Critical Thinking Skills for Nurses

1. Critical Thinking Skills for Nurses Develop your Problem Solving Skills! Kindred Hospital Louisville Shannon Ash, RN, BSN

2. Objectives 1. Define critical thinking. 2. Identify critical thinking tools to use in nursing practice. 3. Explain how to integrate the nursing process with critical thinking. 4. Apply critical thinking processes to solve patient care situations.

3. What IS Critical Thinking? • Critical thinking can be defined several ways. One definition is “an active, organized, cognitive process”. • Another definition is “a process for identifying underlying assumptions and variables in order to draw conclusions and make decisions”. • You could even use the definition “a process used to explore alternatives to determine what is important”.

4. What IS Critical Thinking? • No matter which definition you choose, critical thinking involves the use of several concepts, including: exploring, analyzing, prioritizing, explaining, deciding, andevaluating to identify solutions and determine a course of action to solve patient care problems.

5. What IS Critical Thinking? • Exploring encourages you to identify all the variables within a situation. • Analyzing is the process of studying each variable to understand its meaning and its relationship to the other variables. • Prioritizing requires you to weigh the relative importance of each variable to the others, at a given point in time.

6. What IS Critical Thinking? • Explaining the variables involves the exercise of amplifying each variable to understand its meaning in the situation and to the involved parties. • Decidingmeans to choose a specific course of action. • Evaluating requires the thinker to assess how correct the thinking process was, and if further action is needed.

7. Exercise # 1 • Mrs. Vernon, a 67-year old patient who suffers from COPD has been admitted to your unit from another facility. Upon admission you note her to be alert, oriented and appropriate. She provides you with information to complete her history. After completing & charting your assessment, you leave her to see to your other patients. An hour later when you return, you note that Mrs. Vernon does not seem as alert, and appears to be confused. On each of the 5 components of critical thinking, write down what could be going on with your patient.

8. Mrs. Vernon • Exploring: what could be causing this previously alert woman to be so suddenly confused? • Hypoxia • Hypotension • Fatigue • Infection • Medications • Unfamiliar Surroundings • Stroke

9. Mrs. Vernon • Analyzing: what other information can I gather to help me narrow down the possible causes of her confusion? • Vital Signs • Oxygen Saturation/ ABG • Medications taken & last dose time • Further assessment of confusion level • Previous history of confusion? • Potential infection sites & their appearance

10. Mrs. Vernon • Prioritizing/Deciding: is this change significant to this patient, and do I need to even look further? This also includes the decision that is made whether to inform the physician of the change in their patient’s status.What would you say? • Considering that Mrs. Vernon is a new patient, and that this is a sudden change, it is potentially clinically significant, and should be investigated thoroughly, and reported to the Physician right away.

11. Mrs. Vernon • Evaluating:after reporting the alteration to the patient’s Physician, he orders the following: • STAT ABG & STAT Portable CXR • Blood Cultures • Urine & Sputum Cultures • Head CT in the morning if confusion doesn’t resolve • Discontinue all medications that could cause confusion • At this point, the Physician’s orders indicate to you that he is thinking along the same lines as you did, and your thinking process was complete

12. Mrs. Vernon • Now the next time you have a patient who suddenly presents with confusion, you have a “history” with that experience, and have a knowledge base to draw from.

13. Other Concepts • The other concepts of deciding and evaluating also take part in your assessment of the situation! • As you started this exercise, and every critical thinking episode, you start with your existing knowledge base. Each time you are faced with a new situation, you identify from it what you already know.

14. Tools for Critical Thinking • Ask questions! Sometimes people hesitate to ask questions because they fear that asking a question may be interpreted as a lack of knowledge on their part. However, the question is a key element of critical thinking. • Questions serve many purposes, and only serve to broaden your knowledge base, and expand your options.

15. Why Question? • Questioning begins the information-seeking process. • All questioning is about seeking information, re-formulating information to new situations, and solving nursing practice dilemmas. • Can you think of some other examples of information seeking that you do?

16. Information Seeking • Some examples of information seeking: • Looking up lab values • Reviewing a policy or procedure • Reading instructions about how to operate a piece of equipment • Reviewing a patient’s chart • Asking a co-worker or resource person.

17. Exercise #2 • Mrs. Riley, a 45-year old wife and mother, has just returned to your nursing unit from the recovery room after a gastric resection for a malignant stomach tumor. She has orders for respiratory care, pain medication, continuous gastric suction, incision monitoring, and NPO status. Eight hours postoperatively she develops sudden dyspnea and decreasing oxygen saturations. On each of the 5 components of critical thinking, write down what could be going on with your patient.

18. Mrs. Riley • Exploring: what could be causing this woman to be so suddenly dyspneic and hypoxic? • Pneumothorax • Hemothorax • Pneumonia • Pleural Effusions • Atelectasis • Electrolyte Disorders

19. Mrs. Riley • Analyzing: what other information can I gather to help me narrow down the possible causes of her dyspnea/hypoxia? • Breath Sounds • ABG • Blood Chemistry • After listening to her breath sounds, you determine that breath sounds are absent on the left side.

20. Mrs. Riley • Prioritizing/Deciding: is this change significant to this patient, and do I need to even look further? This also includes the decision that is made whether to inform the physician of the change in their patient’s status.What would you say? • Any significant change in a patient’s respiratory status should be reported to the patient’s physician right away.

21. Mrs. Riley • Evaluating:after reporting the alteration to the patient’s Physician, he orders the following: • STAT ABG & STAT Portable CXR • Equipment for chest tube insertion to be at bedside STAT • When the chest x-ray comes back, there is a large pneumothorax on the left, as well as diffuse atelectasis. Anesthesia is called to place a chest tube STAT. Your analysis was right on target!

22. Mrs. Riley • Once the chest tube was placed, Mrs. Riley had an immediate improvement of her oxygen saturations, and her dyspnea resolved. Now a new set of critical thinking is demanded of you. How does this chest tube change the care & assessments you will provide for Mrs. Riley?

23. It’s no accident... • It’s no accident that the nursing process mirrors a lot of the critical thinking process. They are both processes developed to gather information, look ahead, plan, and evaluate processes. • Looking at the two, side-by-side really illustrates that example.

24. Side-by-Side

25. Exercise #3 • Mr. Harris is your patient. He is a 18 year old young man thrown from the van in which he was riding, when it was hit head on by an oncoming car. He is unconscious and has a cervical fracture. He has no movement of his extremities. Suddenly during the middle of the night, his legs begin to move. On each of the 5 components of critical thinking, write down what could be going on with your patient.

26. Mr. Harris • Exploring: what could be causing the movement in Mr. Harris’ legs? • Spinal Reflexes • Purposeful movement • Muscular spasms

27. Mr. Harris • Analyzing: what other information can I gather to help me narrow down the possible causes of his movement? • Are the movements purposeful? • Can the movements be duplicated? • How much movement is possible? • Does the patient report any changes in sensation?

28. Mr. Harris • Prioritizing/Deciding: is this change significant to this patient, and do I need to even look further? This also includes the decision that is made whether to inform the physician of the change in their patient’s status.What would you say? • With the patient having a stable overall status, it would most likely be best to report this to the physician first thing in the morning.

29. Mr. Harris • Evaluating:after reporting the alteration to the patient’s Physician, he orders the following: • Spine CT • Neurological Consult • Every 4 hour neurological checks • At this point, the Physician’s orders indicate to you that he is thinking along the same lines as you did, and your thinking process was complete

30. Critical Thinking • Critical thinking is essential in nursing practice. Critical thinking applies to nearly every aspect of your patient care and patient assessment. • The sharper your skills are, the better care you provide for your patients. • Developing your problem-solving skills also help you to provide a high level of patient care.

31. Exercise #4 • You’re doing a routine reassessment on your patient, Mr. Fisher. You notice that his vital signs are as follows: • Temp: 99.9 • Pulse: 144 • Resp: 26 • BP: 90/42 • None of these values are within Mr. Fisher’s normal range. What are you thinking could be going on? Write down everything that comes to mind.

32. What to consider? • Did you consider that there may be an underlying infection, causing the elevated temperature, heart rate, and decreased blood pressure? • Or is the elevated heart rate the reason for the low blood pressure? • The limited information you have should make you want to get more information, to help solve the problem.

33. Assessment • You determine that these vital signs warrant further assessment of his condition. • What questions do you want to answer with your reassessment? • Write down your answers now.

34. What potential routes for infection does he have? An IV, a foley catheter, a G-tube, a surgical site, a wound? How do these areas look? What are his lung sounds like? Is his heart rate regular or irregular? What medications is he on? What is his fluid volume status? What are his I & O’s like? Is he diaphoretic? Does he complain of pain? What color is his urine? I wanna know...

35. Consider the Causes... • First, you used your previous knowledge to identify which of the vital sign values were abnormal. • Then, you gathered potential reasons for those abnormalities based on the individual patient, and decided to look for the information from your assessment to find out if one of those potential reasons could have been the cause.

36. Could it be? • What were some of the potential causes? • Infection • Dehydration • Heart Problem • Pain • By searching for more information, you could narrow down the potential causes!

37. Essential Components • Another essential component of the decision making process, is the consideration of determining if the problem is important. • For a patient whose urine output is normally 150cc/hr, is a drop of urine output to 135cc/hr for 2 hours important? Probably not.

38. Essential Components • Weigh that against a scenario of a patient who usually has a normal urine output and who suddenly has no urine output from his foley catheter for 8 hours. Is that important? Absolutely! • With the above scenario, what are some things you would want to check right away in that patient? What would you want to do? Write down your answers.

39. Remember • Always keep in mind that any affect on one system is going to affect another system! • A sudden drop in urine output could be the result of acute kidney failure; dehydration; bladder or catheter obstruction; disease, etc. • Other findings from your assessment may help you determine which of these situations apply!

40. Practice , Practice, Practice • Remember that with practice, your problem-solving and critical thinking skills will get better and better. • Next time you have a problem, take a minute, sit down, use the critical thinking tools presented here to help gather more information & apply what you already know to help solve your problem!