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Chapter 15: Critical Thinking in Nursing Practice

Bonnie M. Wivell, MS, RN, CNS

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

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

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

Critical Thinking Can Lead To

Sound clinical decisions


Using the Nursing Process to guide patient care

Evidence-Based Practice (EBP)

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

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

Chapter 16: Nursing Assessment

Nursing Process (ADPIE)

Assessment Nursing Diagnosis Planning

Implementation/Intervention
Evaluation

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

Data Collection

Subjective

Patient states Observations or Measurements


Vitals Inspection of a wound

Objective

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 Gather information about the clients health status

Working

Termination

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

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

Chapter 17: Nursing Diagnosis

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

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)

Problem List

Fractured hip In traction Confusion Hypertension (HTN) Insulin Dependent Diabetes (IDDM) History of falls Atrial Fibrillation (A-fib) Pain

TRACTION

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

Potentials for Nursing Diagnosis

Safety

Confusion History of falls Immobility

Skin integrity

Pain

Fractured hip

Building A Nursing Diagnosis

1. PROBLEM 2. ETIOLOGY 3. SYMPTOMS

PES
PROBLEM

P At risk for impaired skin integrity


RELATED TO (R/T)

E Immobilization
AS EVIDENCED BY (AEB)

S Bedrest and traction

Nursing Diagnosis Statement

POTENTIAL FOR SKIN BREAKDOWN RELATED TO IMMOBILITY AS EVIDENCED BY BEDREST AND TRACTION

Nursing Diagnosis Statement

ANOTHER NURSING DIAGNOSIS STATEMENT:


PAIN RELATED TO FRACTURED HIP AS EVIDENCED BY PATIENT STATES PAIN LEVEL 8/10

Chapter 18: Planning Nursing Care

Goals and Outcomes

States in terms of PATIENT goals and outcomes

Not NURSING goals

May be short, intermediate or long term (>one week) Written using S-M-A-R-T acronym

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?

Guidelines for Writing Goals


PATIENT CENTERED

OBSERVABLE
TIME LIMITED REALISTIC

Establishing Goals and Expected Outcomes

Goal

A broad statement that describes the desired change in a clients condition or behavior Measurable criteria to evaluate goal achievement; a specific measurable change in a clients status that you expect to occur in response to nursing care

Expected Outcome

Goals

Client-Centered

A specific and measurable behavior or response; PATIENT WILL An objective behavior or response expected within hours to a week An objective behavior or response expected within days, weeks, or months

Short-term

Long-term

Goal Statement

PATIENTS SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION.

Goal

Client Centered

Skin will remain intact

Observable?

Yes
During hospitalization Yes

Time Limited

Realistic?

NIC/NOC

Nursing Outcomes Classification

Published by the Iowa Intervention Project Linked to NANDA International nursing diagnoses Three levels

Nursing Interventions Classification

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

Chapter 19: Implementing Nursing Care

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

Types of Interventions

Nurse Initiated

Independent Dependent Interdependent

Physician Initiated

Collaborative

Planning Nursing Care

DECIDE ON AN INTERVENTION TO PREVENT SKIN BREAKDOWN

Interventions

Nursing Orders

Reposition every two hours Skin care to all boney prominences with repositioning RN skin assessment every shift Specific dressings/ointments to wounds Wound care consult

MD Orders

Collaborative Orders

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

Chapter 20: Evaluation

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

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

Time Factor in Setting Priorities

The planning of nursing care occurs in three phases:

Initial Ongoing Discharge Planning

Chapter 24: Communication

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

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

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

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

Nonverbal Communication

Personal appearance Posture and gait Facial expressions Eye contact Gestures Sounds Territoriality and Personal space

Professional Nursing Relationships

Nurse-Client Helping Relationships Nurse-Family Relationships Nurse-Health Care Team Relationships Nurse-Community Relationships

Elements of Professional Communication

Courtesy = hello, knock Use of names = convey respect Trustworthiness = without doubt or question Autonomy and responsibility = selfdirected and independent Assertiveness = express feelings and ideas without judging or hurting others

SBAR
Situation
Background

Assessment
Recommendations

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)

Situation

Identify self Where are you calling from? What is the patients name? What is the problem?

Background

Diagnosis Pertinent information:


Vital signs/Pulse oximetry Current medications Mental status

Assessment

Nurses assessment of the situation


Could be . Might be .. I have no idea what is going on!

Recommendation

Could I have an order for .? Would you like to change .? I have tries XYZ without results. Could I .?

Therapeutic Communication
Specific

responses that encourage the expression of feelings and ideas and convey acceptance and respect

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

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

Why Does Communication Break Down?


COMMUNICATION STYLES HIGH LEVEL OF ACTIVITY FREQUENT INTERUPTIONS INATTENTION

Privacy

HIPPA

Healthcare Insurance Privacy and Portability Act

US Dept. of Health and Human Services

PHI

Protected Health Information