Critical Thinking in Nursing

1. Critical Thinking Problem Solving Clinical Reasoning Priority Setting Decision Making Critical Thinking in Nursing Lipe, S. K. & Beasley, S., (2004). Critical Thinking in Nursing: A cognitive skills workbook. Lippincott. Philadelphia, PA.

2. OBJECTIVES • Utilize critical thinking to develop treatment plan in both simulated and clinical situations. • Discuss the process of critically thinking. • Identify common errors in utilizing the critical thinking process.

3. OBJECTIVES • Discuss the characteristics of a critical thinker and standards commonly applied when critically thinking. • Explain how time management, client care needs/activities, multitasking, and nursing diagnoses are integral to the prioritizing processes.

4. OBJECTIVES • Prioritize nursing diagnoses using patient condition as the basis for decisions. • Formulate priorities for management and delivery of nursing care in various settings. • Apply critical thinking and prioritizing to client scenarios and NCLEX-style questions.

5. CRITICAL THINKING • Ennis – ‘reasonable, reflective thinking that is focused on deciding what to believe or do’ [Lipe & Beasley (Nosich, 2001, p.2)] • ‘Critical Thinking is goal directed; it is thinking with a purpose.’ (Lipe & Beasley, 2004, p. 3)

6. Problem Solving • Systematic approach resulting in formation of solutions Decision Making • Involves choosing from options • It is a step in the problem solving process

7. Characteristics of a Critical Thinker • Independent thinker • Questioning • Recognizes biases & assumptions • Observant • Organize/cluster data • Prioritizes • Open minded • Open to new ideas • Flexible-willing to change • Innovative, creative • Analytical • Communicator • Assertive • Knowledgeable • Resourceful • Intuitive • “Out of the box” thinker

8. Process of Critically Thinking

9. http://www.criticalthinking.org/CTmodel/CTModel1.cfm#

10. 6 Essential Cognitive Skills of Critical Thinking • Interpretation – ability to explain the meaning of information • Analysis – examine subjective and objective, advantages, disadvantages, and consequences • Evaluation – Is info source credible? Any bias? Is info relevant? • Inference – draw a conclusion based on info • Explanation – ability to explain one’s conclusions • Self-regulation – reflecting on our own thinking; Did I have all the facts? Are my assumptions correct/ incorrect?

11. Pitfalls in Critical Thinking • Illogical Process • Bias • Closed- mindedness

12. SCENARIO • Situation: Frank Fellow, a 72-year-old patient admitted for acute confusion presented in the emergency department (ED) with a history of hypertension, diabetes type 1, and arthritis. He lives in a single-family home with his wife. • The client is slightly confused and has an unsteady gait. He frequently forgets to use his walker and fails to call for assistance from the nursing staff when ambulating to the bathroom. • Interpretation - clarifying • Analysis - questioning • Outcomes – what do you expect? • Inference - conclusion • Self Regulation – what else?

13. INFLUENCING FACTORS • Emotions • Values • Perceptions • Social climate

14. Characteristics of an Effective Decision Maker • Self Confident • Assertive • Proactive • Flexibility • Knowledgeable • Ability to accept responsibility • Ability to focus • Priorities first Are these characteristics similar to the critical thinker?

15. Prioritizing • Time Management • Maslow Hierarchy of Needs • Prioritizing Nursing Diagnoses • Priority Activities • Multitasking • Nursing Process

16. The 34 yr. patient with cirrhosis is admitted for dehydration and needs a central line for high volume fluid replacement. Vital signs upon arrival on the unit at 2 pm were temp 99, pulse 102, r 24, b/p 90/60. The nurse has finished report and the physician is on the way to the unit to place a central line. Which nursing activity is the highest priority? A. Ensure consent signed B. Take the patient’s vital signs C. Notify the family D. Listen to breath sounds E. Assess urinary output

17. 16-year-old boy transported to the emergency department by ambulance following a MVA. Witnesses report his car slid on ice, and the vehicle became airborne, throwing the adolescent from his car. Initial assessment reveals that the patient has a patent airway, is responsive to painful stimuli, has a laceration to his left thigh that is covered with a dressing, and has contusions to the left flank area. Place the following activities in order of priority. ___Call the parents for consent to treat ___Immobilize head and neck ___Assess level of consciousness and neurologic deficits ___Assess left thigh and apply clean pressure dressing

18. PITFALLS IN PRIORITY SETTING • Inadequate Assessment and Evaluation of Client Needs • Failure to Differentiate Between Priority and Non-priority Tasks • Acceptance of Others’ Priorities Without Assessing All the Variables • Performance of Tasks with a “First Identified, First Completed” Approach • Completion of the Easiest Tasks First

19. The patient is resting quietly, breath sounds clear, respirations easy and unlabored, skin color pink. O2 @ 3 Liters, and O2 sat is 98%. After eating dinner , the patient rings the nurse. The nurse’s assessment reveals respirations are 30 breaths/min and labored, crackles are auscultated bilaterally, skin color dusky, and the SpO2 82%. What are you the nurse going to do?

20. The nurse intervenes by Elevating the head of the bed Applying prescried O2 through a nonrebreather Notify Physician … … …

21. CALLING THE PHYSICIAN • Change in status • Pain w/o ordered mgmt strategies • Lack of treatment orders • Lab values • Risk to safety

22. LAB VALUES • Do not consider lab values in isolation • Evaluate data and compared to patient’s clinical status • Compare to age, medical diagnosis, assessment data, physical status, physical orders, current treatment, previous labs

23. Failure to assess, monitor, and report… • negligence

24. 13. Which patient should the nurse see first? • A. a 40 yo 7 day postpartum female with bright red vaginal bleeding and a hgb of 7.0 g/dL. • B. A diabetic patient with a blood sugar of 400 mg/dL and no orders for insulin coverage. • C. A 46 yo ESRD patient who had an AV fistula placement 2 days ago. No thrill or bruit noted. • D. A 50 yo woman, 2 days after knee replacement. She refuses to use CPM machine due to pain

25. Client Care