Chapter 15
Critical Thinking in Nursing
Practice
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Clinical Judgment in Nursing Practice
0 Registered nurses (RNs) are responsible for making accurate and appropriate
clinical decisions or judgments.
0 Nurses must learn to question, wonder, and explore different perspectives and
interpretations to find a solution that benefits the patient.
Critical Thinking Defined
0 CT is:
0 The ability to think in a systematic and logical manner w/openness to
question / reflect on the reasoning process
0 A continuous process characterized by open-mindedness, continual inquiry,
and perseverance, + a willingness to look at each unique pt. situation and
determine which identified assumptions are true / relevant
0 Recognizing that an issue exists, analyzing information, evaluating
information, and drawing conclusions
Reflection
0 The ability to act on the basis of critical thinking comes with experience.
0 Turning over a subject in the mind and thinking about it seriously is reflection.
0 Reflection is not intuitive.
Levels of Critical Thinking in Nursing
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Rights Reserved.
Critical Thinking
Competencies (Cont.)
0 Nursing process as a
competency
0 Assessment
0 Diagnosis
0 Planning
0 Implementation
0 Evaluation
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A Critical Thinking Model for Clinical Decision
Making
0 Model components:
0 Specific knowledge base
0 Experience
0 Nursing process competency
0 Attitudes for critical thinking
0 Professional standards
Critical Thinking Synthesis
0 Critical thinking and the nursing process
go hand-in-hand in making quality decisions
about patient care.
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Rights Reserved.
Managing Stress
0 The work of professional nursing is difficult as you see patients endure suffering
from disease and painful therapies and as you try to manage care responsibilities
in busy, fast-paced work settings.
0 Stress over a prolonged period or when extreme can lead to poor work
productivity, impaired decision making and communication, and reduced ability
to cope with clinical situations.
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Rights Reserved.
NURSING PROCESS
0 Cyclical CT process / dynamic
0 Pt – centered
0 Framework for decisions
0 5 sequential / overlapping steps
0 Helps nurses base nursing judgments on reason
0 Promotes professionalism
ASSESSMENT
0 Systematic collection of information about patient’s present health status to ID needs and
additional data to collect based on findings.
0 Methods – observation, interviews-therapeutic comm/open-ended questions, medical hx,
comprehensive or focused physical exam, diagnostic & lab reports, and collaboration.
Sources – pt, med record
0 To collect effectively – ask appropriate questions, listen carefully, have excellent head-totoe physical exam skills. Use clinical judgment and CT. Recognize the need to collect data
prior to interventions.
0 Subjective data (symptoms) – nursing hx. Pt’s feelings, perceptions, descriptions. Pts are
the only ones who can describe and verify.
0 Pain
0 Nausea
0 Objective data (signs) – physical exam. What the nurse sees, hears, feels, smells, or can
measure.
0 Grimacing / rubbing
0 Vomiting
0 BP
ANALYSIS
0 Look at the data
0 Recognize patterns / trends
0 Compare data w/expected standards / norms
0 Arrive at a conclusion
0 Decide using reasoning and judgment which data
accounts for the pts health status or problems.
0 Cluster the data / prioritize
0 Nursing Dx / Priority Problem list
0 Document – factual and descriptive
ANALYSIS/Nursing Dx
1. Medical
diagnosis
2. Nursing
diagnosis
3. Collaborative
problem
Identification of a disease
condition based on specific
evaluation of signs and
symptoms
Clinical judgment about the
patient in response to an actual
or potential health problem
Actual or potential physiological
complication that nurses
monitor to detect a change in
patient status
PLANNING
0 Establish priorities – change as pt’s condition changes
0 Initial / Ongoing / Discharge
0 Set priorities, ID goals, determine expected outcomes, select
interventions (evidence-based)
0 Goal
0 A broad statement that describes the desired change in a
patient’s condition or behavior
0 An aim, intent, or end
0 Optimum status
0 Pt-centered, singular
0 Expected outcome
0 Measurable criteria to evaluate goal achievement
0 Observable criterion / measureable / specific
0 Time limited
PLANNING
0 Nurse-initiated / independent interventions
0 Within scope of practice
0 Perform, delegate – are accountable for them
0 Ex: repositioning the pt
0 Provider initiated / dependent interventions
0 Nurses initiate as a result of a provider’s prescriptions or facility’s
protocol.
0 Collaborative interventions – nurses carry out in collaboration w/other
HC team professionals
0 Meeting dietary needs
0 End Product = the Nursing Care Plan
0 Concept Mapping
0 Provide a visually graphic way to show the relationship between
patients’ nursing diagnoses and interventions
IMPLEMENTATION
0 Perform nursing actions, delegate tasks, supervise other
HC staff, and document
0 Care given based on the assessment data, analyses and
the plan they developed
0 Use – Problem-solving, clinical judgment, and CT +
nursing knowledge, priorities of care and planned goals
/ outcomes. Also use therapeutic communication +
good technical skills
0 Use evidence-based rationale for selecting interventions
EVALUATION
0 Evaluate the pt’s responses to the interventions
0 Determine effectiveness of the NCP
0 Questions
0 Did the pt meet the planned outcomes?
0 Were the nursing interventions appropriate & effective?
0 Were measureable outcomes met?
0 Factors that can interfere w/goal achievement
0 Incomplete data, unrealistic outcomes, nonspecific
interventions, inadequate time to achieve the outcome