Critical Thinking & The Nursing Process

Critical Thinking

• aka “the process”

• active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others

Clinical Judgment

• aka “the final decision”

• the way nurses come to understand the problems, issues, or concerns of patients, attend to info, and respond in a concerned and involved way

How do you think critically and make clinical judgements?

(diagram)

Nursing Process: ADPIE

• A: Assessment (recognize cues)

• D: Diagnosis (analyze cues and prioritize hypotheses

• P: Planning (generate solutions)

• I: Implementation (take action)

• E: Evaluation (evaluate outcomes)

Which ADPIE: Looking at the stove, are my burners on? Is it plugged in? Is the power out?

• Assess example

Which ADPIE: Realize I turned on the wrong burner.

• Diagnose example

Which ADPIE: How do I fix this? What’s the goal?

• Plan example

Which ADPIE: Turn on the correct burner.

• Implement / Take action example

Which AIDPIE: Is my water heating now?

• Evaluate example

ADPIE in Nursing

• Assess: collect info

• Diagnose: identify actual or potential problems

• Plan: make a plan based on the problem

• Implement: take action

• Evaluate: did it work?

Assessment Definition

• deliberate and systematic collection of patient info

• info gathered tells us a lot about the patient

Assessment Purpose

• helps establish a baseline

• identify risk factors

• individualize care

• helps develop a nursing diagnosis

A: Recognizing Cues Process (3)

1. data collection

2. validation of data

3. interpretation of data

A: Data Collection Process

1. observation

2. interview

   1. orientation phase

   2. working phase

   3. termination phase

3. examination

4. interpretation of data

Types of Data Collections and Definitions

• subjunctive (what they say)

• objective (what you see)

Components of Nursing Health History (10)

AIDPIE: Diagnosis Definition

• the patient’s actual or potential response to a health problem that is used as the basis for outcomes and nursing interventions

• analyze cues and prioritize hypotheses

Types of Diagnoses (2)

• medical diagnosis

  • identifies the disease/condition based on a specific evaluation of physical sign/symptoms, medical history, diagnostic tests, and procedures

  • identified by physicians and APRNs

vs.

• nursing diagnosis

  • a clinical judgement made by a nurse to describe a patient’s response or vulnerability to health conditions/ life events that licensed nurse is competent to treat

  • identified by nurses

defining characteristics =

= clinical signs/symptoms

Types of Problems (2)

• actual problem

  • nursing diagnosis supported by defining characteristics

  • it’s actually happening

• potential problems

  • something that we want to avoid

  • no defining characteristics are identified by the risk factors could lead to an actual problem

  • “risk for”

• health promotion

  • readiness for enhanced

  • desire to improve

Diagnostic Process

1. assess: collect and validate info

2. cluster and sort data

3. identify concepts and themes based on defining characteristics

Steps for Determining the Nursing Diagnosis

1. identify general concept in Pocket Guide Category

2. skim nursing diagnoses to see if any match/stick out

3. look into all of those to determine which fits the patient BEST based on their assessment data

Nursing Pocket Guide Categories

(image)

Dx/ Division + Definition

(example image)

Etiology + Defining Characteristics

• take the etiology and compare it to patients defining characteristics

• etiology = related factors

Rules & Tips to Identify the Nursing Diagnosis (7)

• collect as much info as possible

• cluster with care

• identify

  • a patient’s response to a health problem

  • a related or risk factor that we can treat with a nursing intervention

  • a problem caused by the treatment or medical condition

• don’t try and make it “fit”

• one diagnosis per category/concept usually

• only write nursing diagnosis as listed

• CANNOT write verbatim (copied exactly) from Pocket Guide

3 Part Statement Components

• Part 1: general concept + nursing diagnosis

• Part 2: etiology of the problem (r/t)

  • cause

• Part 3: defining characteristics (a/m/b)

  • signs and symptoms that prove the problem

Label parts of 3 part statement:

• pain + acute pain

• as manifested by (a/m/b) complaints of pain 9/10 on a 0-10 scale, laying in the fetal position on their bed, and groaning “oh, it hurts so much!”

• related to (r/t) tissue inflammation secondary to appendicitis

• Part 1: pain + acute pain

• Part 2: related to (r/t) tissue inflammation secondary to appendicitis

• Part 3: as manifested by (a/m/b) complaints of pain 9/10 on a 0-10 scale, laying in the fetal position on their bed, and groaning “oh, it hurts so much!”

“Secondary to…”

• indicates that a nursing diagnosis (problem) arises as a result of a specific medical diagnosis or underlying physiological condition

• included sometimes in 3 part statements

• confirmed diagnosis

Label parts of 3 part statement:

• related to (r/t) medication side effects secondary to chemotherapy

• as manifested by (a/m/b) complaints of feeling sick to her stomach, states “I vomited less than 25% of meals

• nutrition + nausea

• Part 1: nutrition + nausea

• Part 2: related to (r/t) medication side effects secondary to chemotherapy

• Part 3: as manifested by (a/m/b) complaints of feeling sick to her stomach, states “I vomited less than 25% of meals

Label parts of 3 part statement:

• as manifested by (a/m/b) tension headaches 3x/week, lashing out at friends and loved ones, reports feelings of being “overwhelmed” and “having too much to do in a short period of time”, consistently chewing nails

• related to (r/t) sudden lack of social life, multiple exams and assignments, secondary to nursing school

• psychosocial + stress overload

• Part 1: psychosocial + stress overload

• Part 2: related to (r/t) sudden lack of social life, multiple exams and assignments, secondary to nursing school

• Part 3: as manifested by (amb) tension headaches 3x/week, lashing out at friends and loved ones, reports feelings of being “overwhelmed” and “having too much to do in a short period of time”, consistently chewing nails

Dissect 3 Part Statement:

Noncompliance related to negative side effects of prescribed treatment as manifested by not taking prescribed medicine.

(Identify problem, etiology, and defining characteristics)

• Problem: noncompliant

• Etiology: negative side effects of prescribed treatment

• Defining Characteristics: not taking prescribed medicine

Dissect 3 Part Statement:

Constipation related to presence of hemorrhoids, immobility and routine use of codeine as manifested by no BM in 4 days.

(Identify problem, etiology, and defining characteristics)

• Problem: constipation

• Etiology: presence of hemorrhoids, immobility and routine use of codeine

• Defining Characteristics: no BM in 4 days

Dissect 3 Part Statement:

Risk for infection related to invasive procedures (two peripheral IVs, one surgical incision) and malnourished state (weight of 102 lbs., albumin 2.4)

(Identify problem, etiology, and defining characteristics)

• Problem: risk for infection

• Etiology: invasive procedures (two peripheral IVs, one surgical incision) and malnourished state

• Defining Characteristics: n/a

Make 3 Part Statement:

Our newly admitted patient reports 4-5 loose, liquid stools per day and cramping in their stomach. The patient states that when they have to go, they “have to go NOW”. Patient has hyperactive bowel sounds in all 4 quadrants and has been taking colace 3x/ day for the last week.

• Part 1: Concept (elimination) + nursing diagnosis (diarrhea)

• Part 2: r/t Colace use 3x day for the last week

• Part 3: a/m/b 4-5 liquid stools/day, cramping in stomach, they have to go NOW, hyperactive bowel sounds in all 4 quadrants

Make 3 Part Statement:

Client states he hardly slept all night, roomate requires much nursing care around the clock. The roommates medication is scheduled for 12am, 6am, 12pm, 6pm. The client stated he’s too tired to go to physical therapy. He appears listless and uninterested in his surroundings.

• Part 1: concept (activity/rest) + nursing diagnosis (sleep pattern, disturbed)

• Part 2: r/t roommates nursing care around the clock / medication schedule for 12am, 6am , 12, 6pm

• Part 3: a/m/b client states he “hardly slept all night: stated he’s “too tired to go to physical therapy”, appears listless and uninterested in his surroundings

Make 3 Part Statement:

Bob is an 89 year old man who has an unsteady gait, disoriented at times, voids 3-4 times during the night. He prefers to use the bathroom rather than use the urinal or bedside commode.

• Part 1: concept (safety) + nursing diagnosis (falls, risk for)

• Part 2: r/t unsteady gait, disorientation, voids 3-4 times during the night, prefers to go to the bathroom rather than use the urinal or bedside commode

• Part 3: a/m/b none

ADPIE: Planning

• setting patient centered goals and outcomes and creating nursing interventions

• identifying goals + outcomes

  • outcome = big picture

  • goals = what can the patient do an show

• creating nursing interventions

  • What can we do as nurses to help?

  • generate solutions

Maslow’s Hierarchy of Needs

(diagram)

Prioritizing Situation

(diagram and 3ish questions to ask)

• establishing priorities

  • What is the need?

    • risk vs. actual problem

    • prioritize current issues first

  • How urgent is the problem?

    • check ABC + P then Maslow’s Hierarchy of Needs

  • What kind of outcome will it be?

Besides, ABC+P and Maslows Hierarchy, what should be considered when prioritizing and planning care? (4)

• What does the patient want?

• Culture, values, and beliefs

• Cost, resources, personnel, time

• State law and hospital policy

Why is prioritizing in the planning process important?

• safe patient care

• time management

Types of Goals (2)

• intermediate (short term, a specific date or time)

• long term

Purpose of Goals

• set clear direction for nursing interventions

• measurement of success

• motivating factor

Parts of a Goal Statement (4)

1. client behavior (action, “the patient will…”)

2. criteria of performance (how far/how much?)

3. conditions (if needed, like do they need assistance to complete goal)

4. time frame

Create one short and long term goal:

• Part 1: pain + acute pain

• Part 2: related to (r/t) tissue inflammation secondary to appendicitis

• Part 3: as manifested by (a/m/b) complaints of pain 9/10 on a 0-10 scale, laying in the fetal position on their bed, and groaning “oh, it hurts so much!”

• Short Term: The patient will verbalize/display a pain scale of less than 5/10 on a 0-10 pain scale by end of the shift

• Long Term: The patient will demonstrate 2 methods of non pharmacological pain management (deep breathing and guided imagery) once by discharge.

ADPIE: Implementation Definition

• treatments or actions that nurses perform to meet individual patient outcomes

• taking action

Implementation Task

• performing nursing and collaborative interventions needed to achieve the goals/overcomes necessary to support or improve health

• nursing scope of practice

Methods of Implementation Types (2)

• direct care

• indirect care

Types of Interventions (5)

• standard nursing interventions

  • clinical practice guidelines, care bundles

  • standing orders

  • NIC = nursing intervention classifications

  • standard of practice

  • QSEN = quality and safety education for nurses

• independent nursing interventions

  • nurse initiated

  • based on scientific evidence based rationale

• dependent nursing interventions

  • provider initiated (MP, NP, PA)

• interdependent interventions

  • consults with interdisciplinary team

• delegated

  • consider scope of practice

Nursing Interventions MUST be: (7)

• safe

• achievable

• acceptable to clients values and beliefs

• congruent with other therapies

• based on nursing knowledge/evidence

• within standards of practice

• based on rational appropriate to the outcomes and situation

To Consider for Interventions (6)

• desired patient outcomes

• characteristics of the nursing diagnosis

• research base knowledge for the intervention

• Is it feasible?

  • cost, time, resources, etc.

• Is it acceptable to the patient?

  • informed consent

• competency of nurse

  • rationale and using resources

Writing Interventions (HAT Method)

• H: How/Method

• A: Action/Amount

• T: Timing/Frequency

  • ask how often?

• (always end with rationale and citation)

• Example: Administer Percocet (hydrocodone/acetaminophen) 5/325 mg 2 tablets PO every 4 hours as needed for mild to moderate pain (treat pain). (insert citation)

When writing Interventions always use a ___ at the beginning.

(7 examples of ___)

• VERB

• examples

  • assess and document

  • encourage

  • administer

  • promote

  • consult (provider)

  • educate

What is wrong with this intervention statement?

Assess respiratory rate and quality, lung sounds.

• needs time

• no rational or citation

What is wrong with this intervention statement?

Administer Ancef q 4 hrs

• how much?

• how to administer?

• no rational or citation

What is wrong with this intervention statement?

Administer cough medication

• what kind?

• when?

• how to administer?

• no rational or citation

Create an intervention statement:

• 3 part statement:

  • Part 1: pain + acute pain

  • Part 2: related to (r/t) tissue inflammation secondary to appendicitis

  • Part 3: as manifested by (a/m/b) complaints of pain 9/10 on a 0-10 scale, laying in the fetal position on their bed, and groaning “oh, it hurts so much!”

• Short Term Goal: The patient will verbalize/display a pain scale of less than 5/10 on a 0-10 pain scale by end of the shift

• Assess and document pain on a pain scale of 0-10 (0 being no pain an 10 being the most pain every hour or as needed (citation).

ADPIE: Evaluation Definition

• determines whether a patient’s condition or well being improved after nursing interventions were delivered

What are we evaluating in the nursing process?

• the goals/outcomes of patients

What does evaluation tell us?

• clients response or progress

• measures the need to modify or revise the car plan

• quality of nursing care

Evaluation Process Steps (3)

1. examine the results

   • goal met, partially, or not?

2. identify errors

   • barriers?

3. correct errors + revise care plan

Components of Evaluation Statement if Goals NOT Met or Partially Not Met (5)

1. state whether the goal was not met or partially met

2. HOW do you know?

3. WHY was the goal not met/partially not met?

4. WHAT will you do to help them meet the goal?

5. “Will continue to monitor/promote ___.”

Components of Evaluation Statements if Goal Met (3)

1. state whether the goal was met

2. HOW do you know?

3. “Will continue to monitor/promote ___.”

Create an Evaluation Statement:

• diagnosis: airway clearance, ineffective

• goals, the patient will…

  • display resp 16-20/min, non labored by the end of shift

  • maintain an O2 sat of greater than 90% on room air by discharge

• goals met in scenario

• Respirations 18 per minute, non labored, Will continue to monitor.

• O2 saturation at 97% on room air. Will continue to monitor

Create an Evaluation Statement:

• diagnosis: airway clearance, ineffective

• goals, the patient will…

  • display clear lung sounds upon auscultation by 4/4/2022

  • verbalize 2 relaxation techniques (meditation and yoga) by discharge

• goals not met/partially met in scenario

• Crackles noted to bilateral bases upon auscultation. Patient has been refusing to participate in breathing exercises and stated, “I just don’t understand how these will help me”. Will provide education regarding breathing exercises. Will continue to monitor

• Client able to verbalize 1 relaxation technique (yoga) at this time. Unable to identify two due to distraction by favorite television show. Will reeducate when TV is turned off. Will continue to monitor