Study Guide for Critical Thinking and Nursing Process
1.
Review the outlines given in class.
See lecture notes
2.
Define and differentiate between critical thinking, problem-solving, decision
making, clinical judgment.
Critical Thinking – reacting by reasoning, interpreting data, problem solving
which involves thinking creatively
Observe
Decide what is important
Look for patterns & Relationships
Identify the problem – prioritizing
Transfer the knowledge from one situation to another
Apply the Knowledge
Evaluate according to criteria
“Critical thinking is the active, organized, cognitive process used to
carefully examine one’s thinking and the thinking of others.”
Problem-Solving – systematic approach to a problem resulting in a
formulation of solutions
Decision Making – process of choosing among alternatives, difference from
problem solving is that decision making does not have to be related to a
problem
Clinical Judgment – ability to safely and competently care for clients, “the
process by which the nurse decides on data to be collected about a client,
makes an interpretation of the data, arrives at a nursing diagnosis and
identifies appropriate nursing actions: this involves problem solving, decision
making, and critical thinking”
3.
What are the standards of critical thinking? Give examples of each.
These standards are used daily to analyze and interpret patient care situations
Clarity – Thinking clearly is central to understanding
Ex. Abbreviations may lead to error
Accuracy – Using reliable sources, evidence-based practice, accuracy of
interpretation
Ex. Correct medical calculations, decimal point
Precision – Exactness, need for details
Ex. Using patient identifiers
Relevance – Discriminate between pertinent and non-pertinent
Ex. Which patient symptoms/observations are important and which are not
Depth – perceive the complexities and visualize relationships
Ex. Using FORM model, care for patient as a person
F – Family
O – Occupation
R – Recreation
M – Message (more willing to listen)
 Leli’s example, abdomen abscesses on diabetic cat-owner
Breadth- Thinking from several different points of view
Ex. End of life decisions
Logic – Does it make sense? Assumptions must be valid, conclusions based
on evidence, procedures performed in a logical order.
Ex. Caring for the most critical patient first
Significance- is the information critical to the situation? Which facts are most
important?
Ex. Assessing whether a patients type of pain is related to a more severe
problem
Fairness – Open to other ideas or information, listening
Ex. Considering the ideas of other healthcare professionals when caring
for a patient
Bias – compromise the integrity of the thinking process
Ex. Assuming a patient demanding pain medication is an addict
** note – unsure why bias is listed as a critical thinking standard & pitfall
Maturity- Develops over time, focusing on client
Ex. Providing the same care for a patient who is rude to you
4.
What are the pitfalls in critical thinking?
Illogical Process – circular logic, “it’s true because it is so”
Appeal to Tradition - doing it the way it’s always been done
Hasty Generalization - Generalizing without considering all of the evidence
Bias – can cause errors in care
Closed-Mindedness – limits care
The critical thinker does not jump to conclusions
5.
Differentiate between critical pathways, algorithms and the nursing process.
Critical Pathways – “management plans that display goals for patients and
provide the sequence and timing of actions necessary to achieve these goals
with optimal efficiency.” (googled)
Ex.
Algorithm – Decision “Tree”
Ex.
(googled)
Nursing Process –
Assessment
Analysis
Nursing Diagnosis
Client Outcomes
Nursing Interventions
Implementation
Evaluation
**pic missing added steps
6.
Decisions have consequences and ignoring a problem is a decision and has a
consequence.
Deciding not to act is a decision, nurses have to be accountable and
responsible for outcome, nurses make their own decisions
7.
Name and define the five problem-solving strategies.
** Know these **
Do it yourself (as opposed to delegation)
Influence Others
Assign Others (delegate)
Do Nothing
Combine Knowledge
Any of these may be appropriate depending on the situation
8.
What are the non-systematic methods of problem solving?
Tradition/Habit – sometimes good, but has to be based on information
Authority – Delegation
Trial and Error – Works sometimes
9.
Define the nursing process. Remember the nursing process is used to
develop nursing care plans (NCP) whose major purpose is to identify nursing
actions to be delivered to clients.
A problem-solving method that is unique to nursing.
An organized plan that facilitates the use of sound judgment in care delivery.
Definition: Deliberative systematic approach for making decision about a
patient’s health state, and improvements that can be achieved through
therapeutic nursing implementation.
A scientific problem-solving method that assist the nurse in using theoretical
knowledge to diagnose the nursing care needs of persona and to plan
interventions to be implemented to attain, maintain & promote optimal
biopsychosocial functioning.
10.
What are the components of the nursing process?
Assessment
Analysis
Nursing Diagnosis
Client Outcomes (Planning)
Specific, measureable, long/short term
Nursing Interventions (Planning)
Interventions, rationale
Implementation Interventions
Evaluation (Outcomes)
11.
What is the first step of the nursing process and what is involved in this step?
The first step of the nursing process is assessment. You collect and validate
data, and begin to cluster clues, and identify problems. This is done through
interview, physical exam, the use of instruments, etc. You collect both
subjective and objective data.
12.
Identify and give example of objective and subjective data.
Objective – observable data, NOT subjective opinion. Obtained by clinical
observation, examination, diagnostic studies.
Ex. Pt grimacing when he turns to left side – observed, evidence of pain
Subjective – Symptoms and “I” messages”
Ex. Patient says his pain is 6 on a scale of 1 to 10.
13.
Define the analysis step of the nursing process.
Analysis – continue to cluster clues and identify problems
Prioritize based on Maslow’s Hierarchy (physiological before psychosocial)
and ABCs (Airway, Breathing, Circulation)
Creating a prioritized problem list.
Ex.
Fluid deficit
Surgical pain
Immobility
Fever
Constipation
Priorities 1 day post op, these priorities change over time (see lecture
notes)
14.
What is the nursing diagnosis? Differentiate this from a medical diagnosis.
Defines the parts of the nursing diagnosis and the PES system. What do the
letters stand for? Give examples of each.
Nursing Diagnosis – Diagnose, treat, and prevent human responses. Holistic
(biological, psychosocial, cultural, spiritual), teaching clients self-care,
promote wellness
PES – Problem, Etiology, Signs/Symptoms
Problem – Diagnostic label, a positive or negative finding
Ex. Alteration in elimination (constipation)
Etiology – cause of problem (r/t)
Must be something the nurse can do something about
Lack of knowledge, resources, compliance, ability…
Can have a secondary to (may be medical diagnosis)
Ex. r/t inadequate fluid intake
Signs/Symptoms – Objective and subjective data (AEB)
From data, defining characteristics, know “normals”
Medical Diagnosis – Diagnose and treat/cure disease, pathophysiology,
biological, physical effects. Teach patients about the treatments for their
disease or injury.
15.
What are the seven steps of the nursing process? Give an example of each.
Assessment – collecting data
Analysis - prioritizing
Nursing Diagnosis – PES statement
Client Outcomes - goals
Nursing Interventions - Plan
Implementation – actual care
Evaluation – assess outcome
“A ADO PIE”
16.
Recognize the NANDA nursing diagnostic labels.
NANDA: North American Nursing Diagnosis Association
12th report, specific
Standard nursing diagnoses we will use
17.
State the four etiological areas of the diagnostic statement and give an
example of each.
**Know each specifically
Lack of Knowledge – does not have/understand information
Ex. Client does not know pickles are high in sodium
Lack of Resources – Money, medication, assistive devices, people
Ex. Does not have enough money to buy medication
Lack of Motivation – has knowledge, resources, ability, but does not do what
is needed. Hardest to deal with.
Ex. Smoking
Lack of Ability – Not able to do what is needed, many clients in hospital are
in this situation. Require much nursing care.
Ex. Patient unable to walk after a broken hip
18.
What are client outcomes? What parts are required when developing a client
outcome?
Fourth step in nursing process. Outline patient goals.
Statement of preferred patient status, “The patient will…”
Outcomes and deadlines – specific, measurable, (clear & objective), realistic,
have time frame
NOC – nursing outcome criteria
Short and long term goals
Ex. “During clinical today (time frame), the client will walk 50 feet and
return to bed without feeling faint or dizzy.”
19.
What are nursing interventions? What parts are required when developing
nursing interventions? What is evidence-based practice and how does it
related to nursing interventions and the nursing process?
Fifth step in nursing process. Address the problem.
Helps resolve etiology.
NIC – Nursing intervention criteria
Need to support interventions with evidence-based practice (rationale)
20.
What is implementation and what is included in this step?
Sixth step of nursing process. Care or delegated care based on priorities.
Implementing the previously mentioned interventions + documentation
21.
What is evaluation? What are the parts of evaluation? What should be
included in the summary portion?
Seventh step of nursing process. Evaluating Outcomes
The planned systematic comparison of client’s current health status with the
stated outcomes.
Step 1 – Evaluate outcomes
Look at outcomes, achieved, not achieved, partially achieved, and how
you know this. Give supporting data.
Ex. Outcome achieved, BP128/78 or Outcome not achieved, BP
92/50
Step 2 – Summary
Are outcomes as a whole achieved?
Is diagnosis continuing, need modifications, resolved?
Document and Communicate
22.
Review the example of the nursing process. Be able to identify all parts of the
process.
Example of Nursing Process & Nursing Care Plan
Mr. S.J.
Step 1 - Assessment of Mr. S.J.
History
Mr. S.J., a 42 year-old W/M presents to the CNC clinic with a chief complaint of “I’m
having trouble breathing (CC). I cough and cough but can’t seem to bring much up.”
“What does come up is white and thick.” He reports that approximately one week ago he
“caught cold.” He thought it would “take care of itself” so he continued to work. His
work involves “roofing homes and apartments.”
States two days ago he started “feeling worse” with an increase in coughing. States he’s
been “sweating a lot at work because it’s been so hot.” States he’s “not drinking much”
as he’s “been too busy.” Mr. S.J. presents at this time for assistance in resolving his chief
complaint.
Additional History
would want – is he a smoker? Is there a history of respiratory infections?
Hematocrit to tell more? Allergies? 24 hour fluid recall?
Step 2
ANALYSIS
Analysis
What fits together?
Respiratory
Fluid deficit
Problem List
upper respiratory infections
fluid deficit
ineffective airway clearance
impaired gas exchange
Step 3 – Nursing Diagnosis
underlined – supports problem
not underlined – supports etiology
Nursing Diagnosis with supportive data
Ineffective airway clearance R/T decreased hydration
Secondary to URI
AEB (as evidenced by)
S – “I cough and cough but can’t seem to bring much up.”
S – “I haven’t been drinking much lately”
O – Client coughs 5-10 times in ten minutes. Two ml thick white mucus obtained.
O - Rhonchi auscultated in right upper lobe. Other lung fields clear.
O – RR = 28 with minimal accessory muscle use
O -Skin color pale. Poor skin turgor = pinched skin takes 10 seconds to return to resting
state
O – Hct. = 54% (Normal Hct = Males = 42% - 52%)
O – voided 200ml dark yellow urine S.G. = 1.07 (N = 1.010 – 1.025)
S - 24 hour fluid recall
0600 – 1 cup caffeinated coffee
1100 – 1 12 oz. caffeinated coke
1400 – 1 12 oz caffeinated coke
1700 – 1 cup caffeinated coffee
O – fluid analysis = 40 oz (1200 ml) caffeinated fluids/24 hr (N = average adult oral
intake = 1100 – 1400 ml/24 hr)
O – “Maintenance of adequate systemic hydration keeps mucociliary clearance normal.”
(P & P, 2001 p 1162)
Planning – Steps 4 & 5
4 - Client Outcomes
&
5 - Nursing Interventions
Client Outcomes
Related to etiology
(Given appropriate nursing interventions are implemented,) Mr. SJ will have
increased hydration within 24 hours AEB (as evidenced by):
1. Skin immediately returning to resting state when released
2. Fluid intake of 2000 – 3000 ml/24 hr non-caffeinated fluids (by client
report)
3. Urine output of 1400 – 1800 ml light yellow/24 hr (by client report)
OTHERS
Client Outcomes – cont.
Related to the problem
(Given that the client has increased hydration), Mr. SJ will have effective airway
clearance within 2 days AEB:
1. Coughing productively of 3-5 ml moderately thin clear mucus within 35 coughs.
2. Breath sounds bilaterally clear and equal in all lung fields A & P
3. RR = 12 – 24 without accessory muscle use.
4. Skin color pink
5. Client states “I am breathing better now and coughing mucus up.”
Others
Nursing Interventions & Rationale
During CNC visit today, the nurse will:
A. Encourage Mr. SJ to drink 100 ml fluid every hour while awake. Instruct him needs to
have 2000-3000 ml/ 24 hr. of non-caffeinated fluids, such as apple juice or water. (SR Increasing fluids between 2000-3000ml/24 hr will help to rehydrate clients. L & S, 1996
p 1105) (SR – Caffeinated ..beverages should be limited or avoided completely, since
they act as diuretics and can contribute to dehydration P & P, 2001 p 1161)
B. Ask Mr. SJ to use a humidifier at the bedside during the time he is in bed. (SR – Air
..with a high relative humidity keeps the airways moist and helps loosen and mobilize
pulmonary secretions. P & P, 2001 p. 1162)
C. Encourage client to deep breath & cough every two hours while awake. (SR –
Coughing permits the client to remove secretions from both the upper and lower airways.
P & P, 2001 p 1162)
Others
Step 6 – IMPLEMENTATION of Nursing Interventions
A. – Implemented as planned
B. - Implemented as planned
C. - Not implemented as planned. The client left the CNC before this could be done.
The nurse will call the client and home and discuss this with him.
Step 7 – Evaluation of Client Outcomes
Evaluation – Etiology Outcomes
At the end of 24 hours, the nurse calls Mr SJ to determine the results of the etiology
outcomes.
Skin immediately returning to resting state when released
Achieved – Client states his skin returns to resting state when
released.
Fluid intake of 2000 – 3000 ml/24 hr non-caffeinated fluids (by client
report)
Achieved – Client states he drank 4 8 oz. Glasses of water, 2 8 oz
glasses of orange juice, 3 8 oz glasses of lemonade, and 2 6 oz
cups of decaffeinated coffee. Total fluid intake = 2520 ml
decaffeinated fluid
 Urine output of 1400 – 1800 ml light yellow/24 hr (by client report)
Achieved - Client states he has urinated 5 times for 500 ml of
clear, light yellow urine each time.
Summary - The outcomes, as a whole, are achieved. The diagnosis is continuing and the
client will be seen tomorrow in the clinic in order to evaluate the ineffective breathing.
No changes needed at this time. Client is adhering to requests. Evaluate client tomorrow
on return to clinic.
Evaluation – Problem Outcomes
At the end of 48 hours from initial clinic visit, Mr. SJ returns to the clinic for evaluation
of his problem outcomes.
1. Coughing productively of 3-5 ml moderately thin clear mucus within 3-5 coughs.
Partially achieved. Coughing productively, but the mucus is thicker and greenishyellow in color.
2. Breath sounds bilaterally clear and equal in all lung fields A & P
Not achieved. Lung sounds are bilaterally diminished with occasional rhonchi
auscultated in right upper lobe.
3. RR = 12 – 24 without accessory muscle use.
Not achieved. RR = 28 with accessory muscle use.
4. Skin color pink
Not achieved. Skin color pale.
5. Client states “I am breathing better now and coughing mucus up.”
Not achieved. Client states “I am having more trouble breathing and feel worse.”
Summary – The outcomes, as a whole, are not achieved. The client’s condition has
worsened. The diagnosis as stated needs modification to include his worsening
respiratory status. The outcomes for the problem continue to be appropriate. Additional
interventions need to be implemented, including contacting his physician for an
immediate appointment. A sputum specimen needs to be obtained for C & S. The client
needs to be evaluated on a daily basis at this time
23.
Example:
“During clinic today, the nurse will instruct the patient to take three deep
breaths in and out and on the third exhalation cough forcefully. This should
be done every two hours while awake.” This is an example of what part of the
nursing process?
a.
assessment
b.
outcome
c.
**intervention
d.
evaluation
Which part of the above is missing?
a. who
b. to whom
c. what
d. **scientific rationale
(** = correct response)
Extra Notes:
**Leli's exam will have select all that apply
it is NEVER all of the above, RARELY only one answer (because that is like a
MC question)
** Nurses almost never provide ALL the care except in extreme cases, nurses promote
independence for patient self-care when appropriate