Critical thinking, nursing diagnoses, and concept maps

Critical Thinking

application of knowledge and experience to identify patient problems and to direct clinical judgements and actions that result in positive patient outcomes

Clinical Judgment

the observed outcome of critical thinking and decision-making; an iterative (repetitive) process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care

Critical thinking steps- thinking ahead

being prepared, anticipating potential challenges, and identifying needed resources

Critical thinking steps- thinking-in-action

requires knowledge and practical experience; thinking about multiple options and safely acting simultaneously

Critical thinking- thinking back

reflection on what worked, what could be improved, and what to do differently next time

Clinical Judgment- Step 1

recognize cues

Clinical Judgment- Step 2

analyze cues

Clinical Judgment- Step 3

prioritize hypotheses

Clinical Judgment- Step 4

generate solutions

Clinical Judgment- Step 5

take actions

Clinical Judgment- Step 6

evaluate outcomes

Thinking like a nurse steps

foundational knowledge and skills, critical thinking, and clinical judgment leading to positive patient outcomes

Foundational knowledge & skills

supports critical thinking and clinical judgment

Critical thinking- thinking ahead (examples)

ATI modules due before lab; simulation prep work; reading chapters before lecture; lab activities

Critical thinking- thinking in action (examples)

simulations in lab; patient care at clincal

Critical thinking- thinking back (examples)

written reflections; debriefing after simulations

Clinical Judgment Measurement Model (CJMM)

National Council of State Board of Nursing’s model used to measure clinical judgment

CJMM Purpose

Each step/layer is a thought process integral to making sound clinical decisions in the moment

NCLEX and CJMM

The NCLEX exam measures the six steps of the CJMM

CJMM – Step 1

Recognize Cues

Recognize Cues

Identify relevant and important information from different sources

Recognize Cues – Key Questions

What information is relevant or irrelevant? What information is most important? What is of immediate concern?

Recognize Cues – Strategy

Highlight or underline cues on the case study paper that are relevant and important

CJMM – Step 2

Analyze Cues

Analyze Cues

Organize and link the recognized cues to the client’s clinical presentation

Analyze Cues – Key Questions

What client conditions are consistent with the cues? Are there cues that support or contraindicate a particular condition? Why is a particular cue or subset of cues a concern? What other information would help establish the significance of a cue or set of cues?

Analyze Cues – Strategy

Review identified cues and group them into related categories; give each category a name that describes the issue

CJMM – Step 3

Prioritize Hypotheses

Prioritize Hypotheses – Considerations

Urgency, likelihood, risk, difficulty, time

Prioritize Hypotheses – Key Questions

Which explanations are most or least likely? Which possible explanations are most serious?

Medical diagnosis

labels for diseases or symptoms

Nursing diagnosis

description of what a nurse observes or discovers during an assessment

What may a nursing diagnosis include?

a single patient, families, enitre communities, or a population

What may a nursing diagnosis address?

an actual problem, a potential problem, or an opportunity for improvement (health promotion)

Example of a medical diagnosis

stage 3 pressure ulcer

Example of nursing diagnosis

risk for infection

Problem statement (example)

impaired skin integrity related to immobility as evidenced by superficial wound on coccyx

Nursing diagnosis (example)

impaired skin integrity

Related to (example)

immobility

As evidenced by (example)

superficial wound on coccyx

Risk nursing diagnosis (example)

risk for falls related to weakness, history of stroke, and diabetic neuropathy

Problem-focused diagnosis sentence template

problem-focused diagnosis related to ____(related factors) as evidenced by ____ (defining characteristics)

Risk diagnosis sentence template

risk for ___ as evidenced by ___ (risk factors)

CJMM – Step 4

Generate solutions

Generate Solutions

Identify expected outcomes (goals) and use hypotheses to define interventions

Generate Solutions — Key Questions

What are the desirable outcomes? What interventions can achieve those outcomes? What should be avoided?

SMART Goals

Desired outcomes written in a structured format

SMART- S

specific

SMART- M

measurable

SMART- A

achievable/acceptable

SMART- R

realistic/relevant

SMART- T

time frame

Short-term goal

achievable in less than one week

Long-term goal

takes weeks or months to achieve

SMART-Goal Example — Short-Term

Patient’s oral intake will equal 1600 mL per day within 72 hours

SMART Goal Example — Long-Term

Patient’s oral input and output will be equal within 2 weeks

CJMM – Step 6

Evaluate outcomes

Evaluate Outcomes

Compare observed outcomes against expected outcomes

Goal Evaluation Options

Yes (goal met), No (goal not met), Not yet (more time needed)

Evaluate Outcomes — Key Rule

Evaluate if the GOAL was met, not whether interventions were completed

Concept Map

A written method of demonstrating critical thinking to support and develop clinical judgment

Concept Map — Step 2

Analyze cues by clustering them to identify problem

Concept Map — Step 3

Prioritize hypotheses and create a nursing diagnosis

Concept Map — Step 4

Generate solutions by creating short- and long-term SMART goals

Concept Map — Step 5

Take action by developing and implementing nursing interventions

Concept Map — Step 6

Evaluate outcomes by determining if SMART goals were met