Transcript 03. Critical Thinking in Nursing Practice, Nursing Assessment

CRITICAL THINKING IN NURSING PRACTICE
NURSING ASSESSMENT
DEFINITION OF CRITICAL THINKING
Cognitive process during which an individual reviews data
and considers potential explanations and outcomes before
forming an opinion or making a decision
“Critical thinking in nursing practice is a discipline specific,
reflective reasoning process that guides the nurse in
generating, implementing, and evaluating approaches for
dealing with client care and professional concerns.”
Critical thinking involves the use of a group of
interconnected skills to analyze, creatively integrate, and
evaluate what you read and hear. To become a critical
thinker you must be able to decide whether an author’s
opinions are true or false, whether he or she has
adequately defended those ideas, whether certain
recommendations are practical, as well as whether
particular solutions will be effective
CRITICAL THINKING SKILLS
 To learn how to think critically, one must learn skills that build upon
each other. Only by concentrating on and practicing these basic skills
can mastery of critical thinking be achieved. The author lists three basic
characteristics of the skills required to think critically: they are
interconnected (review a sample list of these skills), they build on each
other, and they are goal-oriented in that we can constantly apply them
to situations in everyday life.
CHARACTERISTICS OF CRITICAL
THINKING
 Critical thinking involves the use of a kind of thinking
called reasoning, in which we construct and/or evaluate
reasons to support beliefs. Critical thinking also involves
reflection — the examination and evaluation of our own
and others’ thoughts and ideas. Finally critical thinking is
practical. Actions are more rational if they are based on
beliefs that we take to be justified. Critical thinking then, is
the careful, deliberate determination of whether we should
accept, reject or suspend judgement about the truth of a
claim or a recommendation to act in a certain way.
CRITICAL THINKING STEPS
Knowledge
In terms of critical thinking, the basic level of acquisition of
knowledge requires that you be able to identify what is being
said: the topic, the issue, the thesis, and the main points
Comprehension
Comprehension means understanding the material read, heard or
seen. In comprehending, you make the new knowledge that
you have acquired your own by relating it to what you already
know. The better you are involved with the information, the
better you will comprehend it. As always, the primary test of
whether you have comprehended something is whether you can
put what you have read or heard into your own words.
Remember that comprehending something implies that you can
go beyond merely parroting the material back but instead that
you can give the material your own significance.
Application
Application requires that you know what you have read, heard, or
seen, that you comprehend it, and that you carry out some task to
apply what you comprehend to an actual situation.
Analysis
Analysis involves breaking what you read or hear into its component
parts, in order to make clear how the ideas are ordered, related, or
connected to other ideas. Analysis deals with both form and content.
Synthesis
Synthesis involves the ability to put together the parts you analyzed
with other information to create something original.
Evaluation
 Evaluation occurs once we have understood and analyzed what is
said or written and the reasons offered to support it. Then we can
appraise this information in order to \ whether you can give or
withhold belief, and whether or not to take a particular action. Never
put evaluation ahead of the other steps in critical thinking steps;
otherwise, you will be guilty of a "rush to judgement." When
emotion substitutes for reasons, evaluation incorrectly precedes
analysis.
FORMULA FOR CRITICAL THINKING
 Start Thinking
 Why Ask Why
 Ask the Right Questions
 Are you an expert?
ASPECTS OF CRITICAL THINKING
 Reflection
 Language
 Intuition
LEVELS OF CRITICAL THINKING
 Basic
 Complex
 Commitment
Critical Thinking Competencies
 Scientific method
 Problem Solving
 Decision Making
 Diagnostic Reasoning and Inferences
 Clinical Decision Making
 Nursing Process
Components Of Critical Thinking
 Scientific Knowledge Base
 Experience
 Competencies
 Attitudes
 Standards
Nursing Process is a systematic, rational method of planning
and providing care which requires critical thinking skills to
identify and treat actual or potential health problems and to
promote wellness.
It provides a framework for the nurses to be responisble
and accountable.
It consists of five sequential and interrelated steps or
phases:





Assessment
Diagnosis
Planning
Implementation
Evaluation
NURSING ASSESSMENT
 Assessment is the first step in the nursing process and
includes systematic collection, verification, organization,
interpretation, and documentation of data for use by health
care professionals. The accompanying display presents the
essential elements of the assessment process. Effective
planning of client care depends on a complete database and
accurate interpretation of information. Incomplete or
inadequate assessment may result in inaccurate conclusions
and incorrect nursing interventions. Proper collection of
assessment data directs decision-making activities of
professional nurses.
The goal of assessment is the collection and analysis of data
that are used in formulating nursing diagnoses, identifying
outcomes and planning care, and developing nursing
interventions. This chapter discusses the purpose of
assessment, types of assessment, and the use of data in the
assessment process.
Types of assessment
 Comprehensive assessment
 Focused assessment
 Ongoing assessment
COMPREHENSIVE ASSESSMENT
A comprehensive assessment is usually completed upon admission to a health
care agency and includes a complete health history to determine current
needs of the client. This database provides a baseline against which
changes in the client’s health status can be measured and should include
assessment of physical and psychosocial aspects of the client’s health, the
client’s perception of health, the presence of health risk factors, and the
client’s coping patterns.
FOCUSED ASSESSMENT
A focused assessment is an assessment that is limited in scope in order to
focus on a particular need or health care problem or potential health care
risks. Focused assessments are not as detailed as comprehensive
assessments and are often used in health care agencies in which short stays
are anticipated (e.g., outpatient surgery centers and emergency
departments), in specialty areas such as labor and delivery, and in mental
health settings or for purposes of screening for specific problems or risk
factors (e.g., well-child clinics). See the accompanying display for sample
questions used to assess a client experiencing labor.
ONGOING ASSESSMENT
Systematic follow-up is required when problems are
identified during a comprehensive or focused assessment.
An ongoing assessment is an assessment that includes
systematic monitoring and observation related to specific
problems. This type of assessment allows the nurse to
broaden the database or to confirm the validity of the data
obtained during the initial assessment. Ongoing assessment
is particularly important when problems have been
identified and a plan of care has been implemented to
address these problems.
 Systematic monitoring and observations allow the nurse to
determine the response to nursing interventions and to
identify any emerging problems.
DATA COLLECTION
 The nurse must possess strong cognitive, interpersonal, and
technical skills in order to elicit appropriate information
and make relevant observations during the data collection
process. This process often begins prior to initial contact
between the nurse and the client, primarily through the
nurse’s review of biographical data and medical records.
Upon meeting the client, the nurse continues data collection
through interview, observation, and examination. A variety
of sources and methods are used in compiling a
comprehensive database.
TYPES OF DATA
 Subjective data are data from
the client’s point of view and
include feelings, perceptions,
and concerns. The data (also
referred to as symptoms) are
obtained through interviews
with the client. They are called
subjective because they rely on
the feelings or opinions of the
person experiencing them and
cannot be readily observed by
another.
 Objective data are observable
and measurable (quantitative)
data that are obtained through
observation, standard
assessment techniques
performed during the physical
examination, and laboratory and
diagnostic testing.
SOURCES OF DATA
The client should always be considered the primary source of information;
however, other sources should not be overlooked.
The client’s family and significant others can also provide useful information,
especially if the client is unable to verbalize or relate information. In addition,
other health care professionals who have cared for the client may contribute
valuable information. Medical records should also be reviewed, including the
medical history and physical examination; results of laboratory and diagnostic
tests and various health care professionals should also be consulted.
Secondary Source - physical exam, nursing
history, team members, lab reports, diagnostic
tests…..
 Subjective -from the client (symptom)
 “I have a headache”
 Objective - observable data (sign)
 Blood Pressure 130/80
METHODS OF DATA COLLECTION
The nurse collects information through the following
methods: observation, interview, health history, symptom
analysis, physical examination, and laboratory and
diagnostic data. These approaches require systematic use of
assessment skills that are discussed below.
OBSERVATION
 The nurse uses the skill of observation to carefully and attentively note
the general appearance and behavior of the client. These observations
occur whenever there is contact with the client and include factors such
as client mood, interactions with others, physical and emotional
responses, and any safety considerations.
 Observation helps the nurse determine the client’s status, both physical
and mental. By carefully watching the client, the nurse can detect
nonverbal cues that indicate a variety of feelings, including presence of
pain, anxiety, and anger. Observational skills are essential in detecting
the early warning signs of physical changes (e.g., pallor and sweating).
INTERVIEW
An interview is a therapeutic interaction that has a specific purpose The
purpose of the assessment interview is to collect information about the
client’s health history and current status in order to make
determinations about the client’s health needs. Effective interviewing
depends on the nurse’s knowledge and ability to skillfully elicit
information from the client using appropriate techniques of
communication. Observation of nonverbal behavior during the
interview is also essential to effectivem data collection.
 Closed questions are questions that can be answered
briefly or with one-word responses. For example, the
question “Have you been in the hospital before?” is a
closed question that can easily be answered by a one-word
response. Questions about the dates of and reasons for the
hospitalizations are also closed questions that require brief
answers.
 Open-ended questions are questions that encourage the
client to elaborate about a particular concern or problem.
For example, the question “What led to your coming here
today?” is open-ended and allows the client flexibility in
response. Both closed and open-ended questions can be
effective in collecting information
Assessment Techniques:
Inspection
INSPECTION is the most frequently used assessment technique. When
you are using inspection, you are looking for conditions you can
observe with your eyes, ears, or nose. Examples of things you may
inspect are skin color, location of lesions, bruises or rash, symmetry,
size of body parts and abnormal findings, sounds, and odors. Inspection
can be an important technique as it leads to further investigation of
findings.
Assessment Techniques: Auscultation
AUSCULTATION is usually performed
following inspection, especially with
abdominal assessment.
The abdomen should be auscultated before
percussion or palpation to prevent production
of false bowel sounds.
When auscultating, ensure the exam room is
quiet and auscultate over bare skin, listening
to one sound at a time. Auscultation should
never be performed over patient clothing or a
gown, as it can produce false sounds or
diminish true sounds. The bell or diaphragm
of your stethoscope should be placed on your
patient’s skin firmly enough to leave a slight
ring on the skin when removed.
Be aware that your patient’s hair may also
interfere with true identification of certain
sounds.
 Remember to clean your stethoscope between
patients.
Assessment Techniques: Palpation
PALPATION is another commonly used physical exam technique, requires
you to touch your patient with different parts of your hand using different
strength pressures. During light palpation, you press the skin about ½
inch to 3/4 inch with the pads of your ingers. When using deep palpation,
use your finger pads and compress the skin approximately 1½ inches to 2
inches. Light palpation allows you to assess for texture, tenderness,
temperature, moisture, pulsations, and masses. Deep palpation is
performed to assess for masses and internal organs.
Assessment Techniques: Percussion
PERCUSSION is used to elicit tenderness or sounds that may
provide clues to underlying problems.
When percussing directly over suspected areas of tenderness,
monitor the patient for signs of discomfort. Percussion
requires skill and practice.
The method of percussion is described as follows: Press the
distal part of the middle finger of your non-dominant hand
firmly on the body part. Keep the rest of your hand off the
body surface. Flex the wrist, but not the foreman, of your
dominant hand. Using the middle finger of your dominant
hand, tap quickly and directly over the point where your
other middle finger contacts the patient’s skin, keeping the
fingers perpendicular. Listen to the sounds produced.
NURSING CARE PLANS
STUDENT____________________________________PATIENT INITIALS____________ROOM NUMBER__________DATES________________
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
(supportive data)
FACTUAL DATA
(patient's need)
PROBLEM STATEMENT
(nursing care needed)
NURSING PLAN FOR PROBLEM
(documentation of care)
DOCUMENTATION
(status of goal)
STATUS OF THE GOAL
Supports your problem. This
information has to be
current, or perhaps past
history and NOT “make
believe”. Think of it as
supportive data that proves
you have an actual or
potential problem. It must
have at least 2 pieces of
information to support
problem.
This is the name you give the
problem. Ask yourself,
“What is the problem?”
You can use the NANDA list
of problem statements OR if
none apply, make a problem
statement using one of the
words:
Alteration
Impaired
Deficit
Ineffective
Dysfunction Intolerance
Excess
Ask yourself, “What can I do for
the problem?”
Ask yourself, “Why do I
think this is a problem?”
Think about your pt’s:
1. Medical Diagnoses
S & S from Dx that your
pt is having right now
If no S&S right now, just
list the Dx as support
2. Medication List
Side effects?
3. Abnormal Lab?
These are not to be numbered.
Think about the following:
Observations you make related to
this problem, (include assessment of the pt re: to the body
system re: this problem, diagnostic tests, and reporting of
findings to charge nurse. (Use
your senses).
Refrain from using:
Decreased Cardiac Output*
Disuse Syndrome
Impaired Gas Exchange*
Impaired Physical Mobility
Decreased Mobility (of any kind)
Risk for Infection**
Risk of Ineffective Management of
Therapeutic Regimen*
*These problems must have specific
data, measurements, lab tests, etc. in
order to use these problems.
**There may be some very specific
cases where it may be applicable.
Think, what can an “infection” can
cause? Use that as a problem instead.
Goal: What do you plan to
accomplish? Must be pt centered, AND specific,
measurable, attainable,
realistic, & time-sequenced.
Tasks you can do (things you can
do to prevent, repair, or reduce
the problem). This includes
medication adm., oxygen,
dressing changes, turning,
enema, catheter insertion,
nutrition, fluids, etc.
Teaching of patient & family
(includes not only what the
doctor orders but what you as
the “nurse” will teach the
patient. Also should include
how you will determine the
patient’s understanding of the
teaching.)
Ask, “What will I document?”
Any information that pertains to
the problem.
This is your actual narrative
charting notes just like on your
Assessment Sheet in Level 1 or
charted observations in the nurses
notes in the chart. NOTE: This is
Ask yourself, “Did I
accomplish my goal?”
1. Look at your goal & ask
yourself a question related
to it - whether your Goal
was met completely, met
partially, or not met at all.
Write this down.
2. Answer the question in a
Summarized Evaluation
Statement and relate it to
the Measurable Part of the
Goal. Write this down.
Does the problem or
potential for the problem
still exist? Write this down.
4. Then, state if you will
Continue with your plan either as stated or as
revised or Discontinue Plan.
NOT a restatement of your plan in the
past tense! Also it DOES NOT have to
address each part of the plan. DO
NOT number this section or leave
3.
spaces. Also any conclusions, or
judgments that are improper in
charting are not proper here.
Students have best results in
learning how to word this section
when they do not even look at the
planning section.
Document: Date/Time
1. Observations you made
2. Reporting observations and
changes in condition to
appropriate personnel
3. Care given to the patient
4. Response of the pt to the care
5. Results of your actions,
diagnostic tests, medications
Be very SPECIFIC and very
administered, etc.
THOROUGH. Include details like
6. Teaching specific to patient
how much, frequency (how often),
meds, needs, problems,
etc.
preventative care.
DATE REVISIONS OR
ADDITIONS EVERY DAY!
DATE ENTRY EVERY DAY!
Write this down.
NOTE: You must have
something to back up this
evaluation in your
documentation in the
Implementation column
(Implementation supports or
proves your evaluation
statement).
Examaple:
Goal was partially met. The
patient washed his face but did not
brush his teeth himself. The
problem still exists. Continue
with the plan as revised.
Revised 0705 – 0495