Critical Thinking in Nursing Practice

Chapter 15 Critical Thinking in Nursing Practice Clinical Judgement in Nursing Practice 1. Critical thinking involves- open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant 2. Define evidence-based knowledge- knowledge based on research or clinical expertise 3. As you care for a patient, you need to reflect after the caring by asking what specific questions? a. How did I act? b. Why did I choose such an action? c. What could I have done differently? d. Were the results what I expected? e. What should I do in a similar situation in the future? Levels of critical Thinking in Nursing 4. Three levels of critical thinking in nursing have been identified. Briefly describe each. a. Basic- the learner trusts that experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles b. Complex- learners begin to separate themselves from experts and analyze and examine choices more independently c. Commitment- learners anticipate the need to make choices without assistance from others and accept accountability Critical Thinking Competencies 5. Scientific Method- systematic, ordered approach to gathering data and solving problems 6. Problem solving- Obtain information and then use the information plus what you already know to find a solution 7. Decision making- focuses on problem resolution 8. Diagnostic reasoning- determining a patient’s health status after you have assigned meaning to the behaviors and symptoms presented 9. Inference- process of drawing conclusions from related pieces of evidence 10. Clinical decision making- careful reasoning so the best options are chosen for the best outcomes 11. Nursing process- five-step clinical decision-making approach 12. Explain the two terms a. Diagnostic reasoning- analytical process for determining a patient’s health problems and selecting proper therapies b. Inference- the process of drawing conclusions from related pieces of evidence and previous experience with evidence A Critical Thinking Model for Clinical Decision Making 13. The clinical thinking model includes five elements of critical thinking in nursing judgement; identify them and give an example: a. Competence- the use of the nursing process and the ability to perform nursing skills proficiently b. Knowledge- basic nursing education, continuing education courses, additional college degrees c. Experience is necessary to acquire clinical decision-making skills. d. Attitudes- confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, intellectual integrity, humility e. Standard- intellectual standards is a guideline or principle for rational thought; professional standards refer to the ethical criteria for nursing judgements and criteria for professional responsibility 14. Confidence- speak with conviction and always be prepared to perform care safely 15. Thinking independently- read the nursing literature 16. Fairness- listen to both sides in any discussion 17. Responsibility- refer to policy and procedure manual to review steps of a skill 18. Risk taking- be willing to recommend alternative approaches to nursing care 19. Discipline- take time to be thorough and manage your time effectively 20. Perseverance- be cautious of any easy answer look for a pattern and find a solution 21. Creativity- look for difference approaches if interventions are not working 22. Curiosity- explore and learn more about a patient to make appropriate clinical judgements 23. Integrity- do not compromise nursing standards or honesty in delivering nursing care 24. Humility- recognize when you need more information to make a decision 25. Identify the two components of “knowing the “patient” a. A nurse’s understanding of a specific patient b. A nurse’s subsequent selection of interventions 26. List the tips suggested to foster knowing your patient. a. Spend more time during initial patient assessment to observe behavior and measure physical findings b. Listen to their accounts of their experiences with illness c. Consistently check on patients to assess and monitor problems d. Ask to have the patient assigned to you over consecutive days e. Social conversation and continuity 27. List ways that you can start developing critical thinking skills. a. Reflective journaling which helps to clarify concepts b. Meeting with colleagues to discuss and examine work experiences and validate decisions c. Concept mapping is a visual representation of patient problems and interventions that show their relationship to one another. Managing Stress 28. Identify some ways the nurse may better manage stress. a. Nurses should take advantage of educational self-help programs for stress management. b. Exercises on grieving and coping with the demands of the dying patients c. Learn assertive communication, conflict resolution, and problem-solving strategies Nursing Assessment Chapter 16 Critical Thinking in Assessment 1. Identify the two steps of a nursing assessment. a. Collection of information from primary (patient) and secondary (family, caregiver) sources b. Interpretation and validation of data to determine if more data is needed or if the database is complete. 2. List some types of nursing assessments. The patient-centered interview during the history, periodic assessments during rounding or administering care and physical examination 3. List Gordon’s 11 functional health patterns. a. Health perception- health management pattern b. Nutritional- metabolic pattern c. Elimination pattern d. Activity- exercise pattern e. Sleep- rest pattern f. Cognitive- perceptual pattern g. Self-perception- self-concept pattern h. Role- relationship pattern i. Sexuality- reproductive pattern j. Coping- stress tolerance pattern k. Value- belief patten 4. Discuss the two primary types of date. a. Subjective data- include patients’ verbal descriptions of their health problems (feeling, perceptions, and self-reported symptoms). b. Objective data- include observations or measurements of a patient’s health status (see, hear, and touch). 5. Identify the variety of sources where data can be obtained. a. Patient is the best source. b. c. d. e. Family caregivers and significant others Health care team Medical records Other records and scientific literature Patient- Centered Interview 6. Describe motivational interviewing A process that addressed a patient’s ambivalence to medically indicated behavior change and supports patients in making health care decisions in cases in which there is more than one reasonable option. 7. List the communication skills that are needed to effectively communicate. a. Courtesy b. Comfort c. Connection d. Confirmation 8. List the three phases of all patient-centered interviews. a. Orientation and setting an agenda b. Working phase- collecting assessment c. Terminating an interview 9. During an interview, the following are used. Briefly explain. a. Observation: nonverbal communication b. Open-ended: prompts patients to describe a situation (tell their story) in more than one or two words. c. Leading question: risky, limits information d. Back channeling: active listening prompts e. Probing: encourages a full description without trying to control the direction of the story f. Close-ended: Limit the patient’s answered to one or two words Nursing Health History 10. Biographical information- factual demographic data about the patient. Ex. Age,gender 11. Reasons for seeking health care- chief concerns or problems 12. Patient expectations- Patient’s understanding of why he or she is seeking health care 13. Present illness/ health concerns- essential and relevant data about the nature and onset of symptoms 14. Health history- health care experiences and current health habits and lifestyle patterns 15. Family history- to determine whether the patient is at risk for illness of a genetic or a familiar nature 16. Environmental history- patient’s home and work, focusing on determining the patient’s safety 17. Psychosocial history- Reveals the patient’s support systems and coping mechanisms 18. Spiritual history- represents the totality of one’s being 19. Review of systems(ROS)- systematic approach for collecting the patient’s self-reported data on all body systems 20. Diagnostic and laboratory data provide- further explanation of alterations or problems identified during the history and physical examination. 21. Define the term data validation: the comparison of data with another source to determine data accuracy 22. A concept map- is a visual representation that allows you to graphically show the connections between a patient’s many health problems. Chapter 17 Nursing Diagnosis Comprehensive Reading 1. Medical diagnosis- identification of a disease condition based on a specific evaluation of the history and physical exam 2. Collaborative problem- is a problem that requires both medicine and nursing interventions to treat 3. Defining characteristics- the clinical criteria or assessment findings that support an actual nursing diagnosis 4. Nursing diagnosis- patient’s response or vulnerability to health conditions or live events that a nurse is license to treat 5. Health promotion nursing diagnosis- desire to increase well-being and actualize human health potential 6. Problem- focused nursing diagnosis- clinical judgement concerning an undesirable human response to a health condition or life process Critical Thinking and the Nursing Diagnostic Process Define the following components of the diagnostic reasoning process. 7. Data cluster- critically organizing all data elements about a patient into meaningful patterns 8. Data interpretation- involves placing a label on your data pattern or cluster to clearly identify a patient’s response to health problems Explain the following components of the nursing diagnosis. 9. Diagnostic label- the name of the diagnosis; it describes the essence of the patient’s response to health conditions 10. Related factor- a patient’s response to a health problem, which is related to a set of conditions that caused or influenced the response 11. Identify the purpose of concept mapping a nursing diagnosis. It is a way to graphically represent the connections among concepts (nursing diagnosis) and ideas that are related to a central subject (patient’s problem) 12. Questions to consider using in making a culturally competent nursing diagnosis. a. How has this health problem affected you and your family? b. What do you believe will help or fix this problem? c. What worries you the most about this problem? d. What cultural practices do you do to keep yourself well? Sources of Diagnostic Errors Identify the sources of error in the steps of the nursing process related to: 13. Errors in data collection: avoid inaccurate or missing data, be thorough in your collection of data 14. Errors in data clustering: insufficient cluster of cues, premature or early closure, incorrect clustering 15. Errors in interpretation and analysis of data: inaccurate interpretation, failure to consider conflicting cues, insufficient number of cues, invalid cues, failure to consider cultural influences 16. Errors in the diagnostic statement: wrong label, evidence exists for another diagnosis, collaborative problem, failure to validate with the patient, failure to seek guidance 17. State the guidelines to use to reduce errors when formulating the diagnostic statement. a. Identify the patient’s response, not the medical diagnosis b. Identify diagnostic statement rather than the symptom c. Identify a related factor or risk factor treatable through nursing intervention d. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself e. Identify the patient’s response to the equipment rather than the equipment itself f. Identify the patient’s problems rather than your problem with nursing care g. Identify the patient’s problem rather than the nursing intervention h. Identify the patient’s needs rather than the goal of care i. Make professional rather than prejudicial judgements j. Avoid legal inadvisable statements k. Identify the problem and etiology to avoid a circular statement l. Identify only one patient problem in the diagnostic statement 18. Explain how you would document a patient’s nursing diagnosis. Enter them either on the written plan of care or in the agency’s electronic health information record. List the nursing diagnosis chronically, placing the highest priority nursing diagnosis first; date the diagnosis at time of entry; review the list; reevaluate the priority. Planning Nursing Care Chapter 18 Establishing Priorities 1. Planning involves- setting priorities based on patient diagnoses and collaborative problems, setting patient-centered goals, and expected outcomes, prescribing individualized nursing interventions appropriate for each diagnosis 2. Nurses establish priorities in relation to importance and time. Briefly explain the following. a. High priority: If untreated, result in harm to the patient or others b. Intermediate priority: involve nonemergent, non-life-threatening needs of the patient c. Low priority: are not always directly related to a specific illness or prognosis but affect a patient’s well being 3. Identify some factors within the health care environment that affect the ability to set priorities. a. Workflow routine of a nursing unit b. Staffing levels c. Interruptions from other care providers d. Available material resources Critical Thinking in Setting Goals and Expected Outcomes 4. Goal- a broad statement that describes a desired change in a patient’s condition or behavior 5. Patient-centered goal- Specific and measurable behavior or response that reflects a patient’s highest possible level of wellness 6. Short-term goal- objective behavior that you expect the patient will achieve in a short time 7. Long-term goal- objective behavior that is expected over a long period 8. Expected outcome- a measurable criterion to evaluate goal achievement 9. Nursing-sensitive patient outcome- an individual, family, or community state, behavior, or perception that is measurable in response to a nursing intervention 10. The SMART approach for writing goals and outcome statement stands for: Specific, Measurable, attainable, realistic, timed Briefly explain the guidelines to follow when writing goals and expected outcomes. 11. Specific- addresses only one behavior or response 12. Measurable- terms describing quality, quantity, frequency, length, or weight allow the nurse to evaluate outcomes precisely. 13. Attainable- for a patient’s health to improve, he or she must be able to attain the outcomes of care that are set; mutually set attainable goals and outcomes. 14. Realistic- a realistic goal or outcome is one that a patient is able to achieve 15. Timed- a time-limited outcome is written so that it indicates when the nurse expects the response to occur Critical Thinking in Planning Nursing Care There are three categories of interventions, and category selection is based on the patient’s needs. Define each. 16. Independent nursing interventions: nurse-initiated interventions that do not require direction or an order from another health care professional 17. Dependent nursing interventions: physician-initiated interventions that require an order from a physician or other health care professional 18. Collaborative interventions: interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals. 19. Identify the six factors the nurse uses to select nursing interventions for a specific patient. a. Desired patient outcomes b. Characteristics of the nursing diagnosis c. Research base knowledge for the intervention d. Feasibility for doing the intervention e. Acceptability to the patient f. Your own competency Systems for Planning Nursing Care 20. Define the purposes of the nursing care plan. The nursing care plan should direct clinical nursing care and decrease the risk of incomplete, incorrect, or inaccurate care. It identifies and coordinates resources for delivering care. It lists the interventions needed to achieve the goals of care. Briefly explain the following types of care plans. 21. Briefly explain what a interprofessional care plan is: focuses on patient priorities and improves the coordination of all patient therapies and communication among all disciplines. 22. Explain the process of “nursing handoffs” as a practice of communication information at the end of the shift. In a “nursing handoff,” nurses collaborate and share information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions. Consulting With Health Care Professionals 23. Consultation is a process in which: the nurse seeks the expertise of a specialist to identify ways to handle problems in patient management or the planning and implementation of therapies. 24. List the six steps of the nurse’s role when seeking consultation. a. Identify the general problem area b. Direct the consultation to the right professional c. Provide the consultant with relevant information about the problem area d. Do not prejudice against or influence the consultants e. Be available to discuss the findings and recommendations f. Incorporate the recommendations into the plan of care Ch 19 Implementing Nursing Care Comprehensive understanding 1. Define the fourth step of the nursing process. Implementation begins after the nurse develops a plan of care. The interventions are designed to achieve the goals and expected outcomes needed to support or improve the patient’s health status. 2. Define the following terms related to a nursing intervention. a. Direct care- treatments performed through interacts with patients b. Indirect care- treatments performed away from the patient but on behalf of the patient 3. a. b. c. d. e. f. g. List the domains of nursing practice when intervening with patients. Helping role Teaching- coaching function Diagnostic and patient monitoring function Effective management of rapidly changing situations Administering and monitoring therapeutic interventions and regimens Monitoring and ensuring the quality of health care practices Organizational and work role competencies Clinical Practice Guidelines and Protocols Define the following terms. 4. Clinical practice guideline: protocol, is a systematically developed set of statements about interventions for specific health care problems or clinical situations 5. Standing order: preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, or diagnostic procedures for patients with identified clinical problems. 6. Nursing Interventions Classification (NIC) interventions: offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes. Critical Thinking in Implementation 7. Briefly explain the activities for making decisions during implementation. a. Review the set of all possible nursing interventions for a patient’s problem b. Review all possible consequences associated with each possible nursing action c. Determine the probability of all possible consequences d. Judge the value of the consequence to the patient Implementation Process Briefly explain the five preparatory activities for implementation of safe and effective nursing care. 8. Reassessing the patient: a continuous process that occurs each time you interact with the patient; you collect new data, identify a new patient need, and modify the care plan. 9. Review and revise the existing nursing care plan: If the patient’s status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan. 10. Organize resources and care delivery- time management, equipment, personnel, environment, and the patient 11. Anticipate and prevent complications: risks to patients come from both the illness and the treatments. Observe for and recognize risks, adapt your choice of interventions to each situation, assess the relative benefit of the intervention vs the risk, and take riskprevention measures. 12. Implement nursing interventions: implementation skills include cognitive (application of critical thinking in the nursing process), interpersonal (trusting relationship, level of caring, and communication), and psychomotor skills (integration of cognitive and motor activities) Direct Care 13. Define Activities of daily living(ADLSs): activities usually performed in the course of a normal day, such as ambulation, eating, dressing, bathing, and grooming 14. Instrumental ADLS’s (IADLs) include skills such as shopping, preparing meals, writing checks, and taking medications. 15. Physical care techniques include: the safe and competent administration of nursing procedures 16. Lifesaving measures are: physical care techniques that are used when a patient’s physiological or psychological state is threatened 17. Counseling is: direct care method that helps the patient use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships 18. The focus of teaching is: intellectual growth or the acquisition of new knowledge or psychomotor skills 19. An adverse reaction is: a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention 20. Preventive nursing actions: promote health and prevent illness to avoid the need for acute or rehabilitative health care Achieving Patient Goals 21. Patient adherence is: when patients and families invest time in carrying out required treatments to achieve patient goals. Ch 20. Evaluation Critical Thinking in Evaluation 1. Evaluation is the fifth step of the nursing process that determines: Whether a patient’s condition or well-being improved after nursing interventions were delivered 2. a. b. c. d. Identify the four actions that show a nurse is competent to perform an evaluation. Examine the results of care according to clinical data collects Compare achieved effects or outcomes with goals and expected outcomes Recognize errors or omissions Understand a patient situation, reflect on the situation, and correct the errors 3. List the benefits of the Nursing Outcomes Classification (NOC). a. Provide a means for nurses and other health care providers to evaluate the status of patients b. Providing an outcome measurement system c. Offers a means to quantify the change in patient status after nursing interventions and to monitor patient progress 4. An outcome is: A statement of progressive, step-by-step physical, emotional, or behavioral responses that a patient needs to accomplish to achieve the goals of care desired patient behavior. 5. List the steps to evaluate the degree of success in achieving the outcomes of care a. Examine the outcome criteria to identify the exact desired patient behavior b. Assess the patient’s actual behavior or response c. Compare the established outcome criteria with the actual behavior d. Judge the degree of agreement between outcome criteria and the actual behavior e. If there is no agreement between the outcome criteria and the actual behavior, what are the barriers? 6. Reflection in action involves: the nurse’s ability to recognize how a patient is responding and then adjusting interventions as a result. Briefly explain the following parts of the evaluative process. 7. Care plan revision: each time the nurse evaluates a patient, he or she determines if the plan of care should continue, discontinue, or be revised 8. Discontinuing a care plan: if the nurse and patient agree that the expected outcomes and goals have been met, then that proportion of the care plan is discontinued. 9. Modifying a care plan: identify the factors that interfere with goal achievement 10. Redefining the diagnosis: After reassessment, determine which nursing diagnosis is accurate for the situation and if the related factor or risk factor is accurate. 11. Revising goals and expected outcomes: is each goal and expected outcome realistic for the problem, etiology, and time frame? 12. Revising interventions: Examine the appropriateness of the intervention and the correct application of the intervention 13. Documenting outcomes: Collaboration: patient-centered care is only achieved when a patient and family are actively involved in the evaluation process. Standards for Evaluation 14. Identify the responsibilities of documenting and reporting. The nurse is responsible for consistent, thorough documentation of the patients progress toward the expected outcomes and use of nursing diagnostic language.