Ch. 8: Critical Thinking, the Nursing Process, and Clinical Judgment

Critical Thinking
a process by which the thinker improves the quality of his or her thinking by taking charge of the structures inherent in thinking and imposing intellectual standards upon them

what does a critical thinker do?
– raises questions/problems
– arrives at conclusions/solutions
– open minded/recognizes alternative views
– communicates effectively
– gather/asses relevant info

questions involved in critical thinking
– What assumptions have I made about this patient?
– How do I know my assumptions are accurate?
– Do I need any additional information?
– How might I look at this situation differently?

critical thinking in nursing
– Begins with reflective thinking
– Is a complex, purposeful, and disciplined process
– Is undergirded by standards and ethics of nursing
– Improves with practice and professional experience

critical thinking requires
– the ability to describe how you came to a conclusion
– the ability to support your argument with explicit data and rationales

nursing process
is a method of critical thinking focused on solving patient problems in professional practice.
– goal orientated
– conceptual
– flexible

5 phases of the nursing process
1. assessment
2. diagnosis
3. planning
4. implementation
5. evaluation

assessment phase
the phase of the nursing process that gathers info

info gathered in assessment phase
– patient info
– subjective data
– secondary sources
– objective data

subjective data
aka symptoms : “my tummy hurts”

secondary source
observation, physical exam, diagnostic exam, and info from other health care providers

objective data
data that is obtained through observations
– aka signs
– pulse is 84

diagnosis phase
the phase of the nursing process that is the analysis and ID of patient’s problems and where data collected in validated

nursing diagnosis
– diagnosis that focuses on the human responses to health and illness
– diagnosis that addresses the patient’s problems that the nurse can treat with in their scope of practice
– diagnosis that can change daily and patients’ comfort and alternate

national group of classification of nursing diagnosis
– published the first list of nursing diagnosis
– standardized nursing diagnosis to improve health care
– aka north american nursing diagnosis association

5 components of nursing diagnosis (NANDA-1)
1. label
2. definition
3. defining characteristics (sings and symptoms)
4. risk factors
5. related factors

diagnostic statement
contains the problem, etiology, and signs&symptoms

etiology
what is causing or contributing to the patients’ problems
– “related to…”

signs and symptoms
defining characteristics of problems
– “as evidence by…”

types of nursing diagnosis’
– actual
– risk
– wellness

actual type of diagnosis
pain related to (r/t) fractures collarbone

risk type of diagnosis
risk for impaired parenting r/t maternal history of substance abuse

wellness type
readiness for enhanced knowledge r/t diabetic diet

planning phase
the phase in the nursing process where the nurse and patient make goals of what is to be accomplished
– derived from diagnosis
– outcome criteria ID’d
– time frames established (short – long term)

what written patient goals require
– outcome criteria (measurable/observable)
– time frames (short – long term)

bloom’s domain of learning
1. psychomotor
2. cognitive
3. affective

psychomotor domain
bloom’s domain that involves physical movement
– patient will move from bed to chair 3x without help

cognitive domain
bloom’s domain that involves knowledge and intellectual skills
– patient will list 5 signs of illness in her baby by day of discharge

affective domain
bloom’s domain that involves emotions, feelings, values, and attitudes
– patient will describe feeling more accepting of changes in physical appearance by discharge

interventions
are written based on bloom’s domains within the scope of nursing practice
– “nursing practice”

nursing orders
the actions to assist the patient in achieving a stated goal

3 types of nursing interventions
1. independent
2. dependent
3. interdependent

dependent intervention
intervention that requires written orders or provision of another health professional

independent intervention
intervention that does not require supervision or direction by others
– nurse initiated

interdependent intervention
intervention that requires a nurse to collaborate and/or consult with another health professional before carrying out the actions

care plans
– written once interventions are selected
– individualized
– multidisciplinary framework of “critical paths”

implementation
the actual carrying out of orders
– aimed at individuals, families, and/or community

implementation interventions
– monitoring
– teaching
– assessing
– collaborating

evaluation phase
the phase of the nursing process when the nurse measures the progress of patient against the goals and outcome criteria to determine whether the problem is resolved, in the process of being resolved, or unresolved
– ID changes that need to be made

clinical judgment
is the result of critical thinking

imperial knowledge and expertise
what informed opinions and decisions are based on in clinical judgment

what clinical judgment requires
– recalling facts
– recognizing patterns
– forming a meaningful whole
– knowing your limits
– acting appropriately

gain extensive direct patient care contact
the best means for developing expert clinical judgment

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