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Critical Thinking in Nursing Critical Thinking in Nursing PracticePractice
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CRITICAL THINKINGCRITICAL THINKING
Critical thinking is an Critical thinking is an active, organized, active, organized, cognitive process used cognitive process used to carefully examine to carefully examine one’s thinking and the one’s thinking and the thinking of others (Pg. thinking of others (Pg. 216)216) Recognize that an issue Recognize that an issue
existsexists Analyzing information Analyzing information
about the issueabout the issue Evaluating information Evaluating information Making conclusionsMaking conclusions
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Critical Thinking Requires…Critical Thinking Requires…
Cognitive skillsCognitive skills Ask questionsAsk questions Remain well-informedRemain well-informed Be honest in facing personal biasesBe honest in facing personal biases Be willing to reconsider and think Be willing to reconsider and think
clearly about issuesclearly about issues
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Attributes of a Critical Attributes of a Critical ThinkerThinker
Asks pertinent questionsAsks pertinent questions Is able to admit a lack of Is able to admit a lack of
understanding or informationunderstanding or information Is interested in finding new Is interested in finding new
solutionssolutions Listens carefully to others Listens carefully to others
and is able to give feedbackand is able to give feedback Examines problems closelyExamines problems closely
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Critical Thinking Can Lead Critical Thinking Can Lead To…To…
Sound clinical Sound clinical decisionsdecisions
Using the Nursing Using the Nursing Process to guide Process to guide patient carepatient care
Evidence-Based Evidence-Based Practice (EBP)Practice (EBP)
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Nursing ProcessNursing Process
DefinitionDefinition The act of reviewing the patient’s The act of reviewing the patient’s
situation in order to obtain information situation in order to obtain information of past history, present status, and to of past history, present status, and to identify patient current and potential identify patient current and potential problems and needsproblems and needs
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Developing Critical Thinking Developing Critical Thinking SkillsSkills
Reflection = the process of Reflection = the process of purposefully thinking back or purposefully thinking back or recalling a situation to discover its recalling a situation to discover its purpose or meaningpurpose or meaning
Concept mapping – see other power Concept mapping – see other power pointpoint
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Nursing AssessmentNursing Assessment
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Nursing Process (ADPIE)Nursing Process (ADPIE) AAssessmentssessment
Nursing Nursing DDiagnosisiagnosis
PPlanninglanning
IImplementation/Interventionmplementation/Intervention
EEvaluationvaluation
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AssessmentAssessment The deliberate and systematic collection The deliberate and systematic collection
of data to determine a client’s current of data to determine a client’s current and past health status and functional and past health status and functional status and to determine the client’s status and to determine the client’s present and past coping patterns.present and past coping patterns. Collection and verification of dataCollection and verification of data
Primary source = patientPrimary source = patient Secondary source = family, medical recordSecondary source = family, medical record
Analysis of dataAnalysis of data
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Data CollectionData Collection
SubjectiveSubjective Patient statesPatient states
ObjectiveObjective Observations or Observations or
MeasurementsMeasurements VitalsVitals Inspection of a Inspection of a
woundwound
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Methods of Data CollectionMethods of Data Collection InterviewInterview
Helps clients relate their own interpretation Helps clients relate their own interpretation and understanding of their conditionand understanding of their condition
Three phasesThree phases Orientation Orientation
Begin a relationshipBegin a relationship Understand client’s primary needsUnderstand client’s primary needs
WorkingWorking Gather information about the client’s health statusGather information about the client’s health status
TerminationTermination
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Methods of Data Collection Methods of Data Collection Cont’d.Cont’d.
Nursing Health HistoryNursing Health History Biographical informationBiographical information Reason for seeking health careReason for seeking health care Client expectationsClient expectations Present illness or health concernsPresent illness or health concerns Health historyHealth history Family historyFamily history Environmental history (work, home, exposure)Environmental history (work, home, exposure) Psychosocial history (support system, coping Psychosocial history (support system, coping
skills)skills) Spiritual healthSpiritual health Review of systemsReview of systems Documentation of findingsDocumentation of findings
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Putting It All TogetherPutting It All Together Physical examPhysical exam Observe client behaviorObserve client behavior Diagnostic and laboratory dataDiagnostic and laboratory data Interpreting assessment data and making Interpreting assessment data and making
nursing judgmentsnursing judgments Validate data, ensure it isn’t an inferenceValidate data, ensure it isn’t an inference Holistic perspective for better clinical Holistic perspective for better clinical
decision makingdecision making Leads to nursing diagnosisLeads to nursing diagnosis
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Nursing Nursing DiagnosisDiagnosis
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Nursing DiagnosisNursing Diagnosis
Classifies health problems within the Classifies health problems within the domain of nursingdomain of nursing DOMAINDOMAIN
A TERRITORY GOVERNED BY A SINGLE A TERRITORY GOVERNED BY A SINGLE RULERRULER
A REALM OR RANGE OF PERSONAL A REALM OR RANGE OF PERSONAL KNOWLEDGE AND RESPONSIBILITYKNOWLEDGE AND RESPONSIBILITY
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Nursing Diagnosis Cont’d.Nursing Diagnosis Cont’d.
A nursing diagnosis is a clinical A nursing diagnosis is a clinical judgment about individuals, families, judgment about individuals, families, or communities and their responses or communities and their responses to actual and/or potential health to actual and/or potential health problems or life processes (problems or life processes (Pg. 248)Pg. 248)
(NANDA International, 2007)(NANDA International, 2007)
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Problem List Problem List
Fractured hip – In tractionFractured hip – In traction ConfusionConfusion Hypertension (HTN)Hypertension (HTN) Insulin Dependent Diabetes (IDDM)Insulin Dependent Diabetes (IDDM) History of fallsHistory of falls Atrial Fibrillation (A-fib)Atrial Fibrillation (A-fib) PainPain
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TRACTIONTRACTION
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Establishing PrioritiesEstablishing Priorities
Helps nurses to anticipate and Helps nurses to anticipate and sequence nursing interventions sequence nursing interventions
Classification of priorities:Classification of priorities: High = if untreated may result in harmHigh = if untreated may result in harm Intermediate = non-life threatening Intermediate = non-life threatening
needsneeds Low = not always directly related to Low = not always directly related to
specific illness or prognosis; affects the specific illness or prognosis; affects the client’s future well-beingclient’s future well-being
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Potentials for Nursing Potentials for Nursing DiagnosisDiagnosis
SafetySafety ConfusionConfusion History of fallsHistory of falls
Skin integritySkin integrity ImmobilityImmobility
PainPain Fractured hipFractured hip
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Building A Nursing DiagnosisBuilding A Nursing Diagnosis
11. . PROBLEMPROBLEM
2. 2. ETIOLOGYETIOLOGY
3. 3. SYMPTOMSSYMPTOMS
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PESPES
PROBLEMPROBLEM
P –P – At risk for impaired skin integrityAt risk for impaired skin integrity
RELATED TO (R/T) RELATED TO (R/T)
E –E – ImmobilizationImmobilization
AS EVIDENCED BY (AEB)AS EVIDENCED BY (AEB)
S –S – Bedrest and tractionBedrest and traction
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Planning Planning Nursing CareNursing Care
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Goals and Outcomes Goals and Outcomes
States in terms of States in terms of PATIENTPATIENT goals and goals and outcomesoutcomes Not Not NURSINGNURSING goals goals
May be short, intermediate or long May be short, intermediate or long term (>one week)term (>one week)
Written using “S-M-A-R-T” acronymWritten using “S-M-A-R-T” acronym
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S-M-A-R-TS-M-A-R-T Specific: Specific: What needs to be What needs to be
accomplished?accomplished? Measurable: Measurable: How will we know when How will we know when
the goal has been met?the goal has been met? Attainable: Attainable: Possible to meet goal with Possible to meet goal with
available resources.available resources. Realistic: Realistic: Patient must have the Patient must have the
capacity to meet the goal.capacity to meet the goal. Time-specific: Time-specific: When will the goal be When will the goal be
achieved?achieved?
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Guidelines for Writing GoalsGuidelines for Writing Goals
PATIENT CENTEREDPATIENT CENTERED
OBSERVABLEOBSERVABLE
TIME LIMITEDTIME LIMITED
REALISTICREALISTIC
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Establishing Goals and Establishing Goals and Expected OutcomesExpected Outcomes
GoalGoal A broad statement that A broad statement that
describes the desired change in describes the desired change in a client’s condition or behaviora client’s condition or behavior
Expected OutcomeExpected Outcome Measurable criteria to evaluate Measurable criteria to evaluate
goal achievement; a specific goal achievement; a specific measurable change in a client’s measurable change in a client’s status that you expect to occur status that you expect to occur in response to nursing carein response to nursing care
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GoalsGoals
Client-CenteredClient-Centered A specific and measurable behavior or A specific and measurable behavior or
response; “PATIENT WILL”response; “PATIENT WILL” Short-termShort-term
An objective behavior or response An objective behavior or response expected within hours to a weekexpected within hours to a week
Long-termLong-term An objective behavior or response An objective behavior or response
expected within days, weeks, or expected within days, weeks, or monthsmonths
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Goal StatementGoal Statement
PATIENT’S SKIN WILL REMAIN INTACT PATIENT’S SKIN WILL REMAIN INTACT THROUGHOUT HOSPITALIZATION. THROUGHOUT HOSPITALIZATION.
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GoalGoal Client CenteredClient Centered
Skin will remain Skin will remain intactintact
Observable?Observable? YesYes
Time Limited Time Limited During During
hospitalizationhospitalization Realistic?Realistic?
YesYes
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NIC/NOCNIC/NOC Nursing Outcomes ClassificationNursing Outcomes Classification
Published by the Iowa Intervention ProjectPublished by the Iowa Intervention Project Linked to NANDA International nursing Linked to NANDA International nursing
diagnosesdiagnoses Nursing Interventions ClassificationNursing Interventions Classification
Three levelsThree levels Domains: use broad terms to organize the more Domains: use broad terms to organize the more
specific classes and interventionsspecific classes and interventions Classes: 30 which offer useful clinical categories to Classes: 30 which offer useful clinical categories to
refer to when selecting interventionsrefer to when selecting interventions Interventions: 542 treatments based upon clinical Interventions: 542 treatments based upon clinical
judgment and knowledge that a nurse performs to judgment and knowledge that a nurse performs to enhance outcomesenhance outcomes
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ImplementinImplementing Nursing g Nursing
CareCare
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Nursing InterventionsNursing Interventions
Any treatment, based upon Any treatment, based upon clinical judgment and clinical judgment and knowledge, that a nurse knowledge, that a nurse performs to enhance client performs to enhance client outcomesoutcomes Direct = tx performed through Direct = tx performed through
interactions with clientinteractions with client Indirect = tx performed away from Indirect = tx performed away from
the client but on behalf of the clientthe client but on behalf of the client
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Types of InterventionsTypes of Interventions
Nurse InitiatedNurse Initiated IndependentIndependent
Physician InitiatedPhysician Initiated DependentDependent
CollaborativeCollaborative InterdependentInterdependent
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Planning Nursing CarePlanning Nursing Care
DECIDE ON DECIDE ON AN AN INTERVENTIOINTERVENTION TO N TO PREVENT SKIN PREVENT SKIN BREAKDOWNBREAKDOWN
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InterventionsInterventions
Nursing OrdersNursing Orders Reposition every two hoursReposition every two hours Skin care to all boney Skin care to all boney
prominences with repositioningprominences with repositioning RN skin assessment every shiftRN skin assessment every shift
MD OrdersMD Orders Specific dressings/ointments to Specific dressings/ointments to
woundswounds Collaborative OrdersCollaborative Orders
Wound care consultWound care consult
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EvaluationEvaluation
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EvaluationEvaluation
You conduct evaluative measures to You conduct evaluative measures to determine if you met expected determine if you met expected outcomes, not if nursing outcomes, not if nursing interventions were completedinterventions were completed
Did you meet the expected Did you meet the expected goal/outcome?goal/outcome?
Evaluation is ongoing, as is the Evaluation is ongoing, as is the nursing processnursing process
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The Nursing Process in The Nursing Process in Ongoing CareOngoing Care
Each care plan must evolve as the Each care plan must evolve as the patient progressespatient progresses
Based on evaluation (assessment), Based on evaluation (assessment), the nursing diagnoses, priorities, and the nursing diagnoses, priorities, and interventions will changeinterventions will change
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Time Factor in Setting PrioritiesTime Factor in Setting Priorities
The planning of nursing care occurs The planning of nursing care occurs in three phases:in three phases: InitialInitial OngoingOngoing Discharge PlanningDischarge Planning
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CommunicationCommunication
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Communication and Nursing Communication and Nursing PracticePractice
Communication is a lifelong learning processCommunication is a lifelong learning process Functioning as a client advocate, nurses need Functioning as a client advocate, nurses need
to be assertiveto be assertive The intimate moment of connection that The intimate moment of connection that
makes all the difference in the quality of care makes all the difference in the quality of care and meaning for the client and the nurseand meaning for the client and the nurse
Effective communication helps maintain Effective communication helps maintain effective relationships and helps meet legal, effective relationships and helps meet legal, ethical, and clinical standards of careethical, and clinical standards of care
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Communication and Communication and Interpersonal RelationshipsInterpersonal Relationships
Requires a sense of mutuality and a Requires a sense of mutuality and a belief that the nurse-client belief that the nurse-client relationship is a partnership and both relationship is a partnership and both are equal participantsare equal participants
Every nuance of posture, every small Every nuance of posture, every small expression and gesture, every word expression and gesture, every word chosen, and every attitude held all chosen, and every attitude held all have the potential to hurt or healhave the potential to hurt or heal
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Levels of CommunicationLevels of Communication
Intrapersonal = Occurs within an individualIntrapersonal = Occurs within an individual Interpersonal = One-to-one interactionInterpersonal = One-to-one interaction Transpersonal = Occurs within a person’s Transpersonal = Occurs within a person’s
spiritual domain; prayer, meditation, spiritual domain; prayer, meditation, guided reflection, religious ritualsguided reflection, religious rituals
Small-Group = Occurs when a small Small-Group = Occurs when a small number of persons meet togethernumber of persons meet together
Public = Interaction with an audiencePublic = Interaction with an audience
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Basic Elements of the Basic Elements of the Communication ProcessCommunication Process
Referent = refers to, object of conversationReferent = refers to, object of conversation Sender and Receiver = encodes and decodesSender and Receiver = encodes and decodes Messages = content of the communicationMessages = content of the communication Channels = means of conveying and Channels = means of conveying and
receiving messages through sensesreceiving messages through senses Feedback = the message the receiver Feedback = the message the receiver
returnsreturns Interpersonal Variables = factors that Interpersonal Variables = factors that
influence communication; perceptioninfluence communication; perception Environment = the setting for the Environment = the setting for the
interaction; needs to meet participant needsinteraction; needs to meet participant needs
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Nonverbal CommunicationNonverbal Communication
Personal appearancePersonal appearance Posture and gaitPosture and gait Facial expressionsFacial expressions Eye contactEye contact GesturesGestures SoundsSounds Territoriality and Territoriality and
Personal spacePersonal space
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Professional Nursing Professional Nursing RelationshipsRelationships
Nurse-Client Helping RelationshipsNurse-Client Helping Relationships Nurse-Family RelationshipsNurse-Family Relationships Nurse-Health Care Team Nurse-Health Care Team
RelationshipsRelationships Nurse-Community RelationshipsNurse-Community Relationships
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Elements of Professional Elements of Professional CommunicationCommunication
Courtesy = hello, knockCourtesy = hello, knock Use of names = convey respectUse of names = convey respect Trustworthiness = without doubt or Trustworthiness = without doubt or
questionquestion Autonomy and responsibility = self-Autonomy and responsibility = self-
directed and independentdirected and independent Assertiveness = express feelings and Assertiveness = express feelings and
ideas without judging or hurting othersideas without judging or hurting others
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SBARSBAR
SSituationituation BBackgroundackground AAssessmentssessment RRecommendationecommendation
ss
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Communicating ClearlyCommunicating Clearly
Using SBAR facilitates accurate Using SBAR facilitates accurate communication between:communication between: NURSES AND PHYSICIANSNURSES AND PHYSICIANS NURSES AND COLLEAGUESNURSES AND COLLEAGUES
Recommended by Joint Commission Recommended by Joint Commission (JCAHO) and the Institute for (JCAHO) and the Institute for Healthcare Improvement (IHI)Healthcare Improvement (IHI)
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SSituationituation
Identify selfIdentify self Where are you calling Where are you calling
from?from? What is the patient’s What is the patient’s
name?name? What is the problem?What is the problem?
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BBackgroundackground
DiagnosisDiagnosis Pertinent Pertinent
information:information: Vital signs/Pulse Vital signs/Pulse
oximetryoximetry Current Current
medicationsmedications Mental statusMental status
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AAssessmentssessment
Nurse’s assessment of the situationNurse’s assessment of the situation Could be …….Could be ……. Might be ……..Might be …….. I have no idea what is going on!I have no idea what is going on!
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RRecommendationecommendation
Could I have an Could I have an order for .…?order for .…?
Would you like to Would you like to change ….?change ….?
I have tries XYZ I have tries XYZ without results. without results. Could I ….? Could I ….?
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Therapeutic CommunicationTherapeutic Communication
Specific responses that Specific responses that encourage the expression of encourage the expression of feelings and ideas and feelings and ideas and convey acceptance and convey acceptance and respectrespect
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Components of Therapeutic Components of Therapeutic CommunicationCommunication
Active listeningActive listening Sharing Sharing
observationsobservations Sharing empathySharing empathy Sharing hopeSharing hope Sharing humorSharing humor Sharing feelingsSharing feelings Using touchUsing touch Using silenceUsing silence
ClarifyingClarifying FocusingFocusing ParaphrasingParaphrasing Asking relevant Asking relevant
questionsquestions SummarizingSummarizing Self disclosureSelf disclosure ConfrontationConfrontation
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Non-Therapeutic Non-Therapeutic CommunicationCommunication
Asking personal Asking personal questionsquestions
Giving personal Giving personal opinionsopinions
Changing the Changing the subjectsubject
Automatic Automatic responsesresponses
False reassuranceFalse reassurance
SympathySympathy Approval or Approval or
disapprovaldisapproval Defensive Defensive
responsesresponses Passive or Passive or
aggressive aggressive responsesresponses
ArguingArguing
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Why Does Communication Why Does Communication Break Down?Break Down?
COMMUNICATION COMMUNICATION STYLESSTYLES
HIGH LEVEL OF HIGH LEVEL OF ACTIVITYACTIVITY
FREQUENT FREQUENT INTERUPTIONSINTERUPTIONS
INATTENTION INATTENTION