Transcript Critical Thinking Skills for Nurses

Critical Thinking Skills for Nurses
Develop your Problem Solving Skills!
Kindred Hospital Louisville
Shannon Ash, RN, BSN
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.
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”.
What IS Critical Thinking?
• No matter which definition you choose,
critical thinking involves the use of
several concepts, including:
exploring, analyzing, prioritizing,
explaining, deciding, and
evaluating to identify solutions and
determine a course of action to solve
patient care problems.
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.
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.
• Deciding means 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.
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.
Mrs. Vernon
• Exploring: what could be causing this
previously alert woman to be so suddenly
confused?
• Hypoxia
• Hypotension
• Fatigue
• Infection
• Medications
• Unfamiliar Surroundings
• Stroke
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
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.
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
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.
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.
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.
Why Question?
• Questioning begins the informationseeking 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?
Information Seeking
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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.
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.
Mrs. Riley
• Exploring: what could be causing this
woman to be so suddenly dyspneic and
hypoxic?
• Pneumothorax
• Hemothorax
• Pneumonia
• Pleural Effusions
• Atelectasis
• Electrolyte Disorders
Mrs. Riley
• Analyzing: what other information can I
•
•
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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.
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.
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!
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?
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.
Side-by-Side
NURSING
PROCESS
Assessment
CRITICAL
THINKING
Exploring
Diagnosis
Analyzing
Planning
Prioritizing/decision
making
Prioritizing and
deciding
Evaluating
Implementation
Evaluation
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.
Mr. Harris
• Exploring: what could be causing the
movement in Mr. Harris’ legs?
• Spinal Reflexes
• Purposeful movement
• Muscular spasms
Mr. Harris
• Analyzing: what other information can I
gather to help me narrow down the
possible causes of his movement?
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•
•
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Are the movements purposeful?
Can the movements be duplicated?
How much movement is possible?
Does the patient report any changes in
sensation?
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.
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
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.
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.
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.
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.
I wanna know...
• 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?
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.
Could it be?
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What were some of the potential causes?
Infection
Dehydration
Heart Problem
Pain
By searching for more information, you
could narrow down the potential causes!
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.
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.
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!
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!