CRITICAL THINKING AND

THE NURSING PROCESS

Critical Thinking
 Is a cognitive skill in all nursing activities and enhances
the application of the nursing process.
 A process of purposeful and creative thinking about
resolutions of problems or the development of ways to
manage situations.
 More than problem solving; it is a way to apply logic and
cognitive skills to the complexities of client care.
Five Essential Elements of Critical
Thinking
 Collection of information
 Analysis of the Situation
 Generation of Alternatives
 Selection of Alternatives
 Evaluation
 Five essential elements of Critical
Thinking
I. Collection of Information
A. Identifying assumptions
B. Organizing data collection
C. Determining the reliability of the data
D. Determine the relevance of the information in relation
to the client’s current, evolving, or potential
condition
or situation.
E. Identifying inconsistencies.
II. Analysis of the Situation
A. Distinguish data as normal or abnormal
B. Cluster related information
C. Identify patterns in the information
D. Identify missing information
E. Draw valid conclusions

III. Generation of Alternatives

A. Articulate options
B. Establish priorities
IV. Selection of Alternatives
A. Develop outcomes
B. Develop a plan

V. Evaluation
The Nursing Process
 A systematic method of providing care
to clients.
5 components of the Nursing Process:
1. Assessment

2. Diagnosis

3. Planning

4. Implementing

5. Evaluating
Assessment or Data Collection

 The first step in the nursing

process involves the following:
 Collecting data.
 Organizing data.
 Validating data.
 Documenting data
Purpose of Assessment

 To establish a database concerning a

client’s physical, psychosocial, and
emotional health.

 To identify health-promoting behaviors

as well as actual and/or potential health
problems.
Types of Assessment

 Comprehensive - Provides baseline data including

complete health history and current needs
assessment.

 Focused - Limited in scope in order to focus on a

particular need or concern or potential risk.

 Ongoing - Includes systematic monitoring and

observation related to specific problems.
Sources of Data

 Primary Source: The client.

 Secondary Source: The client’s family

members, other health care providers,
and medical records, literature.
Types of Data

 Subjective: Data from client’s (and sometimes

family’s) point of view. Includes feelings, perceptions,
and concerns. Collected by the interview.

 Objective: Also called signs. Observable and

measurable data obtained through physical
examination and laboratory and diagnostic testing.
Subjective data
 sensations or symptoms (pain, hunger)
 feelings- happiness, sadness
 perceptions
 preferences
 ideas
 desires, beliefs, values
 personal information that can be elicited and verified
only by the client.
Major areas of subjective data
 biographical information (name, age)
 physical symptoms related to each body part or
system
 past and family history
 holistic information regarding the client’s health
(health practices that put the client at risk,
nutrition, activity, relationships).
COLDSPA
Character: Describe the S/S. How does it feel,
look, sound….
Onset: When did it begin?
Location: Where is it? Does it radiate?
Duration: How long does it last? Does it recur?
Severity: How bad is it?
Pattern: What makes it better? Worse?
Associated factors:
What other symptoms occur with it?
Collecting Objective Data
 directly or indirectly observed through measurement
 includes
physical characteristics (skin, color, posture)
body function (HR, RR)
appearance (dress, hygiene)
behavior (mood, affect)
measurement (BP, T, Ht, Wt)
results of laboratory testing
Organizing Data

 Collected information must be

organized to be useful.

 Data Clustering is a useful tool to

identify issues.
Validating Data

 Validation prevents omissions,

misunderstandings, and incorrect
inferences and conclusions.
Data requiring validation
 discrepancies or gaps between the
subjective or objective data
 discrepancies or gaps between what the
client says at one time and then at
another time.
 findings that are very abnormal and
inconsistent with other findings
Methods of Validation
 recheck your own data through a reassessment.
 clarify data with the client by asking additional
questions
 verify the data with another health care
professionals= ask an experienced nurse to listen
to the abnormal heart sounds you think you have
heard.
 compare your objective findings with your
subjective findings to uncover discrepancies.
Documenting Data

 Assessment data must be recorded and

reported.

 Accurate and complete recording of

assessment data is essential for
communicating information to health
care team.
Guidelines for documentation

 document legibly or print in unerasable ink

 use correct grammar and spelling- abbreviation
 avoid wordiness that creates redundancy
auscultated gurgly bowel sounds in RU, RL, LU, LL.
abdominal quadrants. Heard 36 gurgles/ min
Bowel sounds present in all quadrants at 36/ min.
 use phrases instead of sentences
“The client’s lung sounds were clear both in the R and L
lungs”
“Bilateral lung sounds clear”
 Record data findings, not how they were obtained.
client was interviewed for past history of HB pressure and BP was
taken
Has 3-yr history of hypertension treated with medication. Bp sitting
right arm 140/80, LA 136/86
 Write entries objectively without making premature judgments
or diagnosis
“client depressed due to fear of breast biopsy report and not
getting along well with husband
“client crying in room, refuses to talk, husband has gone home”
avoid making inferences and diagnostic statements until you have
collected and validated all data with client and family.
 Record the client’s understanding and perception of problems
client expresses concern regarding being discharged soon after
gallbladder surgery because of inability to rest at home with 6
children
 Avoid recording the word “normal” for normal findings
Liver palpatation normal
Liver spam 10 cm in R MCL and 4cm in MSL. no tenderness on
palpatation
 in some health care setting, however, only abnormal findings are
documented if the policy is to chart by exception only. in that case,
no normal findings would be documented in any format.
 Record complete information and details for all clients,
symptoms or experiences.
client has pain in lower back
client has had aching- burning pain in lower back for 2 weeks. Pain
worsens after standing for several hours. Rates pain as 7 on scale
of 1 to 10.
 Include additional assessment content when applicable
 information about the caregiver or last physician contact
 Support objective data with specific observations obtained
during the PE
 ex.- depressed= support with descriptions of the ways depression
is demonstrated- dressed in dirty clothing, avoids eye contact,
unkempt appearance, and slumped shoulders.
Diagnosis

 A medical diagnosis is a clinical judgment by the

physician that determines a specific disease,
condition or pathological state.

 A nursing diagnosis is a clinical judgment about

individual, family, or community responses to actual
or potential health problems/life processes.
Nursing Diagnosis Questions

 Are there problems here?

 If so, what are the specific problems?
 What are some possible causes?
 Is there a situation involving risk factors?
 What are the risk factors?
 What are the client’s strengths?
 What data are available to answer these questions?
 Is more data needed?
 If so, what are the possible sources of further data?
Nursing Diagnosis is a Two-
Part Statement

 A problem statement or diagnostic label

that describes the client’s response to
an actual or potential health problem or
wellness condition.

 And the etiology - the related cause or

contributor to the problem.
Nursing Diagnosis is a Three-
Part Statement

 Includes first two parts of Two-Part

Statement: the diagnostic label and the
etiology.

 Also includes defining characteristics,

the collected data, also known as signs
and symptoms, subjective and objective
data, and clinical manifestations.
Types of Nursing Diagnosis

 Actual nursing diagnosis: A problem exists; it is

composed of the diagnostic label, related factors,
and signs and symptoms.

 Risk nursing diagnosis: A problem does not yet exist,

but special risk factors are present.

 Wellness nursing diagnosis: Indicates client’s desire

to attain higher level of wellness in some area of
function.
Diagnostic Reasoning Process

1. Identify abnormal data and strengths

2. Cluster data
3. Draw Inferences and identify problems
4. Propose possible nursing diagnosis
5. Check defining characteristics
6. Confirm or rule out
7. Document conclusions.
Planning and Outcome
Identification

 Planning combines with outcome

identification to comprise the third step
of the nursing process.
Three Phases of Planning

 Initial Planning: developing a preliminary plan of care

by the nurse who performs the admission
assessment.

 Ongoing Planning: continuous updating of client’s

plan of care.

 Discharge Planning: Involves critical anticipation and

planning for client’s needs after discharge.
Tasks Involved with Planning

 Prioritizing list of nursing diagnoses.

 Identifying and writing client-centered long- and

short-term goals and outcomes.

 Developing specific nursing interventions.

 Recording entire nursing plan in client’s record.

Components of Desired Outcomes
 Subject
 Verb
 Conditions or modifiers : may be added to the verb
to explain the circumstances under which the
behavior is to be performed. It explains what,
where, when and how.
 Criteria : indicates the standard by which a
performance is evaluated or the level at which the
client will perform the specified behavior. It may
specify time or speed, accuracy, distance and
quality.
Relationship of desired outcomes to nursing
diagnosis
 Goals are derived primarily from the client’s
nursing diagnoses--- primarily from the
diagnostic label, which contains the unhealthy
response.

 The goal is stated as the opposite of the

problem and then followed by a list of
observable outcomes.
Example:
Risk for Deficient Fluid Volume r/t
diarrhea and inadequate intake s/t
nausea
The client will reestablish fluid balance, aeb
urinary and stool output in balance with
fluid intake, normal skin turgor, and moist
mucous membrane.
Intervention

 A nursing intervention is an action

performed by the nurse that helps the
client achieve the results specified by
the goals and expected outcomes.
Categories of Nursing
Interventions

 Independent: Actions initiated by nurse that do not

require direction or an order from another health care
professional

 Interdependent: Actions implemented in collaborative

manner by nurse in conjunction with other health
care professionals

 Dependent: Actions that require an order from a

physician or other health care professional.
Types of Nursing Interventions
 Specific order: written by physician or nurse
especially for an individual client
 Standing order: A standardized intervention
written, approved and signed by a physician
that is kept on file to be used in predictable
situations or in circumstances requiring
immediate attention.
 Protocol: A series of standing orders or
procedures
The Nursing Care Plan

 A written guide that organizes data

about a client’s care into a formal
statement of the strategies that will be
implemented to help the client achieve
optimal health.
Implementation

 This fourth step of the nursing process

involves the execution of the nursing
care plan derived during the Planning
phase.
Activities
 Reassess the client
 Determine the nurse’s need for
assistance
 Implement the nursing intervention
 Supervise delegated care
 Document nursing activities
Evaluation

 This fifth step of the nursing process,

determining whether client goals have
been met, partially met, or not met.
Activities
 Collect data related to outcomes
 Compare data with outcomes
 Relate nursing actions to client
goals/outcomes
 Draw conclusion about problem status
 Continue, modify or terminate the client’s
care plan
Evaluation Statement
 It consists of two parts:
1. Conclusion : A statement that the
goal/desired outcome was met, partially met, or
not met.
2. Supporting data: the list of client responses
that support the conclusion
Ex. Goal met. Oral intake 300 more than the
output, skin turgor resilient, mucous membrane
moist
The Nursing Process
is Critical Thinking

 Critical thinking, problem-solving, and

decision-making are important in the use
of the nursing process.

 These skills can be learned!

 THANK YOU