Transcript Chapter 15: Critical Thinking in Nursing Practice

Chapter 15: Critical Thinking
in Nursing Practice
Bonnie M. Wivell, MS, RN, CNS
CRITICAL THINKING
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Critical thinking is an active, organized,
cognitive process used to carefully
examine one’s thinking and the thinking of
others (Pg. 216)
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Recognize that an issue exists
Analyzing information about the issue
Evaluating information
Making conclusions
Critical Thinking Requires…
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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
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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…
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Sound clinical decisions
Using the Nursing Process to guide patient
care
Evidence-Based Practice (EBP)
Nursing Process
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Definition
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The act of reviewing the patient’s 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
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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)
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Assessment
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Nursing Diagnosis
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Planning
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Implementation/Intervention
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Evaluation
Assessment
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The deliberate and systematic collection of
data to determine a client’s current and
past health status and functional status
and to determine the client’s present and
past coping patterns.
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Collection and verification of data
Primary source = patient
 Secondary source = family, medical record
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Analysis of data
Data Collection
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Subjective
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Patient states
Objective
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Observations or Measurements
Vitals
 Inspection of a wound
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Methods of Data Collection
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Interview
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Helps clients relate their own interpretation
and understanding of their condition
Three phases
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Orientation
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Working
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Begin a relationship
Understand client’s primary needs
Gather information about the client’s health status
Termination
Methods of Data Collection Cont’d.
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Nursing Health History
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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
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Physical exam
Observe client behavior
Diagnostic and laboratory data
Interpreting assessment data and making
nursing judgments
Validate data, ensure it isn’t an inference
Holistic perspective for better clinical decision
making
Leads to nursing diagnosis
Chapter 17: Nursing Diagnosis
Nursing Diagnosis
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Classifies health problems within the
domain of nursing
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DOMAIN
A TERRITORY GOVERNED BY A SINGLE RULER
 A REALM OR RANGE OF PERSONAL KNOWLEDGE
AND RESPONSIBILITY
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Nursing Diagnosis Cont’d.
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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
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Fractured hip – In traction
Confusion
Hypertension (HTN)
Insulin Dependent Diabetes (IDDM)
History of falls
Atrial Fibrillation (A-fib)
Pain
TRACTION
Establishing Priorities
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Helps nurses to anticipate and sequence
nursing interventions
Classification of priorities:
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High = if untreated may result in harm
Intermediate = non-life threatening needs
Low = not always directly related to specific
illness or prognosis; affects the client’s future
well-being
Potentials for Nursing Diagnosis
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Safety
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Skin integrity
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Confusion
History of falls
Immobility
Pain
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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
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POTENTIAL FOR SKIN BREAKDOWN
RELATED TO IMMOBILITY AS EVIDENCED
BY BEDREST AND TRACTION
Nursing Diagnosis Statement
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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
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States in terms of PATIENT goals and
outcomes
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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
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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
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Goal
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A broad statement that describes the desired
change in a client’s condition or behavior
Expected Outcome
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Measurable criteria to evaluate goal
achievement; a specific measurable change in
a client’s status that you expect to occur in
response to nursing care
Goals
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Client-Centered
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Short-term
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A specific and measurable behavior or response;
“PATIENT WILL”
An objective behavior or response expected within
hours to a week
Long-term
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An objective behavior or response expected within
days, weeks, or months
Goal Statement
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PATIENT’S SKIN WILL REMAIN INTACT
THROUGHOUT HOSPITALIZATION.
Goal
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Client Centered
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Observable?
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Yes
Time Limited
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Skin will remain intact
During hospitalization
Realistic?
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Yes
NIC/NOC
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Nursing Outcomes Classification
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Published by the Iowa Intervention Project
Linked to NANDA International nursing diagnoses
Nursing Interventions Classification
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Three levels
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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
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Any treatment, based upon clinical
judgment and knowledge, that a nurse
performs to enhance client outcomes
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Direct = tx performed through interactions
with client
Indirect = tx performed away from the client
but on behalf of the client
Types of Interventions
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Nurse Initiated
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Physician Initiated
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Independent
Dependent
Collaborative
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Interdependent
Planning Nursing Care
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DECIDE ON AN INTERVENTION TO
PREVENT SKIN BREAKDOWN
Interventions
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Nursing Orders
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MD Orders
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Reposition every two hours
Skin care to all boney prominences with repositioning
RN skin assessment every shift
Specific dressings/ointments to wounds
Collaborative Orders
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Wound care consult
Rationale
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Why did we choose maintaining skin
integrity as a priority goal?
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Anticipate and prevent complications
Prevent infection
Research evidence in support of nursing
interventions
Citation
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Potter, P.A. and Perry, A.G. (2009) p. 1279
Chapter 20: Evaluation
Evaluation
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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
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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
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The planning of nursing care occurs in
three phases:
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Initial
Ongoing
Discharge Planning
Chapter 24: Communication
Communication and Nursing
Practice
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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
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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
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Intrapersonal = Occurs within an individual
Interpersonal = One-to-one interaction
Transpersonal = Occurs within a person’s
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
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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
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Personal appearance
Posture and gait
Facial expressions
Eye contact
Gestures
Sounds
Territoriality and Personal space
Professional Nursing Relationships
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Nurse-Client Helping Relationships
Nurse-Family Relationships
Nurse-Health Care Team Relationships
Nurse-Community Relationships
Elements of Professional
Communication
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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
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Using SBAR facilitates accurate
communication between:
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NURSES AND PHYSICIANS
NURSES AND COLLEAGUES
Recommended by Joint Commission
(JCAHO) and the Institute for Healthcare
Improvement (IHI)
Situation
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Identify self
Where are you calling from?
What is the patient’s name?
What is the problem?
Background
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Diagnosis
Pertinent information:
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Vital signs/Pulse oximetry
Current medications
Mental status
Assessment
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Nurse’s assessment of the situation
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Could be …….
Might be ……..
I have no idea what is going on!
Recommendation
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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
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Active listening
Sharing observations
Sharing empathy
Sharing hope
Sharing humor
Sharing feelings
Using touch
Using silence
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Clarifying
Focusing
Paraphrasing
Asking relevant
questions
Summarizing
Self disclosure
Confrontation
Non-Therapeutic Communication
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Asking personal
questions
Giving personal
opinions
Changing the subject
Automatic responses
False reassurance
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Sympathy
Approval or
disapproval
Defensive responses
Passive or aggressive
responses
Arguing
Why Does Communication Break
Down?
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COMMUNICATION STYLES
HIGH LEVEL OF ACTIVITY
FREQUENT INTERUPTIONS
INATTENTION
Privacy
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HIPPA
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Healthcare Insurance Privacy and Portability
Act
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US Dept. of Health and Human Services
PHI
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Protected Health Information