Chapter 15 Critical Thinking in Nursing Practice Copyright © 2017, Elsevier Inc. All Rights Reserved. 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 3 Copyright © 2017, Elsevier Inc. All Rights Reserved. Critical Thinking Competencies (Cont.) 0 Nursing process as a competency 0 Assessment 0 Diagnosis 0 Planning 0 Implementation 0 Evaluation Copyright © 2017, Elsevier Inc. All Rights Reserved. 4 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. 5 Copyright © 2017, Elsevier Inc. All 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. 6 Copyright © 2017, Elsevier Inc. All 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