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Critical Thinking in The Nursing Process. Separating the Professional from the Technical. Aspects of Critical Thinking. “the active, organized, cognitive process used to examine one’s own thinking and the thinking of others”
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Critical Thinking in The Nursing Process Separating the Professional from the Technical
Aspects of Critical Thinking • “the active, organized, cognitive process used to examine one’s own thinking and the thinking of others” • Using reflection, intuition, and previous experiences to make sound decisions • Requires a habit of asking questions, remaining well informed, a willingness to reconsider, and avoiding premature decision making
Components of Critical Thinking • Knowledge base • Theoretical • Experiential • Experience • Practice making decisions • Technical Skills & Competencies • Attitudes and behaviors
Critical Thinking Indicators R. Alfaro-LeFevre
Specific Critical Thinking in Nursing • The Nursing Process: a systematic problem solving approach consisting of; • Assessment • Diagnosis • Planning • Implementation • Evaluation • Nursing involves both thinking and doing • Nursing deals with complex issues
Synthesis of Critical Thinking & Nursing Process • Brings together • Critical thinking • Nursing process • Nursing knowledge • Patient situation
Step 1 of Nursing ProcessAssessment • Types of Assessment • Comprehensive • Focused • Special needs • Initial • Ongoing
Nursing Assessment • Types of Data • Subjective • Objective • Sources of Data • Primary data • Client • Secondary data • Family • Health Records • Health Team Members
Nursing Assessment • Methods of collection • Observation • Use all 5 senses • Physical assessment • Interview • Health history
Physical Assessment • Performed after nursing history • Collection of objective data • Ht., Wt., V.S. • General Survey • Head to toe exam • Inspection • Palpation • Percussion • Auscultation • Olfaction
Nursing Health History • Biographical Data • Reason for Seeking Health Care / Chief complaint • Client’s Expectations • History of Present Illness • Past Health History • Family History / social history • Medications • Review of body systems
Validating Data • To ensure data is • accurate • Complete • Factual • And you are not jumping to conclusions • When to validate • Subjective and objective data do not agree • Patient’s statements differ at different times • Data falls outside normal range
Organizing Data • Systematic • Usually controlled by agency forms • Body systems framework • Maslow’s Hierarchy of Needs • Gordon’s functional patterns • Orem’s Self care model • Roy Adaptation Model • NANDA nursing diagnosis Taxonomy II
Data Clustering • Organizing data into meaningful clusters • A set of signs or symptoms grouped together into logical order • Groupings of associations • Helps you recognize significant cues
Data Interpretation • Utilizes critical thinking to • Judge the value or significance of the data • Validate and verify assumptions with client and other health care team members
Step 2 of the Nursing ProcessNursing Diagnoses • Identify patterns in data and draw conclusions about client’s status • Describes client’s actual or potential response to a health problem • A statement of client health that nurses can identify, prevent, or treat independently • Stated in terms of unique human responses to diseases, injuries, or stressors • Must be accurate because it provides direction for nursing care
Types of Nursing Diagnoses • Actual (3-part statement) • Presently exists • Risk (2-part statement) • Likely to develop in vulnerable patient • Possible (2 or 3- part statement) • Suspect on intuition but don’t have enough data yet • Syndrome (1 part statement) • Collection of nursing diagnoses that occur together • Wellness (1-part statement) • Not a health problem, wants to move to higher level of wellness
Nursing Diagnosis Statement • Diagnostic Label (title or name) • Approved by NANDA • Related Factors • Etiology must be in nurses domain to intervene • Don’t use medical diagnoses • Defining Characteristics • Cues from assessment data • must support diagnosis • Eg. Impaired mobility R/T lack of peripheral sensation AEB inability to walk from bed to chair.
Sources of Diagnostic Error • Data collection • Omitted, incomplete, inaccurate, disorganized • Data analysis & interpretation • Inaccurate interpretation of cues, conflicting cues, incorrect judgments of inferences • Data clustering • Incorrectly clustered or not clustered at all • Diagnostic Statement • Problem & etiology must be in scope of nursing to treat
Avoiding Errors in Nursing Diagnoses • Identify client’s response not medical diagnosis • One symptom is insufficient for problem identification • Nursing interventions directed at correcting etiology of problem • Identify client response to equipment not the equipment itself • Client problems not nurse problems • Develop in cooperation with client
Medical Diagnosis vs. Nursing Diagnosis • Nursing diagnosis • Defines nursing needs of clients related to the medical diagnoses • Medical Diagnosis • Reflects specific disease, illness, or injury • Goal – prescribe treatment
Prioritizing Problems • Place in order of importance or urgency • Maslow’s Hierarchy of Human Needs • Physiological • Safety and security • Love and belonging • Self-esteem • Self-actualization • A,B,C’s • Nursing Process
Step 3 of the Nursing ProcessPlanning / Outcomes • Client centered goals / outcomes • Specific measurable objective • Are precise, descriptive, clearly stated • Reflects highest level of wellness • Should be realistic • Observable client behavior • Measurable criteria for each goal • Projected time frame for goal achievement • Provide a guide for selecting interventions • Short term goals • Achieve in hours or days, less than 1 week • Long term goals • Achieved over weeks or months
Properly Written Expected Outcomes • Subject • The client • Action verb • Action that will be performed by client • Performance criteria • Specific measurement to be evaluated • Target time • When action should be achieved • Special conditions • Amt. of assistance, what equipment, resources needed
7 Guidelines for Writing Goals/Outcomes • Client centered… • Singular factors/ criteria… • Observable factors… • Measurable factors… • Time limited factors… • Mutual factors… • Realistic factors…
Purpose of Care Plans • Serves as Written guidelines for client care • Communicates care • Enhances continuity • Organizes information – promotes efficiency • Involves client and family • Meets requirements of accrediting agencies • Care plans help students learn problem solving, skills of written communication, organizational skills, and application of theory
Step 4 of the Nursing ProcessPlanning Nursing Interventions • AKA Nursing • Actions • Measures • Strategies • Activities • Actions based on clinical nursing judgment and knowledge that nurses perform to achieve client outcomes • Include activities of observation/assessment, prevention, treatment, & health promotion
3 Types of Interventions • Independent • Nurse initiated interventions • In realm of independent nursing practice • No MD order required • Dependent • Physician initiated interventions • Require MD orders • Collaborative (interdependent) interventions • Coordination of multiple professionals
Interventions • Include activities of • Observation/assessment • Prevention • Therapeutic Treatments • Health promotion • Activities of daily living • Teaching • Discharge planning • Flow from Client goals/outcomes / orders • Individualize standardized interventions
Nursing Orders • Instructions on care plan describing implementation of interventions • Include • Date • Subject • Action verb • Times and limits • Signature • Standing Orders • Protocols • Critical Pathways • Evidence Based Practice
Errors in Writing Nursing Interventions • Nursing action nonspecific • Fail to indicate frequency • Fail to indicate quantity • Fail to indicate method • Fail to indicate person to perform
5th step of Nursing ProcessImplementation & Evaluation • Implementation • The action phase of the nursing process • You will perform or delegate planned interventions • Implementation ends when you record the nursing actions on chart • Evolves into evaluation as you record resulting client responses
Preparing for Implementation • Check your knowledge and abilities • Organize your work • Prepare the patient • Implement the plan • Coordinate/collaborate • Delegate appropriately • Right task • Right circumstance • Right person • Right directions / communication • Right supervision
The final stepEvaluation • Planned • Ongoing • Does not end the nursing process • Systematic • Make judgments about • Client’s progress toward expected outcomes/goals • Effectiveness of nursing care plan • Quality of nursing care delivered
Types of Evaluation • Ongoing evaluation • At each contact with patient • Intermittent evaluation • At outcome evaluation specified times • Terminal evaluation • At time of discharge
Evaluating Patient Progress • Review Outcomes • Collect Reassessment Data • Judge Goal Achievement • Achieved (met) • Partially achieved (partially met) • Not achieved (unmet) • Record evaluative statement • Revise care plan if indicated • Begin with assessment data and go through entire nursing process
Documentation • Written evidence of interactions • Health professionals • Clients • Families • Health care organizations • Diagnostic tests • Treatments • Education • Client results/responses
Documentation Guidelines • Correct client record • Client name on each page • Document immediately • Date and time each entry • Sign each entry with name and professional credentials • No space between entries • Never change another’s entry • Use “quotes” for client statements • Chronological order
Elements of Documentation • Use appropriate vocabulary / terminology • Only approved abbreviations / symbols • Use organized and logical sequence • State only factual not inferences • Use correct spelling, legible writing • Protect client confidentiality by not releasing records to anyone without patient permission • Write neatly, legibly, & in ink • Use concrete specific terms • Follow agency guidelines
Documentation Methods • Source-Oriented Records • Separate sections for each discipline • Problem-Oriented Records • Consists of database, problem list, plan of care, & progress notes
Types of Charting • Narrative • SOAP • PIE • Focus • Charting by exception • Computerized