Chapter 15: Critical Thinking in Nursing Practice

The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard? 1. Deep 2. Relevant 3. Consistent 4. Significant

Consistent

A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are: 1. Problem solving. 2. Showing humility. 3. Conducting reflective practice. 4. Exercising responsibility.

Conducting reflective practice

Completing nursing actions necessary for accomplishing a care plan is an example of which component of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Implementation 5. Nursing diagnosis

Implementation Rationale: Implementation

Scientific method

A series of steps followed to solve problems including collecting data, formulating a hypothesis, testing the hypothesis, and stating conclusions

Define concept mapping.

Concept mapping is a visual representation of patient problems and interventions that shows their relationships to one another.

Define evidenced-based knowledge.

Evidence-based knowledge is knowledge based on research or clinical expertise.

Which of the following is not one of the five steps of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Hypothesis testing

Hypothesis testing Rationale: The five steps are assessment, diagnosis, planning, interventions, and evaluation.

Focuses on problem resolution

decision making

Decision making

a product of critical thinking that focuses on problem resolution

Concept map

a visual representation of patient problems and interventions that shows their relationships to one another

Listen to both sides in any discussion

fairness

Recognize when you need more information to make a decision

humility

Process of drawing conclusions from related pieces of evidence

inference

Do not compromise nursing standards or honesty in delivering nursing care

integrity

Problem solving

involves evaluating the solution over time to make sure that it is effective

Evidence-based knowledge

knowledge based on research or clinical expertise, makes you an informed critical thinker

Five-step clinical decision-making approach

nursing process

Be cautious of an easy answer; look for a pattern and find a solution

perserverance

Obtain information and then use the information plus what you already know to find a solution

problem solving

Clinical decision making

problem-solving approach that nurses use to define patient problems and select appropriate treatment

Refer to policy and procedure manual to review steps of a skill

responsibility

Be willing to recommend alternative approaches to nursing care

risk taking

Systematic, ordered approach to gathering data and solving problems

scientific method

Diagnostic reasoning

the analytical process for determining a patient's health problems

Inference

the process of drawing conclusions from related pieces of evidence and previous experience with the evidence

Reflection

the process of purposefully thinking back or recalling a situation to discover its purpose or meaning

Read the nursing literature

thinking independantly

Key Points:

• Clinical decision making involves judgment that includes critical and reflective thinking and action and application of scientific and practical logic. • Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, single solutions. • Following a procedure step by step without adjusting to a patient's unique needs is an example of basic critical thinking. • In complex critical thinking a nurse learns that alternative and perhaps conflicting solutions exist. • In diagnostic reasoning you collect patient data and analyze them to determine the patient's problems. • The nursing process is a blueprint for patient care that involves both general and specific critical thinking competencies in a way that focuses on a particular patient's unique needs. • The critical thinking model combines a nurse's knowledge base, experience, competence in the nursing process, attitudes, and standards to explain how nurses make clinical judgments that are necessary for safe, effective nursing care. • Clinical learning experiences are necessary for you to acquire clinical decision-making skills. • Critical thinking attitudes help you to know when more information is necessary and when it is misleading and to recognize your own knowledge limits. • The use of intellectual standards during assessment ensures that you obtain a complete database of information. • Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria for evaluation, and criteria for professional responsibility. • Meeting regularly with colleagues allows you to discuss anticipated and unanticipated outcomes in any clinical situation to continually learn and develop your expertise and knowledge.

During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?" 1. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." 2. "I see that you're uncomfortable. I'll call your doctor to decide the next step." 3. "Show me exactly where your pain is and rate it for me on a scale of 0 to 10." 4. "Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?"

"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."

A nurse is working with a nursing assisstive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.) 1. A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. 2. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead. 3. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. 4. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room. 5. The nurse offers support to the NAP when needed but allows her to complete patient care tasks without constant oversight.

1. A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. 3. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. 4. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room.

The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.) 1. Data entry of time of day, who was present, and condition of the child 2. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response 3. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death 4. A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future

2. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response 3. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death 4. A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future

A 67-year-old patient will be discharged from the hospital in the morning. The health care provider has ordered three new medications for her. Place the following steps of the nursing process in the correct order. ____ 1. The nurse returns to the patient's room and asks her to describe the medicines she will be taking at home. ____ 2. The nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit. ____ 3. The nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her new medicines. ____ 4. The nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her. ____ 5. The nurse considers what she learns from the patient and identifies the patient's nursing diagnosis.

3 Assessment 5 Nursing diagnosis 2 Planning 4 Intervention 1 Evaluation

A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.) 1. Experience 2. Ethical 3. Analyticity 4. Self-confidence 5. Risk taking

Analyticity and Self-confidence

Which of the following is unique to the commitment level of critical thinking? 1. Weighs benefits and risks when making a decision. 2. Analyzes and examine choices more independently. 3. Concrete thinking. 4. Anticipates when to make choices without others' assistance.

Anticipates when to make choices without others' assistance.

Gathering, verifying, and communicating data about the patient to establish a database is an example of which component of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Implementation 5. Nursing diagnosis

Assessment Rationale: Identifying a patient's health care needs.

A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is: 1. Commitment. 2. Scientific method. 3. Basic critical thinking. 4. Complex critical thinking.

Basic critical thinking

A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.) 1. Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. 2. Think about past experience with patients who develop postoperative complications. 3. Decide which activities can be combined for patients B and C. 4. Carefully gather any assessment information and identify patient problems.

Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction and decide which activities can be combined for patients B and C.

Describe the steps of critical thinking.

Critical thinking involves recognizing that an issue exists, analyzing information about the issue, evaluating information, and making conclusions.

The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of: 1. Diagnostic reasoning. 2. Competency. 3. Inference. 4. Problem solving.

Diagnostic reasoning

Clinical decision making requires the nurse to: 1. Improve a patient's health. 2. Standardize care for the patient. 3. Follow the health care provider's orders for patient care. 4. Establish and weigh criteria in deciding the best choice of therapy for a patient.

Establish and weigh criteria in deciding the best choice of therapy for a patient. Rationale: Involves recognizing an issue exists, analyzing information, evaluating information, and making conclusions.

A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of: 1. Planning. 2. Evaluation. 3. Intervention. 4. Diagnosis.

Evaluation

The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is: 1. Experience. 2. Problem solving. 3. Knowledge application. 4. Clinical decision making.

Knowledge application

While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of: 1. Inference. 2. Diagnostic reasoning. 3. Competency. 4. Problem solving.

Problem solving

Define reflective journaling.

Reflective journaling is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning.

In which of the following examples is the nurse not applying critical thinking skills in practice? 1. The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. 2. The nurse uses a fall risk inventory scale to determine a patient's fall risk. 3. The nurse observes a change in a patient's behavior and considers which problem is likely developing. 4. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

Critical thinking

a continuous process characterized by 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

Nursing process

a five-step clinical decision-making approach: assessment, diagnosis, planning, implementation, and evaluation. The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems

Three levels of critical thinking in nursing have been identified. Briefly describe each. a. Basic b. Complex c. Commitment

a. In basic critical thinking, 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. In complex critical thinking, learners begin to separate themselves from experts and analyze and examine choices more independently. c. In commitment, learners anticipate the need to make choices without assistance from others and accept accountability.

List the five components of critical thinking.

a. Knowledge base b. Experience c. Critical thinking competencies d. Attitudes e. Standards

Identify the concepts and behaviors of a critical thinker. a. Truth seeking b. Open-mindedness c. Analyticity d. Systematicity e. Self-confidence f. Inquisitiveness g. Maturity

a. Seek the true meaning of a situation. b. Be tolerant of different views and one's own prejudices. c. Anticipate possible results or consequences. d. Be organized. e. Trust in your own reasoning processes. f. Be eager to acquire new knowledge and value learning. g. Reflect on your own judgments.

Explain the two standards used in the critical thinking model. a. Intellectual b. Professional

a. The intellectual standard is a guideline or principle for rational thought. b. The professional standard refers to evidence-based ethical criteria for nursing judgments used for evaluation and criteria for professional responsibility.

Careful reasoning so the best options are chosen for the best outcomes

clinical decision making

Speak with conviction and always be prepared to perform care safely

confidence

Look for different approaches if interventions are not working

creativity

Explore and learn more about a patient to make appropriate clinical judgments

curiosity

Determining a patient's health status after you have assigned meaning to the behaviors and symptoms presented

diagnostic reasoning

Take time to be thorough and manage your time effectively

discipline