1. Nursing Process and Critical Thinking
Chapter 4
Nursing Process and Critical Thinking
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Chapter 4
Lesson 4.1
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Learning Objectives Theory Explain the use of the nursing process.
Identify the components of the nursing process.
Compare and contrast the terms critical thinking, clinical reasoning, and clinical judgment.
Identify the steps of the problem-solving process.
List the steps used in making decisions.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Learning Objectives Theory
Identify ways to improve critical reasoning skills.
Apply the critical thinking process to a real-life problem.
Discuss the use of critical thinking in nursing.
Clinical Practice
Apply nursing process to a patient care assignment.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. The Nursing Process
A way of thinking and acting based on the scientific method
Used as a tool identify patients’ problems and an organized method to meet patients’ needs
It was developed in the 1950s to describe the independent role of the nurse in providing patient care.
What are the goals of the nursing process?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

6. The Nursing Process (cont’d)
Components of the nursing process
Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
The construction of a plan of care for the patient is a collaborative process among the nurse, the patient, and other health team members.
Patient input during the planning stage results in more success with the plan of care.
How is the nursing process similar to other methods used to organize tasks in daily life?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

7. Assessment
Collecting, organizing, documenting, and validating a patient’s health data
Data are gathered from patient (physical assessment and interview) and family, as well as from the physician and patient’s medical record
Data from other health professionals and diagnostic tests included in assessment
Using hypothetical examples of patients with prevalent health conditions such as diabetes, congestive heart failure, or from a cancer diagnosis, what are some examples of data that are likely to be gathered from the various sources?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Nursing Diagnosis
Sorting and analyzing the assessment data to identify potential health problems
Problems identified during the process are specific nursing diagnoses
Nursing diagnoses prioritized and entered into the nursing plan of care
On what level does a nurse arrive at a diagnosis?
How does the nursing diagnosis complement the overall patient history?
Only RNs are to develop a nursing diagnosis. LPN/LVNs use the nursing diagnosis and interventions planned by the RN to provide patient care. It is important to know why the RN develops the nursing diagnosis in order for you to suggest changes based on the patient’s condition.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Planning
A series of steps in which the nurse and the patient set priorities and goals to eliminate, diminish, or control identified problems
Goals should be stated with specific outcomes
Nurse and patient collaborate to choose specific interventions to enable the patient to meet the specific outcomes listed in the plan of care
Using your hypothetical patients with prevalent diseases, what are some planning steps likely to be needed? What are the desired outcomes for the diabetic or the CHF patient, for example?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Implementation
Carrying out nursing interventions prioritized during the planning process
Some interventions may be delegated or carried out by other members of the health care team
Which tasks in the care plan are likely to require a staff nurse and which tasks might be delegated to a student nurse?
How should the work be monitored to ensure safe procedures?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Evaluation
Assessing the patient to evaluate his or her response to the nursing interventions
Responses compared with expected outcomes to evaluate whether outcomes have been met
Based on results from the evaluation process, the nursing plan of care may need to be changed
Again, referring to the hypotheticals, what are some likely outcomes, both healthy and unhealthy?
In the latter cases of poor health outcomes, how might the nursing plan be changed to address these?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Critical Thinking Required to use the nursing process successfully
Means requiring careful judgment
Directed, purposeful mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are decided
What is the difference between memorization and critical thinking?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Critical Thinking (cont’d)
Problem solving and decision making
First define the problem clearly
Second, consider all possible alternatives as solutions
Third, consider outcomes for each alternative
Fourth, predict likelihood of each outcome occurring
Finally, choose alternative with best chance of success and fewest undesirable outcomes
What is good decision making?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Skills for Critical Thinking
Effective reading
Effective writing
Attentive listening
Effective communicating
Practicing careful consideration of problems and purposeful thinking, rather than random thinking, will help you develop these skills and attributes.
Why is critical thinking necessary?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Critical Thinking in Nursing
Requires skills and experience as well as knowledge
Influenced by professional standards and codes of ethics
The use of facts and details assists in the formation of active resolutions of problems.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Critical Thinking and Nursing (cont’d)
Critical thinking and the nursing process
Assessment: organized and systematic; includes gathering and recording data
Nursing diagnosis requires analysis of data gathered, clustering related information, identifying problem areas, and choosing appropriate nursing diagnoses
Planning involves determining specific desired outcomes for each nursing diagnosis
During assessment, what specific, detailed data and information will the nurse collect, and from which sources?
While planning interventions to achieve those outcomes, one considers way to promote optimum wellness and independence.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Critical Thinking and Nursing (cont’d)
Critical thinking and the nursing process
Implementation involves preparing for and performing the interventions
Evaluation involves gathering data to determine if expected outcomes have been achieved
During implementation, equipment and supplies are gathered and procedures are thought through before beginning them. Responses to interventions are also assessed.
If the expected outcomes are not achieved, the plan of care needs to be reconsidered.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Question 1
Which of the following is an example of a nurse’s statement that reflects using the scientific method in the nursing process?
“I believe that this patient is getting depressed.”
“The patient doesn’t look right to me; I think something is wrong.”
“The patient’s husband told me that she is feeling very uncomfortable.”
“The patient reports more pain than yesterday and her blood pressure is elevated.”
Answer: 4
Rationale: “Reporting more pain than yesterday and elevated blood pressure” reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the patient is depressed or thinking something is wrong reflects intuition. Speaking with the husband reflects information-gathering, which may be used in diagnostic reasoning.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Chapter 4
Lesson 4.2
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Learning Objectives Theory
Explain the basic principles of setting priorities for nursing care.
List factors to be considered when setting priorities.
Clinical Practice
Use critical thinking to prioritize care for a patient assignment.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Priority Setting and Work Organization
Priority setting (prioritizing): placing nursing diagnoses/interventions in order of importance
High priority: life-threatening problems
Medium priority: problems that threaten health or coping ability
Low priority: problems that do not have a major effect on the person if not attended to that day or week
Nurses must be able to prioritize the tasks assigned to them.
Prioritizing patient problems is usually based on the adaptation of Maslow’s hierarchy of needs.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Organizing Workload Priorities change as patient conditions change
To maintain an organized workload you must:
Write out a worksheet; list major tasks to accomplish
Be flexible and frequently reorder your tasks
Evaluate and reprioritize work plan at least every 2 hours
Know when to ask for help and when to delegate a task to others
Why is it important for a nurse to be flexible and reevaluate the work plan at least every 2 hours?
What should a nurse do if he is overwhelmed or does not know how to proceed to address the workload?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Application of Problem Solving and Critical Thinking
Goal is to avoid having your decision cause injury to anyone
With critical thinking skills, you can weigh many factors and skillfully solve problems, making good decisions a majority of the time
Operating in critical thinking mode while pursuing nursing studies helps develop clinical judgment needed to practice safe nursing
The nursing process is a way of thinking as well as organizing.
The nurse is constantly gathering data and evaluating.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Question 2
Which of the following nursing actions is the best example of problem solving?
Requesting the IV team to start an antibiotic drip on a patient with a history of being a difficult stick
Offering to call the kitchen to provide an alternate breakfast for a patient who does not like cooked cereal
Trying several difficult wound dressings to determine which one the patient can apply the most effectively
Calling for another pain medication order when the current drug results in the patient experiencing nausea
Answer: 3
Rationale: This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the patient. Effective problem solving involves the examination of alternatives. While requesting the IV team solve a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.