Week 9- Nov 10- Slide Class.pdf

NUSC 1P12: WEEK 9 PART 1: CHAPTER 7 CRITICAL THINKING IN NURSING PRACTICE (Potter et al., 2024) THINKING CRITICALLY ABOUT OUR ABILITY TO THINK CRITICALLY… Are you a critical thinker? What does that mean? What skills do you think you would improve to further develop this skill? Why is it important...

NUSC 1P12: WEEK 9 PART 1: CHAPTER 7 CRITICAL THINKING IN NURSING PRACTICE (Potter et al., 2024) THINKING CRITICALLY ABOUT OUR ABILITY TO THINK CRITICALLY… Are you a critical thinker? What does that mean? What skills do you think you would improve to further develop this skill? Why is it important- to you in your personal life, as a student, as a future nurse? Think critically about your own personal and academic growth over the past 8 weeks, what have you learned about how you learn? What changes have you made? CREATIVE ACTIVITY Creativity is one component of critical thinking. The purpose of this imaginative exercise is to promote thinking that alters the pattern of our usual thinking (to think beyond what you know). Imagine that you are writing an ad for a RN in the year 2050. It could be a position for anywhere in the world. Think about your current knowledge and understanding of healthcare and nursing. Take some time to think about how you envision healthcare to look in the future. What special skills and attributes do you imagine will be required of an RN in 2050? CRITICAL THINKING DEFINED o A process and a set of skills o Recognition that an issue exists, analyzing information, evaluating information, and drawing conclusions o Use of evidence-informed knowledge and the clinical decisionmaking process CRITICAL THINKING SKILLS (TABLE 7-1) Interpretation Looking for patterns, clarifying things you are uncertain about Analysis Being open minded about patient information/ presentation; avoid making assumptions; consider if other scenarios are possible (think again, be curious) Inference Find meanings and relationships in the data; form reasonable hypotheses and conclusions based on patterns observed (if x then y) Evaluation Assess all situations objectively; measure effectiveness of nursing actions based on outcomes/ criteria; identify required changes; reflect on your actions, attitudes and behaviour Explanation Support your findings and conclusions; use knowledge and experience to justify how you care for patients (rationale, why) Self-regulation Reflect on your experiences; adhere to standards of practice; apply ethical principles in your practice; consider what you can do to improve your performance CNO REQUISITE SKILLS & ABILITIES R/T CRITICAL THINKING https://www.cno.org/globalassets/docs/reg/41078-skillabilities-4pager-final.pdf Cognitive requirements: Ability to perform skills that demonstrate thinking capacity: o Remember information from past experiences o Demonstrate problem-solving skills o Demonstrate concentration skills o Use reasoning to develop professional judgment o Exercise critical thinking skills to develop professional judgment Examples: The student/nurse: uses past experiences to inform current decision-making; perceives when situations require further inquiry (sometimes questions are more important than answers); makes sense of complex information. CNO REQUISITE SKILLS & ABILITIES R/T CRITICAL THINKING More than just cognitive skills. Critical thinking requires us to: o o o o Ask questions Be well informed Be honest in facing personal biases Be willing to reconsider and think clearly about issues CRITICAL THINKING DISPOSITIONS (TABLE 7-1) Truth-Seeking Aim to learn what is actually happening in a situation; consider evidence even if it does not support your preconceptions/personal beliefs (put aside your own “truth” to seek the truth and see facts related to a situation) OpenMindedness Receptive to new ideas and tolerant of other points of view; respect the right of other people to hold different opinions; be aware of your own prejudices Analyticity Determine the significance of a situation; interpret meaning; anticipate possible results or consequences; use evidence-informed knowledge in your practice Systematicity Be organized and focused in data collection; use an organized approach to problem solving and decision-making Self-Confidence Trust your own reasoning process; seek confirmation from others/ experts when uncertain (it’s okay not to know, but reach out for help/ advice) Inquisitiveness Be curious; seek new knowledge. Ask questions! Maturity Accept that multiple situations are possible; reflect on your own judgements; consider other possibilities/ explanations; be thoughtful/ careful when making, suspending and revising judgments CRITICAL THINKING MODEL FOR CLINICAL DECISION MAKING Models serve to explain concepts and help nurses make decisions and judgements about patients. Kataoka-Yahiro and Saylor (1994) devised the critical thinking model of nursing judgement. o Defines the outcome of critical thinking as nursing judgement that is relevant to nursing problems in a variety of settings Kataoka-Yahiro and Saylor’s (1994) critical thinking model o Basic critical thinking o Complex critical thinking o Commitment See next slide… LEVELS OF CRITICAL THINKING A PROCESS ACQUIRED THROUGH LEARNING (KNOWLEDGE BASE) AND EXPERIENCE Basic Critical Thinking o The learner trusts that experts have the answers for every problem, but this fails to recognize the need to individualize things, troubleshoot, adapt, etc. Thinking is concrete and based on rules or principles. Complex Critical Thinking o Separating your thinking from that of experts/others and beginning to analyze & examine your choices independently. A willingness to consider other options or explanations. Thinking is more creative and innovative. Commitment o Anticipating the need to make choices without assistance and assume responsibility/accountability for those choices. You give attention to the results of the decision and determine whether it was appropriate or if a different approach was/is required. DEVELOPING CRITICAL THINKING SKILLS Case-based learning o A strategy that lets the nurse explore complex problems without the risk of harming a patient Reflective writing o A tool for developing critical thought for which the nurse uses reflection Concept mapping o A visual representation of patient problems and interventions that depicts their relationships to one another Questioning o Fosters critical thinking o Based in philosophy o “Sometimes questions are more important than answers” CRITICAL THINKING SYNTHESIS Critical thinking o A reasoning process by which you use knowledge, reflect on previous experience, and integrate professional practice standards to provide competent, ethical nursing care o Requires a desire to grow intellectually o Requires the use of the nursing process to make nursing care decisions SELF-REFLECTION Do you think of yourself as having strong or weak critical thinking skills? Based on what? Yourself over time, yourself compared to others, etc. Think of a time you impressed yourself with your ability to think critically in a situation- maybe you saw something others didn’t, solved a problem you didn’t think you could or that others couldn’t, thought “outside of the box”, could see “the big picture”, etc. EXAMPLES… PATIENT ASSESSMENTS Doing a thorough assessment on your patient can help you detect when something is wrong, even if you’re not sure what it is. When you notice a change, or something concerning, you have to use your critical thinking skills to decide the next step, and maybe that includes choosing a nursing diagnosis. Critical thinking allows you to provide the best and safest care possible. MANAGING SITUATIONS Imagine a patient has an accelerated heart rate. As a nurse, it is your job to recognize the issue, investigate the cause (ask questions, collect data), and implement nursing actions/ interventions to decrease the heart rate. You may also call the doctor. A nurse with poor critical thinking skills may fail to detect the patient’s distress, may fail to assess the heart rate at the appropriate frequency, may fail to notice signs of stress and deterioration, may fail to reach out and call the doctor, and this could cause an adverse outcome. PATIENT INTERACTIONS Nurses listen to patients and use their communication skills to discern what patients are telling them (or not telling them) and whether they are getting the whole story. To know what questions to ask, and make sense of the information/ data collected. Nurses use detective skills, curiosity, and intuition, to guide them and their lines of inquiry when assessing and re-assessing patients. PRIORITIZING Nurses receive report from the last shift/ nurse, and decide which patient to see first based on information gathered. They prioritize their actions for each patient individually, and for all of their patients (their workload). They strategize, synthesize, plan, and organize information from the beginning of their shift, constantly re-evaluating and re-prioritizing to manage their time. They establish routines and leave room for the unplanned events that will inevitably occur. Even experienced nurses can struggle to juggle their workload, prioritize responsibilities, and delegate tasks. SUMMARY Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes. Critical thinking allows nurses to ensure patient safety and is essential to being a good nurse. Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients’ and providers’ needs, and prioritize accordingly. Such actions require critical thinking ability and advanced problemsolving skills (again, this a process and will come in time as you build your knowledge base and gain experience!). NUSC 1P12: WEEK 9 PART 2: CHAPTER 14 NURSING ASSESSMENT, DIAGNOSIS & PLANNING (Potter et al., 2024) WHAT DO WE KNOW ABOUT RELATIONAL PRACTICE, HEALTH PROMOTION, THE HEALTH CARE SYSTEM, AND SDOH THAT WE SHOULD REMEMBER WHEN PLANNING NURSING CARE? NURSING PROCESS 5 Steps (we will focus today on the first 3 steps, and you will continue to build your knowledge of the complete nursing process in 1F18 in the Winter term) Assessment Diagnosis o Nursing diagnosis Planning o Outcomes identification Implementation Evaluation NURSING PROCESS ASSESSMENT Ongoing process involving critical thinking and data collection (objective + subjective) Determines a client’s current and past health status, and functional status Determines a client’s current and past coping patterns Used every time nurses interact with a patient Includes collecting, organizing, validating, and documenting data to establish an individualized database ASSESSMENT o o Types of data o Subjective: E.g., “I have pain in my chest” o Objective: E.g., “BP 162/90, HR 120“ o What are other examples of subjective/objective data? Sources of data o Client (primary) o Secondary sources: o Family and significant other o Health care team o Medical records ASSESSMENT o Ways to collect data (depends on purpose, setting, patient acuity, etc.) o Interview (what are you learning about communication? Building trust?) o Physical examination (objective data, observation of behaviour, dx and lab data) o Form completion (incl. standardized forms, intake forms, checklists, etc.) o Nursing health history o Family history o Documentation - why is this important? o Organizing data - consolidate, prioritize, cluster o Recognize patterns/trends, compare with baseline (client’s normal) or normal standards (i.e. normal range from text) o Use nursing judgment and think critically- how does this relate to our cognitive requisite skills and abilities (CNO)? WHAT IS A DIAGNOSIS? Nursing Diagnosis A clinical judgement about client responses to an actual or potential health problem Medical Diagnosis The identification of a disease condition on the basis of specific evaluation of signs and symptoms Collaborative Problem An actual or potential complication that nurses monitor to detect a change in client status WHAT IS A DIAGNOSIS? https:/ https://nurseslabs.com/nursing-diagnosis/#h-syndrome-diagnosis /nurseslabs.com/nursing-diagnosis/#h-syndrome-diagnosis NURSING DIAGNOSIS o o o o o Employ clinical judgement to formulate nursing diagnosis Purpose: focus, prioritize, plan and implement patient care Involves analysis of data (from assessment), identification of health problems/risks/strengths and formation of diagnostic statement Focuses on a client’s actual or potential response to a health problem rather than the physiological event, complication, or disease Is it the same as a medical diagnosis??? Medical dx=identification of a disease condition Nursing diagnosis=identification of patient condition, specifically threats to health (impaired…risk of…) and strengths (readiness for…) NANDA INTERNATIONAL Where does a nursing diagnosis come from (what are the available options)? Means of translating nursing observations and assessments into standard conclusions in a common nomenclature Provides a precise definition of the client’s needs Gives all members of the health care team (all members, or all nurses?) a common language to use (standardized) What might be some benefits and limitations of a standardized list? CRITICAL THINKING & THE NURSING DIAGNOSTIC PROCESS Diagnostic reasoning o A process of using assessment data to create a nursing diagnosis Defining characteristics o Clinical criteria or assessment findings that help confirm an actual nursing diagnosis Clinical criteria o Objective or subjective signs and symptoms that lead to a diagnostic conclusion TYPES OF NURSING DIAGNOSIS Actual/ProblemFocused Nursing Diagnosis Describes human responses to health conditions or life processes E.g., Impaired skin integrity (nursing diagnosis) related to (related factors)… as evidenced by (defining characteristics)… Risk Nursing Diagnosis Describes human responses to health conditions or life processes that may develop E.g., Risk for impaired skin integrity as evidenced by (defining characteristics)… Syndrome Diagnosis Cluster of diagnosis’ best understood together E.g., Chronic pain syndrome Health Promotion/Wellness Nursing Diagnosis Clinical judgement of client’s motivation and desire to E.g., Readiness for enhanced family increase well-being by readiness to enhance specific coping health behaviours, such as nutrition and exercise; describes levels of wellness in a client that can be enhanced. Possible Nursing Diagnosis Describes a suspected problem for which additional data are needed to confirm or rule out the suspected problem. E.g., Possible social isolation NURSING DIAGNOSIS 1. The problem or “diagnostic label”, which has two components o Qualifier: e.g “impaired” o Focus of the diagnosis: e.g. “gas exchange” 2. The related factors (cause/risk, the why) o Written as “related to” 3. The defining characteristics (subjective/objective data, the what) o Written as “as evidenced by” o What data (subjective or objective) do you have to support this? EXAMPLE CASE You are assigned to care for Mr. James Jones who is a 97-year-old male currently residing in long term care. Mr. Jones is wheelchair bound as he had a stroke 2 years ago. Due to paralysis on the left side of his body, he requires a catheter which is changed every month as per the doctor’s order (last changed 4 days ago). Mr. Jones is unable to move in bed independently and is often incontinent of stool. His past medical history includes stroke, type 2 diabetes, hypertension and hyperlipidemia (high cholesterol). On assessment today, Mr. Jones complains of “not feeling well” and “being exhausted” and states he “feels pressure in my low back.” The nurse notes that Mr. Jones appears somewhat confused, anxious and agitated. Upon assessment, his vitals are: HR: 98, BP: 138/92, O2: 92% on room air, RR: 22, Temp: 38.5 Upon assessment, you find: Adequate air entry, regular heart sounds, pulse regular and strong, swelling in lower legs, skin is pale and clammy. Mr. Jones appears to be shivering, urine in catheter is cloudy and blood tinged and has a foul odour. Answer the following questions: List one “Actual” nursing diagnosis: _____ related to _____ as evidenced by _____. List one “Risk For” nursing diagnosis: Risk for _____ as evidenced by _____. List one “Wellness” nursing diagnosis: Readiness for _____ as evidenced by _____. EXAMPLE CASE CONTINUED... Risk for infection as evidenced by increased temperature, foul smelling, cloudy and blood-tinged urine, and patient stating he is “not feeling well” and “feeling pressure in his low back”. Readiness for enhanced comfort as evidenced by [signs of discomfort] Fatigue related to possible infection as evidenced by patient stating he feels ”exhausted” Impaired physical mobility related to paralysis as evidenced by inability to move independently. Impaired urinary elimination related to paralysis as evidenced by use of indwelling foley catheter. Acute confusion related to possible infection as evidenced by patient presenting as confused, anxious, and agitated. PLANNING o o o o o Planning begins after identification of a client’s nursing diagnoses and strengths. Nurse sets client-centered goals and expected outcomes, plans nursing interventions, and prioritizes interventions. Requires critical thinking, applied through deliberate decision making and problem solving. Helps nurses anticipate and sequence nursing interventions. Classification of priorities (helps us sequence or “prioritize” interventions): o High-priority nursing diagnoses (threat to life, risk of harm/danger) o Intermediate-priority nursing diagnoses (less urgent e.g. knowledge deficit) o Low-priority nursing diagnoses (future, long-term) o 3 Phases (time factor in setting priorities): o Initial - immediate (may be upon admission) o Ongoing - continuous (may be while admitted, expect to change based on re-assessment) o Discharge - help with discharge planning- from your care, from hospital, etc. GOALS OF CARE Planning & Goals o Role of the Client in Goal Setting o Mutual goal setting o Include client and family o Active participation o Client goal o A specific, measurable outcome/behaviour or response reflecting client’s highest possible wellness level and independence o Short-term goal o An objective outcome/behaviour or response expected within hours to a week o Long-term goal o An objective outcome/behaviour or response expected within days, weeks, or months Expected Outcomes o Specific, measurable (objective) change in a client’s status that is expected in response to nursing care o Provides focus or direction, gives us the opportunity to evaluate whether what we are doing is effective o Determine when a specific goal has been met GOALS OF CARE PLANNING: WRITTEN PLANS OF CARE Care plans outline the holistic care to be provided o May be referred to as (or related to): o Nursing care plan o Institutional care plans o Computerized care plans o Care plans for communitybased settings o Critical/clinical pathways TO BE CONTINUED IN 1F18… Implementation and Evaluation are covered in Chapter 15. You will learn more about these stages of the nursing process when you are learning about nursing interventions. REMINDER ABOUT PAPER Reflective Paper: Caring in Context is due Sunday, November 19th at 2359