The Nursing Process: Critical Thinking

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The Nursing ProcessCritical Thinking
Assessment

• Amy C. Chavarria, RN, MSN, MBA, HCM, CCE

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Thinking Critically, Making Decisions, Solving
Problems
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Critical Thinking Skills

• Critical analysis
• Inductive and deductive reasoning
• Making valid inferences
• Differentiating facts from opinions
• Evaluating the credibility of information sources
• Clarifying concepts
• Recognizing assumptions

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Critical Thinking Attitudes

• Independence
• Fair-mindedness
• Insight
• Intellectual humility
• Intellectual courage

• Integrity
• Perseverance
• Confidence
• Curiosity

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Significance of Developing Critical Thinking

• Essential for safe, competent, skillful nursing
  practice
• Rapid and continuing growth of knowledge
• Make complex and important decisions
• Draw meaningful information from other subject
  areas
• Work in rapidly changing, stressful environments
• Recognize important cues, respond quickly, and
  adapt interventions

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Top 10 Reasons to Improve Thinking

• Things change
• Sicker clients
• More consumer involvement
• Need to move from one setting to another
• Need for new learning and workplace skills
• Requirement for evidence of benefits, efficiency,
  and results
• New problems cant be solved with old ways of
  thinking
• Thinking skills needed to deal with todays world
• Possible to improve thinking
• Difference between success and failure

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Critical Thinking and Nursing

• Critical thinking underlies each step of the
  nursing, problem-solving, and decision-making
  processes

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The Nursing Process

• Method of planning and providing individualized
  care
• Modified problem-solving process
• Assess, diagnose, plan, implement, evaluate

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Problem-Solving Process

• Clarify the nature of a problem and suggests
  possible solutions
• Evaluate solutions and choose best one to
  implement
• Commonly used approaches
• Trial and Error
• Intuition
• Research process
• Scientific method

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Decision-Making Process

• Choosing the best actions to meet a desired goal
• Identify purpose
• Set and weigh criteria
• Seek and examine alternatives
• Project, implement, and evaluate outcome

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Ways of Demonstrating Critical Thinking

• Rigorous personal assessment
• Reflection
• Analysis of thinking processes and attitudes
• Cultivation of critical thinking abilities
• Attendance at conferences
• Awareness of own thinking-while thinking
• Create environments that support critical thinking

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Mind Map
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NURSING PROCESSASSESSMENT
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Historical Development

• Nursing Process is synonymous with the
  __________________ solving approach.
• Before Nursing Process, proof of care was loosely
  structured and unorganized.
• Nursing Process introduced in 1955 by Lydia Hall
  but wasnt used extensively until the
  ___________s.

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• Started with a _____ step process.
• Social Policy Statement (1980) The ANA
  identified diagnosis of ______________ and
  potential health problems as part of nursing
  practice.
• The actual development of nursing process as a
  _____ step model, which is used today, was
  introduced by the ANA in 1991 and includes
  Outcomes.

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• Your text has a 5 step (phase) model.
• Is one better than the other?
• Why different models?
• What did the leave out?

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6 Steps (Phases) Model

• Assessment
• Diagnosis
• Outcome Identification
• Planning
• Implementation
• Evaluation

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KE Identifies 5 Steps Or Phases

• Assessing
• Diagnosing
• Planning
• Implementing
• Evaluating

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Comparison of both model

• 6 STEP
• Assessment
• Diagnosing
• Outcome Identification
• Planning
• Implementation
• Evaluation

• 5 STEP
• Assessment
• Diagnosing
• Planning
• Implementation
• Evaluation

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What Is Nursing Process?

• ______________________ problem-solving approach
  to giving individual nursing care.
• It is a model used to make decisions about client
  ______________.
• Serves as a ______________ for professional
  nursing practice.
• It requires ________________ thinking skills.

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Characteristics

• The nursing process has unique characteristics
  that enable responsiveness to the
  __________________ health status of the client.
• Cyclic (____________ itself) and dynamic (ever
  ______________________)
• Client ________________ using client strengths
  not nurse or physician centered

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Characteristics (cont.)

• Focuses on problem solving and decision making
• In every ________________ of the process
• Allowing nurses to be creative and use all their
  skills and ________________________
• This facilitates ________________________ of
  client care

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Characteristics (cont.)

• Interpersonal and collaborative -- involves
  communication with
• ________________________
• ________________________
• Others in the health care team

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Characteristics (cont.)

• Universal applicability
• Appropriate throughout _______________
• Can be used in ___________ settings
• Use of critical thinking
• See page 261 of text TABLE 16-2

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Characteristics (cont.)

• Looks at _________________ person
• ___________________ AND SYSTEMATIC
• Framework for CARE to individuals, families and
  communities

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Interactive Nature

• Each phase interacts and is influenced by
  _____________ phases.
• As condition ________________, the nurse gathers
  and incorporates information into __________ plan
  of care.

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Skills Requirements

• ________________ knowledge based of basic
  sciences and humanities.
• Ability to communicate in _________________.
• Ability to ______________.

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Nursing Process And Nursing Practice

• Professional Relevance
• Systematic, organized way of providing nursing
  care for any client in ____________ situation
• Focuses on clients unique problems
• Recognized as a ____________________ of care

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Nursing Process And Nursing Practice

• Professional Relevance (cont.)
• Recognized _________________________ as method of
  practicing nursing
• ________________ bound to use NP by Nurse
  Practice Act
• Ensures __________________ nursing care

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• Professions require a sound scientific base
• Nursing requires a __________________ system to
  provide a structure for nursing practice.
• Our system is the Nursing Process

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ASSESSMENT
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Assessment

• Is the _____________________, organizing,
  validating, and documenting of client data.
• It is systematic and ___________________
• What is data? _______________________
• You assess throughout the entire nursing process
  (all the phases/steps)
• All phases of the NP depend on accurate and
  ___________________ data collection.

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Purpose Of Assessment

• To establish a database about the clients
• ___________________ to health concerns or
  illness.
• Their ability to manage health care
  _______________.

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Activities of Assessment

• Establish a database
• Obtain a nursing health _____________________.
• Conduct a _____________________ assessment.
• Review client ______________________.
• Review nursing __________________________.
• Consult ___________________________ persons.
• Consult health professionals.

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Activities of Assessment (cont.)

• Update data as ____________________.
• ___________________ data.
• ____________________ data.
• Communicate/____________________ data.

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Texas Nurse Practice Act 217.11 3

• States (the professional nurse will) _________
  (a) systematic approach to provide
  individualized, __________-directed nursing care
  by performing a __________________ assessment
  regarding health status of the client.

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4 types of Assessments

• _____________ assessment
• Problem-_________________ assessment
• __________________ assessment
• _______________-lapsed reassessment

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Types Of Assessments

• Initial - 1st client _____________________
• Comprehensive nursing history physical exam.
• Performed within specified time after
  ______________________.
• Purpose is to establish a complete database for
  problem identification, reference, and future
  _________________.

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Types Of Assessments (cont.)

• Problem focused assessment - ____________ scope
• Ongoing process integrated with nursing care
• Purpose
• To determine the status of a ________________
  problem identified in an earlier assessment.
• To identify _________ or overlooked problems.
• Such as
• Hourly assessment of clients IO in and ICU.
• Assessment of clients ability to perform ADLs.

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Types Of Assessments (cont.)

• Time lapsed - ongoing assessment
• Done several months ______________ initial
  assessment.
• Purpose is to compare the clients current status
  to _____________________ data previously
  obtained.
• Such as reassessment of a clients functional
  health patterns in a
• Home care setting
• Outpatient setting
• Hospital setting
• Shift change

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Types Of Assessments (cont.)

• Emergency - may be initial for ____________-threat
  ening problems
• Done during any physiologic or psychologic
  ______________ of the client.
• Purpose is to identify life-threatening problems.
• Such as
• Rapid assessment of a persons airway, breathing
  status, and circulation during a cardiac arrest.
• Assessment of suicidal tendencies or potential
  for ______________________.

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Types of Data

• Subjective
• Also called ______________ or covert data.
• Only things the client can ______________ that we
  cannot test or see.
• Clients sensations, feelings, values, beliefs,
  attitudes, and perception of personal health
  status and life situation.

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Types of Data (cont.)

• Objective
• Also called ______________ or overt data.
• You can see, smell, heart, taste, feel, or
  _______________.
• Such as
• Wound size, color and drainage
• Blood pressure, temperature, _________

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Sources Of Data

• Primary source - the ______________
• Secondary sources -
• Family-significant others (____________ people)
• Past and current health ______________
• _______ test and diagnostic procedures
• Reports from other health members
• Reviewing literature

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Setting And Environment

• Should be scheduled so client is not
  _____________, hungry or in pain.
• Should provide ___________________.
• Allow family to ___________ if client desires.

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Conducting The Assessment

• Reviewing general information - primary and
  secondary data.
• Considering _______________ language, beliefs,
  values
• ____________________ the client and environment.
• _________________ for seeking healthcare.

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Conducting The Assessment

• What types of things are we going to assess?
• ______________
• Activity and Exercise
• Nutrition and Metabolism
• Elimination
• _____________ and rest

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Conducting The Assessment

• What types of things are we going to assess?
  (cont.)
• ________________ and perception
• Self-perception and self-_______________
• Roles and relationships
• ___________________ and stress tolerance
• Sexuality and reproduction
• Values and __________________

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Assessment Skills

• Observation using your _____________
• Vision
• Smell (body or breath odor)
• ____________________
• Touch

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Assessment Skills (cont.)

• Overall appearance
• Body ____________
• General ___________________
• Posture
• ________________________

Observation Vision
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Assessment Skills (cont.)

• Signs of distress or discomfort
• ____________ and body gestures
• ____________ color or lesions

Observation Vision
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Assessment Skills (cont.)

• Abnormalities of ________________
• _________-verbal demeanor
• Signs of anger or anxiety

Observation Vision
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Assessment Skills (cont.)

• ________________ or cultural artifacts
• Books
• Icons
• Candles
• Beads
• Pictures

Observation Vision
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Assessment Skills (cont.)

• Lung and heart ________________
• _________________ sounds
• Ability to communicate
• Language spoken

Observation Hearing
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Assessment Skills (cont.)

• Ability to ______________ when spoken to
• __________________ to time, place and person
• Thoughts and feelings
• About self, others and health status

Observation Hearing
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Assessment Skills (cont.)

• Skin temperature and ____________
• ____________ strength hand grips
• Pulse rate, rhythm, and __________
• Palpatory lesions lumps, masses, nodules

Observation Touching
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Assessment Skills (cont.)

• Interviewing - planned or conversation with a
  purpose
• 2 approaches
• _________________
• Structured
• Gets _________________ information
• _______________ controls the purpose
• Non-direct-
• ___________________ building interview
• _______ controls the purpose, topic and pace

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Assessment Skills (cont.)

• Interviewing continued
• Types of interview questions
• Close-ended
• Answer with ____________ words
• Used in directive interviews
• Restrictive or blocking to conversation
• Usually beings with when, where, who,
  what, does or is
• Highly ______________ or people who have
  difficulty communicating like close-end questions

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Assessment Skills (cont.)

• Interviewing continued
• Types of interview questions (cont.)
• Open-ended
• Used with nondirective interview
• Invites client to ________________ on thoughts,
  feeling or information
• Invites ________________ answers
• Begin with what or how or tell me
• See BOX 16-2 on page 267 of text.

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INTERVIEWING PHASES

• Maintenance Phase
• Keep focused
• Encourage client to talk
• Concluding Phase
• Explain action to client
• Review goals and plans for action

• Preparatory Phase
• Review chart
• Evaluate Data
• Assess your own feelings
• Plan for quiet time
• Introductory Phase
• When nurse and client meet
• Establish rapport

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Planning the Interview Setting

• Time when
• Client is _______________________
• There will be ________ interruptions
• When the client will feel comfortable and
  unhurried.

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Planning the Interview Setting

• Place
• Well-_______________, well-ventilated
• Moderate size room
• ____________ of noise, movement and interruption
• A place where others cannot overhear or
  ______________ the client is desirable

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Planning the Interview Setting

• Setting
• Without barriers between nurse and client
• Nurse __________ client on same eye level
• Sit at a ______ degree angle to clients bed
• Dont
• Sit on their bed
• ___________ and look down at the client
• Stand at the ___________ of the bed

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Planning the Interview Setting

• Distance
• Neither too _____________ or too far
• Most people feel comfortable with a distance of
  __________ feet
• _______________ will dictate appropriate distance

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Personal Space Variables

• Accepted distance between individual in
  conversation varies with ethnicity.
• About 8-12 inches in Arab countries
• _______ inches in the US
• _______ inches in Britain
• _______ inches in Japan

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Personal Space Variables (cont.)

• Men of all cultures usually require ____________
  space than women.
• Anxiety increases the need for ________________.

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Personal Space Variables (cont.)

• Direct eye contact ? the need for space.
• In East Asian and Scandinavian countries, direct
  eye contact is considered __________________.
• Physical contact is used _____________ if it has
  a therapeutic purpose.
• Touch can be misinterpretedespecially between
  persons of opposite _______________.

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Planning the Interview Setting

• Language - See Practice Guidelines
  Communication during an Interview, page 268
• Failure to communicate in language the client can
  communicate is a form of discrimination.
• Dont using _________________ terms.
• Interpreters (from hospital preferred) or
  Language Line (ATT 24-7)
• Written documents-make sure client can __________

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Physical Exam Techniques

• Inspection - ______________ inspection of the
  client done in a methodical deliberate manner.
• Palpation - use of ______________-fingertips and
  palms to determine size, shape and configurations
  of underlying structures.
• Percussion - both hands used to ____________ body
  surface to produce a sound for denseness or
  hollowness.

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Percussion

• Uses fingers and hands to _________ on area of
  the client to produce sound
• Resonance - The degree to which the sound
  _________________ (magnifies the sound)
• Type of percussion tone is determined by the
  _____________ of the medium through which sound
  is traveling
• Use fingers of both hands - requires practice and
  repetition.

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Percussion
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Auscultation

• Auscultation - listening to body sounds with a
  stethoscope place on a body surface to
  ___________________ sounds
• Listening to the sounds of ________________
  within the body
• Stethoscope collects and transmits sounds
• The Bell detects _________-pitched sounds
• The Diaphragm detects _______-pitched sounds

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What Types of Things are Listening For

• Heart listen for moving __________
• Lungs listen for moving ______
• Abdomen for movement of GI ________________

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What Types of Things are Listening For

• Properties of sound
• _______________ - measure of vibration
• Intensity _____________ of the sounds
• Quality -musical characteristics blowing,
  squeaking, ________________
• Duration - ____________ of the sound

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Comprehensive Assessment Includes

• PHYSICAL- body __________________ evaluation
  (cephalocaudal)
• PSYCHOLOGICAL - intellect self- concept
  ___________________
• SOCIAL relationships ___________________ with
  family and friends
• SPIRITUAL belief in a higher being personal
  interpretation of meaning of life attitudes on
  moral decisions.

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How Do You Organize Data

• GORDONS FUNCTIONAL HEALTH FRAMEWORK Evaluates
  persons mind, body, and environment in relation
  to their ability to perform tasks of daily
  living.
• HEAD TO TOE FRAMEWORK System for collecting
  data in an organized manner, starting at the head
  -proceeding systematically downward to the toes.
• BODY SYSTEMS FRAMEWORK Focuses on
  pathophysiology involved within specific body
  systems

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Organizing Data (cont.)

• See text pages 270-273.

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Recording Data

• Systematically recorded and become a
  _______________ part of the client record
• Written
• _________________________

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Validating Data

• Validating
• Double _________________
• _____________________ to confirm that it is
  accurate and factual

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Validating Data (cont.)

• Validating helps the nurse complete the following
  tasks
• Ensure that assessment information is
  ___________________.
• Ensure that objective and related subjective data
  _______________.
• Obtain additional information that may have been
  overlooked.

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Validating Data (cont.)

• Validating tasks (cont.)
• Differentiate between cues and inferences.
• Cues are subjective or objective data that can be
  directly __________________ by the nurse
• What the client says or
• What the nurse can see, hear, feel, smell, or
  measure.
• Inferences are the nurses _______________________
  or conclusion made based on the cues
• Avoid jumping to conclusions and focusing in the
  _______________ direction to identify problems.

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Validating Data (cont.)

• Not ______ date requires validation.
• Height, weight, birth date, and most laboratory
  studies.
• The nurse validates when there are discrepancies
  between data obtained in the nursing interview
  and the physical examination, or when the
  clients statements ___________ at different
  times in the assessment.
• See TABLE 16-6 in text page 274.