MS CH 1 Critical Thinking.pdf

4068_Ch01_001-011 15/11/14 12:31 PM Page 2 1 KEY TERMS assessment (ah-SESS-ment) clinical reasoning (KLIN-ih-kull REE-zon-ing) collaborative (koh-LAB-rah-tiv) critical thinking (KRIT-ih-kull THING-king) data (DAY-tuh) evaluation (e-VAL-yoo-AY-shun) evidence-based practice (EHV-ah-dense baste PRACK-...

4068_Ch01_001-011 15/11/14 12:31 PM Page 2 1 KEY TERMS assessment (ah-SESS-ment) clinical reasoning (KLIN-ih-kull REE-zon-ing) collaborative (koh-LAB-rah-tiv) critical thinking (KRIT-ih-kull THING-king) data (DAY-tuh) evaluation (e-VAL-yoo-AY-shun) evidence-based practice (EHV-ah-dense baste PRACK-tis) intervention (in-ter-VEN-shun) nursing diagnosis (NER-sing DYE-ag-NOH-sis) nursing process (NER-sing PRAH-sess) objective data (ob-JEK-tiv DAY-tuh) subjective data (sub-JEK-tiv DAY-tuh) vigilance (VIJ-eh-lents) 2 Critical Thinking and the Nursing Process PAULA D. HOPPER AND LINDA S. WILLIAMS LEARNING OUTCOMES 1. Explain why good critical thinking is important in nursing. 2. Describe attitudes and skills that promote good critical thinking. 3. Describe the thinking that occurs in each step of the nursing process. 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process. 5. Differentiate between objective and subjective data. 6. Document objective and subjective data. 7. Prioritize patient care activities based on Maslow’s hierarchy of human needs. 4068_Ch01_001-011 15/11/14 12:31 PM Page 3 Chapter 1 Excellence in the deli very of nursing care requires good thinking. Each day nurses mak e many decisions that affect the care of their patients. For those decisions to be effective, the thinking behind them must be sound. CRITICAL THINKING Nursing students must learn to think critically; in other words, to think like a nurse. This means they must use their knowledge and skills to make the best decisions possible in patient care situations. Halpern (1996) says that, “critical thinking is the use of those cognitive [knowledge] skills or strategies that increase the probability of a desirable outcome” (p. 5). Good thinking in nursing care has also been called clinical reasoning. Hawkins et al (2010) define clinical reasoning as “thinking through the various aspects of patient care to arrive at a reasonable decision regarding the prevention, diagnosis, or treatment of a clinical problem in a specific patient.” Good thinking requires critical thinking attitudes and skills, which are described in this section. It also requires a good kno wledge base, so your thinking is based on correct factual material. Our goal in this te xt is to pro vide you with solid medical-surgical knowledge on which to base good decisions. Critical Thinking Traits It is important for nurses to possess an attitude that promotes good thinking. Researchers have identified attitudes or traits associated with good critical thinking. The Foundation for Critical Thinking (2013) identifies seven traits: (1) intellectual humility, (2) intellectual courage, (3) intellectual empathy , (4) intellectual integrity, (5) intellectual perseverance, (6) faith in reason, and (7) fair-mindedness. We summarize these next. Intellectual Humility Have you ever known people who think the y know it all? They do not ha ve intellectual humility. People with intellectual humility have the ability to say, “I’m not sure about that . . . . I need more information.” Certainly, we want our patients to think we are smart and know what we are doing, but patients also respect nurses who can say, “I don’t know, but I’ll find out.” It is unsafe to care for patients when you are unsure of what you need to do. Intellectual Courage Intellectual courage allows you to look at other points of view even when you may not agree with them at first. Maybe you really believe that 8-hour shifts are best for nurses, and you have a lot of good reasons for your belief. But if you have intellectual courage, you will be willing to really listen to the arguments for 12-hour shifts. Maybe you will e ven be convinced. Sometimes you ha ve to ha ve the courage to say , “Okay, I see you were right after all.” Intellectual Empathy Consider the patient who snaps as you enter her room, “I’ve been waiting all morning for my bath. If you don’ t help me Critical Thinking and the Nursing Process 3 with it right now I’m going to call your supervisor.” The first response that comes into your head is, “I have five other patients; you’re lucky I am here!” If you ha ve intellectual empathy, however, you will be able to think, “If I were this patient, who is in chronic pain and is tired of being in the hospital, how would I feel?” Such thinking might change ho w you respond. Intellectual Integrity One of your patients asks a hundred questions when you bring her a medication that has been newly prescribed for her high blood pressure. But later you notice she is taking an herbal remedy from her purse. It is good that she asks a lot of questions about her drug, which has been tested e xtensively by the Food and Drug Administration (FDA). Herbal remedies, however, are not held to the same standards as medications in the United States. Someone with intellectual integrity would want the same level of proof applied to both medications and herbal remedies to determine if they are safe and effective before using them. Intellectual Perseverance Perseverance means you do not gi ve up. Consider this scenario: You have concerns about some side effects you noticed after giving a new drug to a patient. You mention it to the health care provider, who says not to worry about it, but you are still concerned. If you have intellectual perseverance, you might do some research on the Internet, then go to your su pervisor or the pharmacist to further discuss your concerns. Faith in Reason If you have faith in reason, you believe in your heart that good clinical reasoning will result in the best outcomes for your patients. And if you really believe, you will be more likely to attend a seminar or read an article on developing your clinical reasoning skills. Fair-Mindedness One of your coworkers wants to change the medication administration schedule on your unit. She says it will be better for the patients, but you think it might be because it is a better fit for her coffee-break schedule. If you have an intellectual sense of justice, you will be sure that your thinking is not biased by something that you just want for yourself, as seems to be happening with your co worker. You should examine your own motives as well as those of others when you are making decisions. So what does all this mean to you as a nursing student? The term metacognition means to “think about thinking. ” It is important for you to try to develop the attitudes of a critical thinker and to learn to think clearly and critically about your patient care. To do that, you need to constantly reflect on how you are thinking. Are you practicing intellectual humility?Are you trying to be courageous and empathetic? These attitudes create an excellent base on which to build nursing knowledge and develop further thinking skills. 4068_Ch01_001-011 15/11/14 12:31 PM Page 4 4 UNIT ONE Understanding Health Care Issues LEARNING TIP Each time you exit a patient’s room, do a mini critical thinking assessment. Think, “Did I ask the right questions? Was my thinking clear and logical? Is there anything I could have done better?” This 1-minute metacognition exercise will help you develop as a great thinker! Nursing Knowledge Base Nurses must have a solid knowledge base to safely care for patients. You would not drive a car without first learning the basics of how a car w orks and the rules of the road. In the same way, you must understand the human body in health and illness before you can understand how to take care of an ill patient. This is the reason you are going to school and studying this book. Information is found in many places; some information is good, and some is not as good. For example, health information found on a website may have been put there by a major university medical school or other reputable source, or it may have been put there by a patient who has a particular disorder. You may learn about a patient’s experience by reading his or her website, but you certainly w ould not base your patient care on someone’s personal story. The best kno wledge on which to base your practice comes from research. Nurse researchers try new methods of caring for patients and compare them with traditional methods to determine what w orks best. F or example, for many years, nurses were taught to massage patients’ reddened bony prominences to pre vent pressure ulcers. Through research, we now know that this practice should be avoided because it can further harm the damaged tissue. When nursing care is based on good, well-designed research studies, it is called evidence-based practice. You will read more about e vidence-based practice in Chapter 2. Critical Thinking Skills Problem Solving Problem solving is another way to think about clinical reasoning. Nurses solve problems every day. However, a problem can be handled in a way that may or may not help the patient. For instance, consider Mr. Frank, who is in pain and asks for pain medication. You check the medication record and find that his analgesic is not due for another 40 minutes. You can choose to manage this problem in several ways. One approach is to tell Mr . Frank that it is not time for the pain medication and that he will have to wait. This may solve your problem (you can move on to the next patient), but it does not solve the problem in an acceptable way for Mr. Frank. He is still in pain! Another approach is to use a standard problem-solving method: (1) gather data, (2) identify the problem, (3) decide what outcome is desirable, (4) plan what to do, (5) implement the interv entions in your plan, and (6) evaluate the plan of care. 1. Gather data, or factual information, to help you think critically about Mr. Frank’s request for pain medication. As a good critical thinker, you can use intellectual empathy as well as your knowledge base about pain to decide what data you need. You decide to use a pain-rating scale on which the patient rates pain on a scale of 0 (no pain) to 10 (the greatest pain possible). Mr. Frank says that the pain is in his back and rates it as an 8 on a 10-point scale. You check his history and find that he has spinal compression fractures. Your empathetic attitude tells you that waiting for 40 minutes to relieve his pain is not acceptable. You next go to the medication record and find that he has no alternative pain medications ordered. 2. Identify the problem. Here you use your knowledge base about compression fractures, pain, and medication administration to draw the conclusion that Mr. Frank is in acute pain, and the current medication orders are not sufficient to provide pain relief. 3. Decide what outcome (sometimes called a goal) is desirable. The outcome should be determined by you (the nurse) and the patient working together. The patient is intimately involved in this situation and deserves to be consulted. You may also collaborate with the RN or health care provider. In this case, you talk to Mr. Frank and determine that he needs pain relief now; he cannot wait until the next scheduled dose of medication. He states that he can tolerate a pain rating of 3 or less on a 10-point scale. 4. Plan what to do. Formulate and consider some alternate solutions. For example, you can decide to tell Mr. Frank that he has to wait 40 minutes; however, this will not help him reach his desired outcome of pain control. You could give the medication early, but this would not be following the health care provider’s orders and may have harmful effects for Mr. Frank. You could decide to try some nondrug pain-control methods, such as relaxation, distraction, or imagery. These might be helpful, but you recall from pharmacology class that complementary methods should be used in conjunction with, not in place of, medications. Another option is to report to the registered nurse (RN) or health care provider that Mr. Frank’s pain is not controlled with the current pain-control regimen. Once you have several alternative courses of action, decide which will best help the patient. Then you can discuss those options with the RN and together decide the best thing to do; in this case, you might decide to have the RN contact the health care provider while you work with the patient on relaxation exercises. You might decide 4068_Ch01_001-011 15/11/14 12:31 PM Page 5 Chapter 1 to ask Mr. Frank if he would like to listen to some of the music his wife brought for him. You should also tell Mr. Frank that the health care provider is being contacted. This would assure him that his pain is being taken seriously. 5. Implement the interventions in your plan. The RN enters the room and informs you and the patient that the health care provider has changed the analgesic orders. You obtain and administer the first dose of the new analgesic, being sure to explain its effects and side effects to Mr. Frank. The RN also informs Mr. Frank that the health care provider has ordered a consultation with the pain clinic. 6. Evaluate the plan of care. Did the plan work? As you reassess Mr. Frank 30 minutes later, he rates his pain level at 2 on the 10-point scale. He smiles and thanks you for your attentiveness to his needs. You think back to the desired outcome, compare it with the current data collected, and determine that your interventions were successful. Can you see how using good thinking attitudes, a good knowledge base, and the problem-solving process led to a better outcome than simply choosing the first obvious option? You were able to achie ve a desirable outcome: assisting Mr. Frank in relie ving his pain. And you ha ve earned Mr. Frank’s trust in the process. Problem solving is ho w nurses make decisions on a daily basis. You may already know this method as the nursing process. Other Critical Thinking Skills Problem solving is just one critical thinking skill. Another way you can use critical thinking in patient care is by anticipating what might go wrong, w atching carefully for signs that a problem might be occurring, and then preventing it or notifying the RN or health care provider in time to intervene. Nurses save many lives each year by anticipating and preventing problems. Sometimes this is called vigilance. An example would be knowing the signs and symptoms of low blood glucose (because of an excellent knowledge base) and watching for them carefully (being vigilant) in a patient taking medication for diabetes. If early symptoms occur , you can intervene before the problem becomes se vere. In addition, you could teach the patient and family about low blood glucose and how to prevent it, further reducing the risk to the patient. Critical Thinking and the Nursing Process 5 There are many other thinking skills that are be yond the scope of this book. A few questions follow that you can ask yourself as you continue to de velop your thinking skills. These are not in any order, nor would they all be asked for in a given situation. They are just some ideas to get you started. • Have I thought this through? • What information do I need? • How do I know? • Is someone influencing my thinking in ways I am not aware of? • What conclusions can I draw from the information I have? • Am I basing this decision on assumptions that may or may not be true? • Am I thinking creatively about this, or am I in a rut? • What do I need to watch for in order to prevent complications? • Is there an expert I can consult who can help me think this through? • Is there any supporting research or evidence that this is true? • Am I too stressed or tired to think carefully about this right now? NURSING PROCESS You have just used the nursing process to solv e a real problem. The nursing process is an organizing framework that links the process of thinking with actions in nursing practice. The nursing process is used to assess patient needs, formulate nursing diagnoses, and plan, implement, and e valuate care. As a nursing student, you consciously apply the nursing process to each patient problem. With experience, you will internalize the nursing process and use it without as much conscious effort. Role of the Licensed Practical Nurse/Licensed Vocational Nurse The licensed practical nurse (LPN) or licensed vocational nurse (LVN) carries out a specif ic role in the nursing process, as described in Table 1.1. The role of the LPN/LVN is to provide direct patient care. The LPN/LVN often spends more time at the bedside than the RN, which allows the LPN/LVN to develop a therapeutic relationship and understand the patient’ s needs. The LPN/LVN and the RN collaborate to analyze data and develop, implement, and evaluate the plan of care (Fig. 1.1). Data Collection BE SAFE! BE VIGILANT! Always ask yourself as you prepare for patient care each day, “What is the worst thing that could happen to this patient today? What are early signs I should recognize? What will I do if they occur?” Plan ahead to be vigilant and you can prevent many patient care disasters! The first step in the nursing process is data collection. This assessment is a way to evaluate a patient’s condition. The LPN/LVN assists the RN in collecting data from a variety of sources. Data are divided into two types: subjective data and objective data. Subjective Data Information provided verbally by the patient is called subjective data. Symptoms are subjective data. Anxiety or pain 4068_Ch01_001-011 15/11/14 12:31 PM Page 6 6 UNIT ONE Understanding Health Care Issues TABLE 1.1 ROLE OF THE LPN/LVN IN THE NURSING PROCESS Steps of the Process Assessment Role of the LPN/LVN Assists RN in collecting data. Nursing Diagnosis Assists RN in choosing appropriate nursing diagnoses. Planning Care Assists RN in planning care and developing outcomes to meet patient needs. Implementation Carries out portions of the plan of care that are within the LPN/LVN’s scope of practice. Evaluation Assists RN in evaluation and revision of the plan of care. Box 1-1 WHAT’S UP? Guide to Symptom Assessment W—Where is it? H—How does it feel? Describe the quality. (For example, is it dull, sharp, stabbing?) A—Aggravating and alleviating factors. What makes it worse? What makes it better? T—Timing. When did it start? How long does it last? S—Severity. How bad is it? This can often be rated on a scale of 0 to 10. U—Useful other data. What other symptoms are present that might be related? P—Patient’s perception of the problem. The patient often has an idea about what the problem is, or the cause, but may not believe that his or her thoughts are important to share unless specifically asked. Note: There may be slight variations by state. Next, obtain a patient history. Do this by asking the patient and family questions about the patient’ s past and present health problems, including specif ic questions about each body system, family health problems, and risk f actors for health problems. The patient’s medical record may also be consulted for background history information. LEARNING TIP Practice assessing a symptom on a classmate. Ask the WHAT’S UP? questions. FIGURE 1.1 The nursing care team collaborating on a nursing care plan. would be considered subjective data because only the patient can feel them. A nurse cannot objecti vely observe them. Often, subjective information is placed in quotes, such as “I have a headache” or “I feel out of breath. ” You must listen carefully to the patient and understand that only the patient truly knows how he or she feels. When collecting subjective data, start with the patient’ s main concern. Focus on the reason the patient is seeking health care. Try asking, “What happened that brought you to the hospital (clinic, office)?” Once the patient has identified the main concern, further questioning can reveal more pertinent information. Use the phrase “WHAT’S UP?” as a handy way to remember questions to ask the patient (Box 1-1). Asking the right questions can help you obtain better data with which to mak e the best decisions. In addition to assessment of physiological function, ask the patient about personal habits that relate to health, such as exercise, diet, and the presence of stressors, according to institutional assessment guidelines. Finally , assess the patient’s family role, support systems, and cultural and spiritual beliefs. Objective Data Objective data are pieces of f actual information obtained through physical assessment and diagnostic tests that are observable or knowable through the five senses. For example, a rash can be observed with the eyes and palpated with the fingers. Objective data are sometimes called signs. Examples of objective data include the following: • 3-cm red lesion • Respiratory rate 36 per minute • Blood glucose 326 mg/dL • Patient is moaning These are all observable or measurable by a nurse and do not need explanation by the patient. 4068_Ch01_001-011 15/11/14 12:31 PM Page 7 Chapter 1 Objective data are gathered through physical assessment. Inspection, palpation, percussion, and auscultation techniques are used to collect objective data (Fig. 1.2). You can find more on these techniques, as well as how to obtain a complete history, in a nursing assessment te xt. Give special attention to areas that the patient has identified as potential problems. Documentation of Data Collected data are documented in the patient’ s medical record. If you identify any significant problem, change in the patient’s status, or variation from normal, report it immediately to an RN or health care provider and then document it. Recorded data should be accurate and concise. When documenting subjective data, use what was stated by the patient or significant other. Use direct quotations whenever possible, such as, “I feel sad.” Quotes accurately represent the patient’s view and are least open to mistaken interpretation. When documenting objective data, include exactly what you observed. Avoid interpreting the data and using words that have vague meanings. For example, “nailbed color is pink” gi ves clearer information than “nailbed color is normal. ” “Normal” is an interpretation of data, rather than true data. “Capillary refill is 2 seconds” is more precise than “capillary refill is good.” The statement “the wound looks better” is not meaningful unless the reader has previously observed the wound. Stating that “the wound is 1 by 2 inches, red, with no drainage or odor” provides data with which to compare the future status of the wound and determine whether it is responding to treatment. LEARNING TIP Beginners may be tempted to search for elaborate phrases or words to document, when simple, direct words are best. Simply stating exactly what you saw or heard provides the most clear and accurate information. FIGURE 1.2 Nurse auscultating a patient’s chest. Critical Thinking and the Nursing Process 7 Nursing Diagnosis Once data have been collected, the LPN/LVN assists the RN to compare the f indings with what is considered “normal. ” Data are then grouped, or clustered, into sets of related information that identify problems. Problems are then labeled as nursing diagnoses. According to the North American Nursing Diagnosis Association (NANDA-I), a nursing diagnosis is a “clinical judgment about actual or potential individual, family, or community responses to health problems or life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (NANDA-I, 2013). Nursing diagnoses are standardized labels that make an identified problem understandable to all nurses. A list of NANDA-I–approved nursing diagnoses can be found in Appendix A of this book. A diagnosis is considered “medical” when the health care provider directs most of the care. A diagnosis is considered “nursing” if the interventions needed to treat the problem are mainly independent nursing functions. One example of a NANDA-I nursing diagnosis is Acute Pain. In Mr. Frank’s example, the nurse identif ied that pain was a problem, and a plan of care w as developed to manage the pain. The health care pro vider was contacted for analgesic orders, but independent nursing actions were also used, including relaxation and distraction. These independent nursing actions did not require a health care provider’s order. A well-written nursing diagnosis helps guide development of a plan of care. The three parts of a diagnosis follow: • Problem—the nursing diagnosis label from the NANDA-I list • Etiology—the cause or related factor (usually preceded by the words “related to”) • Signs and symptoms—the subjective or objective data that provide evidence that this is a valid diagnosis (often preceded by the words “as evidenced by”). The statement of problem, etiology, and signs and symptoms is called the PES format. Look again at the case study of Mr. Frank. A diagnosis using this format might read: “Acute Pain related to muscle spasms and nerve compression as evidenced by patient’s pain rating of 8 on a 10-point scale.” Note how the complete diagnosis gives you more helpful information than simply the label “pain.” This additional information helps determine an appropriate outcome and guides the selection of interventions. Many patient problems are collaborative—that is, the nurse, health care pro vider, and other members of the health team all w ork together to reach the desired outcome. For example, a patient with pneumonia (a medical diagnosis) has man y needs that depend on health care provider orders, such as respiratory treatments and antibiotics. The role of the LPN/LVN is to collect important data on the patient’s respiratory status and to pro vide nursing measures such as encouraging fluid intake, coughing, and deep breathing. 4068_Ch01_001-011 15/11/14 12:31 PM Page 8 UNIT ONE 8 Understanding Health Care Issues patient in the development of the plan of care. The plan will be most successful if the patient agrees with and under stands the interventions. CRITICAL THINKING Nursing Diagnosis Which of the following are NANDA-I nursing diagnoses? Which are medical diagnoses? (Hint: Check Appendix A for help figuring these out!) ■ 1. 2. 3. 4. 5. 6. 7. 8. Impaired Physical Mobility Ineffective Coping Herniated Disk Fractured Femur Diabetes Impaired Gas Exchange Appendicitis Activity Intolerance Suggested answers are at the end of the chapter. Planning Care Once nursing diagnoses have been identified, an individualized plan of care is designed to help meet the patient’ s care needs. Planning involves setting priorities, establishing outcomes, and identifying interventions that will help the patient meet the outcomes. It is important to include the Prioritize Care Once you know what problems need to be addressed, you must decide which problem or interv ention should be tak en care of first. Because care should always be patient-centered, with the patient at the center of the health team, such decisions should involve the patient as well as the RN and LPN/L VN. Maslow’s hierarchy of human needs is one commonly used system that can be used as a basis for determining priorities (Fig. 1.3). According to Maslow, humans must meet their most basic needs (those at the bottom of the triangle) first. They can then move up the hierarchy to meet higher level needs. Physiological needs are the most basic. F or example, a person who is short of breath cannot attend to higher le vel needs because the physiological need for oxygen is not being met. Once physiological needs are met, the patient can concentrate on meeting safety and security needs. Love, belonging, and self-esteem needs are next; self-actualization needs are generally the last priority when planning care. Throughout life, people move up and down Maslow’s hierarchy in response to life events. If a need occurs on a level below the patient’s current level, the patient will move down to the level of that need. Once the need is fulfilled, the person can move upward on the hierarchy again. SELFACTUALIZATION (The individual possesses a feeling of self-fulfillment and the realization of his or her highest potential.) SELF-ESTEEM ESTEEM-OF-OTHERS (The individual seeks self-respect and respect from others; works to achieve success and recognition in work; desires prestige from accomplishments.) LOVE AND BELONGING (Needs are for giving and receiving of affection; companionship; satisfactory interpersonal relationships; and the identification with a group.) SAFETY AND SECURITY (Needs at this level are for avoiding harm; maintaining comfort; order; structure; physical safety; freedom from fear; protection.) PHYSIOLOGICAL NEEDS (Basic fundamental needs including food, water, air, sleep, exercise, elimination, shelter, and sexual expression.) FIGURE 1.3 Maslow’s hierarchy of human needs. 4068_Ch01_001-011 15/11/14 12:31 PM Page 9 Chapter 1 In a nursing plan of care, the patient’s most urgent problem is listed first. This usually involves a physiological need such as oxygen or w ater because these are life-sustaining needs. If several physiological needs are present, life-threatening needs are ranked first, health-threatening needs are second, and health-promoting needs, although important, are last. LEARNING TIP If you are stuck wondering which physiological need should take priority, ask yourself, “Which problem is most threatening to my patient’s life?” ABCs should also be considered: Airway is most emergent, then Breathing, and then Circulation. Once physiological needs have been met, needs related to the next level of the hierarchy, safety and security, can be addressed. Remaining diagnoses are listed in order of urgency as they relate to the hierarchy . Needs can occur simultaneously on different levels and must be addressed in a holistic manner, with prioritization guiding the care provided. LEARNING TIP If you are developing a plan of care for a patient with complex needs and are not sure where to start, go back to the assessment phase. Often, additional information can help you better understand the patient’s needs and develop a plan of care individualized to the patient’s specific problem areas. CRITICAL THINKING Prioritizing Care ■ Based on Maslo w’s hierarchy of needs, list the following nursing diagnoses in order from highest (1) to lowest (5) priority. Give rationales for your decisions. ____ Deficient Knowledge ____ Constipation ____ Disabled Family Coping ____ Readiness for Enhanced Self-Concept ____ Ineffective Airway Clearance Suggested answers are at the end of the chapter. Establish Outcomes An outcome is a statement that describes the patient’ s desired goal for a problem area. It should be measurable, be realistic for the patient, and have an appropriate time frame Critical Thinking and the Nursing Process 9 for achievement. Measurable means that the outcome is objective, or can be observ ed. It should not be v ague or open to interpretation, with the use of subjecti ve words such as normal, large, small, or moderate. Consider, for example, two outcomes: 1. The patient’s shortness of breath will improve. 2. The patient will be less short of breath within 15 minutes as evidenced by the patient rating the shortness of breath at less than 3 on a scale of 0 to 10, respiratory rate between 16 and 20 per minute, and relaxed appearance. Although the first outcome seems appropriate, in reality it is difficult to know when it has been met. There is nothing to objectively indicate when the problem has been resolved. The second outcome is objective. You can see that when the patient rates his or her shortness of breath at less than 3, is breathing at a rate of 16 to 20 per minute, and appears relaxed, the desired outcome will have been met. The outcome is realistic, and the 15-minute time frame ensures that the patient’s distress is minimized. If the plan of care does not achieve the desired outcome in the given time frame, it should be evaluated and revised as needed. When determining criteria for a measurable outcome, look at the signs and symptoms portion of the nursing diagnosis. The resolution of signs and symptoms identif ied in the NANDA-I nursing diagnoses is evidence that nursing interventions were ef fective. If the desired outcome is not achieved, the problem and interv entions need reevaluation. Look at another outcome example to see how criteria are used for measurement: Nursing diagnosis—Ineffective Airway Clearance related to excess secretions as evidenced by coarse crackles and nonproductive cough Outcome—Patient will have effective airway clearance within 8 hours, as evidenced by clear lung sounds and productive cough. Identify Interventions Interventions are the actions you take to help a patient meet a desired outcome. Therefore, interventions should be goaldirected. Any intervention that does not contribute to meeting the outcome should not be part of the plan of care. One way to create a care plan is to include interv entions that can be categorized as “take, treat, and teach.” In the first intervention category, “take,” or identify, data related to the problem that should be routinely collected. Next, “treat” the problem by identifying deliberate actions to help reach the outcome. Last, identify what to “teach” the patient and family for the patient to learn to care for himself or herself. Look again at the nursing diagnosis of Ineffective Airway Clearance. A plan of care for this problem using the tak e, treat, and teach method might look like this: Take: Auscultate lung sounds every 4 hours and as needed. Assess respiratory rate every 4 hours and as needed. 4068_Ch01_001-011 15/11/14 12:31 PM Page 10 UNIT ONE 10 Treat: Teach: Understanding Health Care Issues Provide 2 L of fluids every 24 hours. Offer expectorant as ordered. Provide cool mist vaporizer in room. Teach the patient the importance of fluid intake. Teach the patient to cough and deep breathe every 1 to 2 hours. In addition to identifying interventions, it is important to understand how and why they will work. The “why” is called a rationale. For example, you should assess lung sounds and respiratory rate every 4 hours because increased crackles and respiratory rate indicate retained secretions. Fluids are provided to minimize mucosal drying and ease secretion removal. Sound rationales that are evidence based (research based) should guide the selection of each nursing interv ention. You will find rationales with interventions throughout this book to help you un derstand why interventions will be effective. Like nursing diagnoses, nursing interv entions can be either independent or collaborative. Independent nursing actions can be initiated by the nurse. Examples of independent nursing actions include teaching the patient deep-breathing exercises, turning a patient e very 2 hours, teaching about medications, and giving a back rub for comfort. Collaborative actions require a health care pro vider’s order to perform. Examples of collaborative interventions include giving prescribed medications, applying elastic stockings, requesting a referral to physical therapy, and inserting a urinary catheter. Implement Interventions Once the plan of care has been identif ied, it must be communicated to the patient, f amily, and health team members and then implemented. One w ay a plan of care is communicated is by writing it as a nursing care plan. The nursing care plan is documented on the patient’s medical record, to communicate to all nurses the patient’ s priority problems, the desired outcomes, and the plan for meeting the outcomes. Man y institutions have standardized care plans that are individualized for each patient by the nurse. Implementation of the plan of care involves performing the interventions. The patient’s response to each intervention is noted and documented. This documentation provides the basis for evaluation and revision of the plan of care. Evaluate Outcomes The last step of the nursing process is evaluation. The nurse continuously evaluates the patient’s progress toward the desired outcomes and the ef fectiveness of each intervention. If the outcomes are not reached within the gi ven time frame or if the interv entions are ineffective, the plan of care is re vised. Any part of the plan of care can be revised, from the diagnosis or desired outcome to the inter ventions. Acute care institutions require routine review and updating of the plan of care. SUGGESTED ANSWERS TO CRITICAL THINKING ■ Nursing Diagnosis 1. 2. 3. 4. 5. 6. 7. 8. Impaired Physical Mobility = nursing Ineffective Coping = nursing Herniated Disk = medical Fractured Femur = medical Diabetes = medical Impaired Gas Exchange = nursing Appendicitis = medical Activity Intolerance = nursing ■ Prioritizing Care 1. Ineffective Airway Clearance—physiological need that can be life threatening 2. Constipation—physiological need that can be health threatening 3. Deficient Knowledge—safety and security need 4. Disabled Family Coping—love and belonging need 5. Readiness for Enhanced Self-Concept—self-esteem need REVIEW QUESTIONS 1. In which of the following ways is critical thinking useful to the nursing process? 1. It highlights the solution to a problem. 2. It can lead to a better outcome for the patient. 3. It simplifies the process. 4. It helps the nurse arrive at a solution more quickly. 2. Which nurse is exhibiting intellectual humility? 1. The nurse who is an expert at wound care. 2. The nurse who reports an error to the supervisor. 3. The nurse who tries to empathize with the patient. 4. The nurse who asks a coworker about a new procedure. 4068_Ch01_001-011 15/11/14 12:31 PM Page 11 Chapter 1 Critical Thinking and the Nursing Process 11 3. Which of the following pieces of information is considered objective data? 1. The patient’s respiratory rate is 28. 2. The patient states, “I feel short of breath.” 3. The patient is short of breath. 4. The patient is feeling panicky. 7. Which of the following parts of the nursing process can be carried out by an LPN/LVN? 1. Implementation of interventions 2. Nursing diagnosis 3. Analysis of data 4. Evaluation of outcomes 4. An LPN/LVN is collecting data on a newly admitted patient who has an ulcerated area on his left hip. It is 2 inches in diameter and 1 inch deep, with yellow exudate. Which of the following statements best documents the findings in the patient’s database? 1. Wound on left hip, 2 inches diameter, 1 inch deep, infected 2. Left hip wound is large, deep, and has yellow drainage 3. Pressure ulcer on left hip, yellow drainage 4. Wound on left hip, 2 inches in diameter, 1 inch deep, yellow exudate 8. Which of the following is a nursing diagnosis? 1. Stroke 2. Renal Failure 3. Fracture 4. Acute Pain 5. A 34-year-old mother of three children is admitted to a respiratory unit with pneumonia. She has all the following problems. Based on Maslow’s hierarchy of needs, which problem should the nurse address first? 1. Frontal headache related to stress of hospital admission 2. Anxiety related to concern about leaving children 3. Shortness of breath related to newly diagnosed pneumonia 4. Deficient knowledge related to treatment plan 9. A nurse teaches a patient the importance of stopping smoking. Which of the following patient responses provides the best evidence that the teaching was effective? 1. “I have a brother who died of lung cancer. I know smoking is bad.” 2. “I tried to quit 5 years ago, and I really would like to, but it is very hard.” 3. “Thank you for the information. I will call the Smoke Stoppers organization today.” 4. “I know you are right; I should stop smoking.” Answers can be found in Appendix C. 6. Place the steps of the nursing process in correct chronological order of use. Use all options. 1. Nursing diagnosis 2. Evaluation 3. Assessment 4. Planning care 5. Implementation References Foundation for Critical Thinking. (2013). Valuable intellectual traits. Retrieved May 13, 2013, from www.criticalthinking.org/pages /valuable-intellectual-traits/528 Halpern, D. (1996). Thought and knowledge: An introduction to critical thinking (3rd ed.). Mahwah, NJ: Lawrence Erlbaum Associates. Hawkins, D., Elder, L., Paul, R. (2010). The thinker’s guide to clinical reasoning. Tomales, CA: Foundation for Critical Thinking Press (www.criticalthinking.org). North American Nursing Diagnosis Association (NANDA-I). (n.d.). Glossary of terms. Retrieved May 16, 2013, from www.nanda.org/nanda-international-glossary-of-terms.html For additional resources and information visit davispl.us/medsurg5