Observations or MeasurementsObservations or Measurements
VitalsVitals Inspection of a woundInspection of a wound
Methods of Data CollectionMethods of Data Collection InterviewInterview
Helps clients relate their own interpretation Helps clients relate their own interpretation and understanding of their conditionand understanding of their condition
Three phasesThree phases Orientation Orientation
Begin a relationshipBegin a relationship Understand client’s primary needsUnderstand client’s primary needs
WorkingWorking Gather information about the client’s health statusGather information about the client’s health status
TerminationTermination
Methods of Data Collection Methods of Data Collection Cont’d.Cont’d.
Nursing Health HistoryNursing Health History Biographical informationBiographical information Reason for seeking health careReason for seeking health care Client expectationsClient expectations Present illness or health concernsPresent illness or health concerns Health historyHealth history Family historyFamily history Environmental history (work, home, exposure)Environmental history (work, home, exposure) Psychosocial history (support system, coping Psychosocial history (support system, coping
skills)skills) Spiritual healthSpiritual health Review of systemsReview of systems Documentation of findingsDocumentation of findings
Putting It All TogetherPutting It All Together Physical examPhysical exam Observe client behaviorObserve client behavior Diagnostic and laboratory dataDiagnostic and laboratory data Interpreting assessment data and making Interpreting assessment data and making
nursing judgmentsnursing judgments Validate data, ensure it isn’t an inferenceValidate data, ensure it isn’t an inference Holistic perspective for better clinical Holistic perspective for better clinical
decision makingdecision making Leads to nursing diagnosisLeads to nursing diagnosis
Chapter 17: Nursing Chapter 17: Nursing DiagnosisDiagnosis
Nursing DiagnosisNursing Diagnosis
Classifies health problems within the Classifies health problems within the domain of nursingdomain of nursing DOMAINDOMAIN
A TERRITORY GOVERNED BY A SINGLE A TERRITORY GOVERNED BY A SINGLE RULERRULER
A REALM OR RANGE OF PERSONAL A REALM OR RANGE OF PERSONAL KNOWLEDGE AND RESPONSIBILITYKNOWLEDGE AND RESPONSIBILITY
Nursing Diagnosis Cont’d.Nursing Diagnosis Cont’d.
A nursing diagnosis is a clinical A nursing diagnosis is a clinical judgment about individuals, families, judgment about individuals, families, or communities and their responses or communities and their responses to actual and/or potential health to actual and/or potential health problems or life processes (problems or life processes (Pg. 248)Pg. 248)
(NANDA International, 2007)(NANDA International, 2007)
Problem List Problem List
Fractured hip – In tractionFractured hip – In traction ConfusionConfusion Hypertension (HTN)Hypertension (HTN) Insulin Dependent Diabetes (IDDM)Insulin Dependent Diabetes (IDDM) History of fallsHistory of falls Atrial Fibrillation (A-fib)Atrial Fibrillation (A-fib) PainPain
TRACTIONTRACTION
Establishing PrioritiesEstablishing Priorities
Helps nurses to anticipate and Helps nurses to anticipate and sequence nursing interventions sequence nursing interventions
Classification of priorities:Classification of priorities: High = if untreated may result in harmHigh = if untreated may result in harm Intermediate = non-life threatening Intermediate = non-life threatening
needsneeds Low = not always directly related to Low = not always directly related to
specific illness or prognosis; affects the specific illness or prognosis; affects the client’s future well-beingclient’s future well-being
Potentials for Nursing Potentials for Nursing DiagnosisDiagnosis
SafetySafety ConfusionConfusion History of fallsHistory of falls
Skin integritySkin integrity ImmobilityImmobility
PainPain Fractured hipFractured hip
Building A Nursing DiagnosisBuilding A Nursing Diagnosis
11. . PROBLEMPROBLEM
2. 2. ETIOLOGYETIOLOGY
3. 3. SYMPTOMSSYMPTOMS
PESPES
PROBLEMPROBLEM
P –P – At risk for impaired skin integrityAt risk for impaired skin integrity
RELATED TO (R/T) RELATED TO (R/T)
E –E – ImmobilizationImmobilization
AS EVIDENCED BY (AEB)AS EVIDENCED BY (AEB)
S –S – Bedrest and tractionBedrest and traction
Nursing Diagnosis Nursing Diagnosis StatementStatement
POTENTIAL FOR SKIN BREAKDOWN POTENTIAL FOR SKIN BREAKDOWN RELATED TO IMMOBILITY AS RELATED TO IMMOBILITY AS EVIDENCED BY BEDREST AND EVIDENCED BY BEDREST AND TRACTIONTRACTION
Nursing Diagnosis Nursing Diagnosis StatementStatement
ANOTHER NURSING DIAGNOSIS ANOTHER NURSING DIAGNOSIS STATEMENT:STATEMENT:
PAIN RELATED TO FRACTURED HIP PAIN RELATED TO FRACTURED HIP AS EVIDENCED BY PATIENT STATES AS EVIDENCED BY PATIENT STATES PAIN LEVEL 8/10PAIN LEVEL 8/10
Chapter 18: Planning Chapter 18: Planning Nursing CareNursing Care
Goals and Outcomes Goals and Outcomes
States in terms of States in terms of PATIENTPATIENT goals and goals and outcomesoutcomes Not Not NURSINGNURSING goals goals
May be short, intermediate or long May be short, intermediate or long term (>one week)term (>one week)
Written using “S-M-A-R-T” acronymWritten using “S-M-A-R-T” acronym
S-M-A-R-TS-M-A-R-T Specific: Specific: What needs to be What needs to be
accomplished?accomplished? Measurable: Measurable: How will we know when How will we know when
the goal has been met?the goal has been met? Attainable: Attainable: Possible to meet goal with Possible to meet goal with
available resources.available resources. Realistic: Realistic: Patient must have the Patient must have the
capacity to meet the goal.capacity to meet the goal. Time-specific: Time-specific: When will the goal be When will the goal be
achieved?achieved?
Guidelines for Writing GoalsGuidelines for Writing Goals
PATIENT CENTEREDPATIENT CENTERED
OBSERVABLEOBSERVABLE
TIME LIMITEDTIME LIMITED
REALISTICREALISTIC
Establishing Goals and Establishing Goals and Expected OutcomesExpected Outcomes
GoalGoal A broad statement that describes the A broad statement that describes the
desired change in a client’s condition or desired change in a client’s condition or behaviorbehavior
Expected OutcomeExpected Outcome Measurable criteria to evaluate goal Measurable criteria to evaluate goal
achievement; a specific measurable achievement; a specific measurable change in a client’s status that you change in a client’s status that you expect to occur in response to nursing expect to occur in response to nursing carecare
GoalsGoals
Client-CenteredClient-Centered A specific and measurable behavior or A specific and measurable behavior or
response; “PATIENT WILL”response; “PATIENT WILL” Short-termShort-term
An objective behavior or response expected An objective behavior or response expected within hours to a weekwithin hours to a week
Long-termLong-term An objective behavior or response expected An objective behavior or response expected
within days, weeks, or monthswithin days, weeks, or months
Goal StatementGoal Statement
PATIENT’S SKIN WILL REMAIN INTACT PATIENT’S SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION. THROUGHOUT HOSPITALIZATION.
GoalGoal Client CenteredClient Centered
Skin will remain Skin will remain intactintact
Observable?Observable? YesYes
Time Limited Time Limited During During
hospitalizationhospitalization Realistic?Realistic?
YesYes
NIC/NOCNIC/NOC Nursing Outcomes ClassificationNursing Outcomes Classification
Published by the Iowa Intervention ProjectPublished by the Iowa Intervention Project Linked to NANDA International nursing Linked to NANDA International nursing
diagnosesdiagnoses Nursing Interventions ClassificationNursing Interventions Classification
Three levelsThree levels Domains: use broad terms to organize the more Domains: use broad terms to organize the more
specific classes and interventionsspecific classes and interventions Classes: 30 which offer useful clinical categories to Classes: 30 which offer useful clinical categories to
refer to when selecting interventionsrefer to when selecting interventions Interventions: 542 treatments based upon clinical Interventions: 542 treatments based upon clinical
judgment and knowledge that a nurse performs to judgment and knowledge that a nurse performs to enhance outcomesenhance outcomes
Chapter 19: Implementing Chapter 19: Implementing Nursing CareNursing Care
Nursing InterventionsNursing Interventions
Any treatment, based upon clinical Any treatment, based upon clinical judgment and knowledge, that a judgment and knowledge, that a nurse performs to enhance client nurse performs to enhance client outcomesoutcomes Direct = tx performed through Direct = tx performed through
interactions with clientinteractions with client Indirect = tx performed away from the Indirect = tx performed away from the
client but on behalf of the clientclient but on behalf of the client
Types of InterventionsTypes of Interventions
Nurse InitiatedNurse Initiated IndependentIndependent
Physician InitiatedPhysician Initiated DependentDependent
CollaborativeCollaborative InterdependentInterdependent
Planning Nursing CarePlanning Nursing Care
DECIDE ON AN INTERVENTION TO DECIDE ON AN INTERVENTION TO PREVENT SKIN BREAKDOWNPREVENT SKIN BREAKDOWN
InterventionsInterventions
Nursing OrdersNursing Orders Reposition every two hoursReposition every two hours Skin care to all boney prominences with Skin care to all boney prominences with
repositioningrepositioning RN skin assessment every shiftRN skin assessment every shift
MD OrdersMD Orders Specific dressings/ointments to woundsSpecific dressings/ointments to wounds
Collaborative OrdersCollaborative Orders Wound care consultWound care consult
RationaleRationale
Why did we choose maintaining skin Why did we choose maintaining skin integrity as a priority goal?integrity as a priority goal? Anticipate and prevent complicationsAnticipate and prevent complications Prevent infectionPrevent infection
Research evidence in support of Research evidence in support of nursing interventionsnursing interventions
CitationCitation Potter, P.A. and Perry, A.G. (2009) p. Potter, P.A. and Perry, A.G. (2009) p.
12791279
Chapter 20: EvaluationChapter 20: Evaluation
EvaluationEvaluation
You conduct evaluative measures to You conduct evaluative measures to determine if you met expected determine if you met expected outcomes, not if nursing outcomes, not if nursing interventions were completedinterventions were completed
Did you meet the expected Did you meet the expected goal/outcome?goal/outcome?
Evaluation is ongoing, as is the Evaluation is ongoing, as is the nursing processnursing process
The Nursing Process in The Nursing Process in Ongoing CareOngoing Care
Each care plan must evolve as the Each care plan must evolve as the patient progressespatient progresses
Based on evaluation (assessment), Based on evaluation (assessment), the nursing diagnoses, priorities, and the nursing diagnoses, priorities, and interventions will changeinterventions will change
Time Factor in Setting PrioritiesTime Factor in Setting Priorities
The planning of nursing care occurs The planning of nursing care occurs in three phases:in three phases: InitialInitial OngoingOngoing Discharge PlanningDischarge Planning
Chapter 24: Chapter 24: CommunicationCommunication
Communication and Nursing Communication and Nursing PracticePractice
Communication is a lifelong learning processCommunication is a lifelong learning process Functioning as a client advocate, nurses need Functioning as a client advocate, nurses need
to be assertiveto be assertive The intimate moment of connection that The intimate moment of connection that
makes all the difference in the quality of care makes all the difference in the quality of care and meaning for the client and the nurseand meaning for the client and the nurse
Effective communication helps maintain Effective communication helps maintain effective relationships and helps meet legal, effective relationships and helps meet legal, ethical, and clinical standards of careethical, and clinical standards of care
Communication and Communication and Interpersonal RelationshipsInterpersonal Relationships
Requires a sense of mutuality and a Requires a sense of mutuality and a belief that the nurse-client belief that the nurse-client relationship is a partnership and both relationship is a partnership and both are equal participantsare equal participants
Every nuance of posture, every small Every nuance of posture, every small expression and gesture, every word expression and gesture, every word chosen, and every attitude held all chosen, and every attitude held all have the potential to hurt or healhave the potential to hurt or heal
Levels of CommunicationLevels of Communication
Intrapersonal = Occurs within an individualIntrapersonal = Occurs within an individual Interpersonal = One-to-one interactionInterpersonal = One-to-one interaction Transpersonal = Occurs within a person’s Transpersonal = Occurs within a person’s
spiritual domain; prayer, meditation, spiritual domain; prayer, meditation, guided reflection, religious ritualsguided reflection, religious rituals
Small-Group = Occurs when a small Small-Group = Occurs when a small number of persons meet togethernumber of persons meet together
Public = Interaction with an audiencePublic = Interaction with an audience
Basic Elements of the Basic Elements of the Communication ProcessCommunication Process
Referent = refers to, object of conversationReferent = refers to, object of conversation Sender and Receiver = encodes and decodesSender and Receiver = encodes and decodes Messages = content of the communicationMessages = content of the communication Channels = means of conveying and Channels = means of conveying and
receiving messages through sensesreceiving messages through senses Feedback = the message the receiver Feedback = the message the receiver
returnsreturns Interpersonal Variables = factors that Interpersonal Variables = factors that
influence communication; perceptioninfluence communication; perception Environment = the setting for the Environment = the setting for the
interaction; needs to meet participant needsinteraction; needs to meet participant needs
Nonverbal CommunicationNonverbal Communication
Personal appearancePersonal appearance Posture and gaitPosture and gait Facial expressionsFacial expressions Eye contactEye contact GesturesGestures SoundsSounds Territoriality and Personal spaceTerritoriality and Personal space
Professional Nursing Professional Nursing RelationshipsRelationships
Nurse-Client Helping RelationshipsNurse-Client Helping Relationships Nurse-Family RelationshipsNurse-Family Relationships Nurse-Health Care Team Nurse-Health Care Team
RelationshipsRelationships Nurse-Community RelationshipsNurse-Community Relationships
Elements of Professional Elements of Professional CommunicationCommunication
Courtesy = hello, knockCourtesy = hello, knock Use of names = convey respectUse of names = convey respect Trustworthiness = without doubt or Trustworthiness = without doubt or
questionquestion Autonomy and responsibility = self-Autonomy and responsibility = self-
directed and independentdirected and independent Assertiveness = express feelings and Assertiveness = express feelings and
ideas without judging or hurting othersideas without judging or hurting others
SBARSBAR
SSituationituation BBackgroundackground AAssessmentssessment RRecommendationsecommendations
Communicating ClearlyCommunicating Clearly
Using SBAR facilitates accurate Using SBAR facilitates accurate communication between:communication between: NURSES AND PHYSICIANSNURSES AND PHYSICIANS NURSES AND COLLEAGUESNURSES AND COLLEAGUES
Recommended by Joint Commission Recommended by Joint Commission (JCAHO) and the Institute for (JCAHO) and the Institute for Healthcare Improvement (IHI)Healthcare Improvement (IHI)
SSituationituation
Identify selfIdentify self Where are you calling from?Where are you calling from? What is the patient’s name?What is the patient’s name? What is the problem?What is the problem?
BBackgroundackground
DiagnosisDiagnosis Pertinent information:Pertinent information:
Vital signs/Pulse oximetryVital signs/Pulse oximetry Current medicationsCurrent medications Mental statusMental status
AAssessmentssessment
Nurse’s assessment of the situationNurse’s assessment of the situation Could be …….Could be ……. Might be ……..Might be …….. I have no idea what is going on!I have no idea what is going on!
RRecommendationecommendation
Could I have an order for .…?Could I have an order for .…? Would you like to change ….?Would you like to change ….? I have tries XYZ without results. I have tries XYZ without results.
Could I ….?Could I ….?
Therapeutic CommunicationTherapeutic Communication
Specific responses that Specific responses that encourage the expression of encourage the expression of feelings and ideas and feelings and ideas and convey acceptance and convey acceptance and respectrespect
Components of Therapeutic Components of Therapeutic CommunicationCommunication
Active listeningActive listening Sharing Sharing
observationsobservations Sharing empathySharing empathy Sharing hopeSharing hope Sharing humorSharing humor Sharing feelingsSharing feelings Using touchUsing touch Using silenceUsing silence
ClarifyingClarifying FocusingFocusing ParaphrasingParaphrasing Asking relevant Asking relevant
questionsquestions SummarizingSummarizing Self disclosureSelf disclosure ConfrontationConfrontation
Non-Therapeutic Non-Therapeutic CommunicationCommunication
Asking personal Asking personal questionsquestions
Giving personal Giving personal opinionsopinions
Changing the Changing the subjectsubject
Automatic Automatic responsesresponses
False reassuranceFalse reassurance
SympathySympathy Approval or Approval or
disapprovaldisapproval Defensive Defensive
responsesresponses Passive or Passive or
aggressive aggressive responsesresponses
ArguingArguing
Why Does Communication Why Does Communication Break Down?Break Down?
COMMUNICATION STYLESCOMMUNICATION STYLES HIGH LEVEL OF ACTIVITYHIGH LEVEL OF ACTIVITY FREQUENT INTERUPTIONSFREQUENT INTERUPTIONS INATTENTION INATTENTION
PrivacyPrivacy
HIPPAHIPPA Healthcare Insurance Privacy and Healthcare Insurance Privacy and
Portability ActPortability Act US Dept. of Health and Human ServicesUS Dept. of Health and Human Services
PHI PHI Protected Health InformationProtected Health Information
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