Critical Thinking & Clinical Judgment

Critical Thinking & Clinical
Judgment
(Nursing Process)

Clinical Thinking
defined as purposeful, self-regulatory
judgment that gives reasoned and reflective
consideration for evidence contexts,
conceptualization, methods, and criteria
( Facione,1990).

• Critical thinking examine all elements of a
situation and think through alternative
strategies to achieve an end.
Specific thinking skills including
• Problem solving
• Decision Making.
• Diagnostic reasoning.
• Clinical judgment.

• Problem solving is
Is a process used to arrive at an answer or
solution. Through:
1- defining a problem
2- selecting information pertinent to its
conclusion
3- formulating alternative solution.
4- drawing a conclusion and judging the
validity of the conclusion.

• Decision- making involves choosing
between two or more option as a means to
achieve a desired result.( goal directed or
goals will direct the outcome)
• In the clinical setting yields approaches for
nsg. Care selected from a variety of
possible nsg. Interventions.
• You must decide which intervention will be
most likely to achieve the desired client
outcomes.

Clinical judgment:
is a conclusion or an opinion that a
problem or situation requires nursing
determines the cause of the problem,
distinguishes between similar problems, or
discriminates between two or more course
of action.

• Process of thinking
T.H.I.N.K. Model
• Five mode of thinking importance to using
together for effectively outcome.
• T: Total Recall.
• H: Habits.
• I: Inquiry.
• N: New Ideas and creativity.
• K: Knowing how you think.

Total Recall:
Involves
Remembering Fact
(depend your memory)
names,
dates
Telephone
number
Normal Value
Help nurses to
-sort of information to solve problems
- Make decision.

• Habits: Are accepted way of doing things that work save time, or are
necessary. Habits are behaviors that have been repeated so many times
that they become second nature.
• Forming Habits allow nurses to
Do one thing while thinking about another

• Inquiry ‏:(األستقصاء)‏ Meaning examining
issues in depth & questioning things that
may seem obvious on the surface.
Inquiry
•Is the primary kind of thinking by which you reach conclusion
• Is Involves analyzing information to confirm your hunch about
situation

New Ideas & creativity
• Is occupy the opposite end the spectrum
from total recall & habit.
• Emphasize new & different ways of
looking at information & they form the
basis for individualized client care,
preferences & concerns.
• Is a creative plan ( depend on some
variable).

Ex: If you need to learn patient how to clean our
wound in home
For creative Plan most depend on some variable these variable are:
• The nurse should know:
1- Level of client anxiety at this time.
2- Supplies are available in the home
3- The complexity of terminology the client can understand.

• Knowing how you think
Metacognition
• Means that you recognize when are using
logical reasoning to reach a conclusion.
• Lead you to ask yourself questions about how
you think.
• Did I get all facts before making decision

Model of critical thinking that helps nurses to make
the clinical judgments needed for effective nursing
care
First component of the model is
( Specific knowledge base)
Physical
Science
Liberal
Arts
Nsg.
Knowledge
Understand
Functioning of
body
Bases for
Understanding
Human value &
Cultural Variation
Understand of
what it means
to be ill & provide
wellness

• Second components of the model
( Experience)
Individual
Experiences
To nsg.
education
Materials
Practices
In clinical
setting
Clinical
conferences
Increased ability to critically in the
setting

Third components model
( Competencies ) Refers to the cognitive
processes used to make clinical judgments
Need to
1- ability to identify problems caused by illness
2- = = recognize health needs.
3- = = make decisions about how to improve
a clients health.
4- ability to recognize when & why nsg. Car has
improved the clients condition.

• Forth & Fifth components model
Attitudes & Standers
Attitudes: associated with critical thinking
include
- a spirit of inquiry
- The desire to understand a situation from
more than one perspective
- The valuing or seeking the truth.

Obstacles to critical thinking
1- Habit mode
2- Anxiety ( lead to unable to perform)
3- Skills.
4- Lack of confidence ( Nursing students)

• Elements of critical thinking applied to nursing
Elements
Application Example
1- Assumption - The nurse-client relationship is a helping
relationship
-Clients have a right to make decision about their
health care
2-Information
-Data, facts, and observations about the client.
- knowledge about the path physiology and etiology
of disease.
-Knowledge about human behavior.
3- concepts - Theories, definition, principles, and laws that give
meaning to information and that are used to
interpret clinical data and make decision about
effective management of the clients problems.

4- purpose of thinking -To make decision about data to
be collected
-To determine client goals or
outcomes.
5- question of an issue. -Determine the nature of the
clients presenting problem
-Identify ethical and legal issues in
practice.
6- points of view. -The nurses and clients perception
of clinical situation.
-Perspective of health team
members.
7- interpretation and inference -Diagnosis reasoning that results
in nursing diagnosis, plans, and
interventions.
8- Implications and consequences -Client outcome and modifications
of care.

• Nursing process
• Is a critical thinking framework in which
you will exercise decision- making,
diagnostic reasoning, problem-solving,
and clinical judgment.
• The nursing process is a process by
which nurses deliver care to patients,
supported by nursing models or
philosophies.

Assessment
Process of
- Discovering
- Making
decision
Nsg. Diagnosis
Clinical judgment
About
Individual
Family
community
Evaluation
Expected
Outcome
And
Effectiveness
Of nursing
Nsg.
Intervention
Direct care
Teaching
Counseling and
others
Planning
Is essential to
Providing
Nursing
Care according
To client need

• A problem-solving method
Systematic, goal-directed, flexible,
rational approach
- Ensures consistent, continuous, quality
nursing care
- Provides a basis for professional
accountability
- Input of nurse and patient/family critical
• Nursing process is a patient centered, goal
oriented method of caring that provides a
frame work to the nursing care.

• involves five major steps
• A- Assess (what is the situation)
• D- Diagnose (what is the problem)
• P- Plan (how to fix the problem)
• I- Implement (putting plan into action)
• E- Evaluate (did the plan work)
• All together equaling ADPIE

• Characteristics of the nursing process
• The nursing process is a cyclical and ongoing process that can
end at any stage if the problem is solved.
• The nursing process exists for every problem that the patient has,
and for every element of patient care, rather than once for each
patient.
• The nurse's evaluation of care will lead to changes in the
implementation of the care and the patient's needs are likely to
change during their stay in hospital as their health either improves or
deteriorates.
• The nursing process not only focuses on ways to improve the
patient's physical needs, but also on social and emotional needs as
well.
• 1- Cyclic and dynamic
• 2- Goal directed and client centered
• 3- Interpersonal and collaborative
• 4- Universally applicable
• 5- Systematic

• Assessment (of patient's needs)
• Diagnosis (of human response needs that
nurses can deal with)
• Planning (of patient's care)
• Implementation (of care)
• Evaluation (of the success of the
implemented

• Assessing Phase
• Assessment: the most critical step
1- Answers the questions:
“ - What is happening” (actual problem), or
“- What could happen” (potential problem)
2- Involves collecting, organizing, and analyzing
information/data about the patient
3- Results in Nursing Diagnoses
4- Two parts: Data collection & Data analysis
• 1. Data Collection: A Holistic Approach

• Types of data
• Subjective: “symptoms” that the patient
describes; e.g. “I can’t do anything for
myself”
Objective: signs that can be observed,
measured, and verified; e.g. swollen joints
• Sources of data
• Primary: the patient; is always the best
source
Secondary: everything/everybody else

• Methods of Data Collection
• 1- Observation
Requires practice and skill
Systematic, head-to-toe
2- Interview
Structured form of communication Purpose: to
provide care specific to this individual’s needs and
problems
Focus: patient’s perceptions
Nurse must: explain purpose of interview, provide
comfort and privacy, ensure confidentiality Result: A
comprehensive Health History

• Components of the Health History
• Demographic data
CC: chief complaint
HPI: history of present illness
PMH: past medical history
FMH: family medical history
(genogram)
ROS: review of systems
Psychosocial history

• 3- Examination
Inspect
Palpate
Percuss
Auscultate
Nurse must: explain what you are doing,
provide privacy, and ask permission
before you touch the patient

• 2- Data Analysis
• Data review
- Are data accurate and complete
- Data interpretation
• What are the patient’s actual and/or
potential problems
Develop a problem list based on the
data
Prioritize the patient’s problems

• 4- Reporting Findings
As soon as you collect your information you must report
abnormal data and record assessment findings so that
they'll be communicated to others.
Failing to communicate is a major basis for malpractice
suits. If you find that a patient's temperature is 105E F,
you should complete a focus assessment and notify the
physician as soon as possible before writing the
information on the record. Until you gain experience and
become confident in determining what to report, the rule
is to "report anything you suspect might be abnormal" to
your instructor.
Timely reporting ensures early diagnosis even if you don't
have the knowledge to diagnose the problem yourself,
keeps accountable parties informed, and helps you to
learn - the instructor will want to help you analyze the
information and determine its significance.

• Diagnosing Phase
• Nursing diagnoses are part of a movement
in nursing to standardize terminology
which includes standard descriptions of
diagnoses, interventions, and outcomes.
Those in support of standardized
terminology believe that it will help nursing
become more scientific and evidence
based. The purpose of this stage is to
identify the patient's nursing [[problems]].

• Nursing Diagnosis: a statement that
describes a specific human response
to an actual or potential health
problem that requires nursing
intervention

• There are three types of nursing diagnosis
• 1- wellness diagnosis
• 2- risk diagnosis
• 3- actual diagnosis with etiology and
related factors specified.
• Medical Diagnosis Nursing Diagnosis
• Rheumatoid Arthritis . Self-care deficit:
bathing, related to joint stiffness
• The primary source for nursing diagnoses
is the NANDA list.

• Once you identify your patient problems, you
can write nursing diagnoses statements using
the PES format:
P:
• Problem - (high risk for injury, pain, constipation,
impaired communication, etc.)
• related to (r/t) use North American Nursing
Diagnosis Association (NANDA) category
E:
• tiology (cause) - (factors that cause the problem)
• manifested by (m/b)
S:
• igns and Symptoms - (the signs and symptoms
that are associated with the problem)

• Example:
• e.g. Ineffective airway clearance related
to the presence of tracheo-bronchial
secretion as manifested by thick
tenacious sputum upon expectoration.
• Problem (Ineffective airway clearance)
+ Etiology (related to) + Defining
Characteristics (as manifested by)'''

• Planning Phase
• Plan: to provide consistent, continuous
care that will meet the patient’s unique
needs.
• Includes Patient Goals & Nursing
Orders
• Patient Goals: describe the desired
result of nursing care

• Patient Goals are:
1- Focused on the patient
2- Clear and Concise
3- Observable, Measurable, Realistic how
much how far how long how well
4- Written with a specific time frame: by
when should the goal be accomplished
5- Determined by the nurse and the
patient

• Nursing Orders must:
1- Focus on nursing actions
2- Describe when and how the nurse will
perform nursing actions
3- Include the date & be signed by the nurse

• Planning - A plan of care is developed in
cooperation with the patient and significant others. The
plan of care is aimed at reducing or eliminating the
problems and promoting health. To plan, priorities must
be set, expected outcomes must be established, and you
must determine what interventions will help achieve the
expected outcomes that you have established. You also
determine who needs to be involved and how and when
the interventions will be done.
• Priority Setting
• Expected Outcomes
• Interventions

• Implementing Phase
• The methods by which the goal will be achieved
is also recorded at this stage.
• - Your plan of care is put into action. During
implementation, you assess the patient's current
status to see if his/her plan is still appropriate or
whether there are new problems. The
interventions and activities are then performed
and you continue to assess the patient to see of
there is any response or whether the
intervention made a difference. Finally, you
report any data that requires additional
treatment, e.g., physician consultation, and
record the nursing actions, patient response,
and other significant assessment data.

• Implement: Carry out the care plan
• 1- Reassess the patient
2- Validate that the care plan is
accurate
3- Carry out nurses’ orders
4- Document on patient’s chart

• Interventions
• Once you have established your expected
outcomes, it is time to determine the
interventions you will use to achieve them.
An intervention is, Any treatment based
upon clinical judgment and knowledge that
a nurse performs to enhance patient/client
outcome. Your interventions should be
written so that another nurse would know
exactly what your plan is. This provides
continuity of care and enhances
communication

• Like the NANDA and NOC taxonomies,
the Nursing Interventions Classification
(NIC) taxonomy was primary designed to
provide nurses with a common language
and allow us to actually identify and
articulate what it is we do. It was also
designed to help students learn clinical
decision making skills. When choosing an
intervention from NIC, you need to
consider six factors:

• 1- desired patient outcome
• 2- characteristics of the problem or nursing diagnosis
(we want to alter the etiology factor, treat the signs and
symptoms, and alter risk factors)
• 3- research base for the intervention (knowing whether
this intervention is appropriate for this patient
• 4- feasibility of doing the intervention (How does it
interaction with other interventions Is it cost and time
effective)
• 5- acceptability of patient
• 6- capability of nurse (You must know rationale, have
required psychological and interpersonal skills and be
able to function within the particular setting to effectively
use health care resources.)

• Evaluate: Compare the patient’s current status with
the stated Patient Goals
• Were the goals achieved Why not
Review the nursing process
• The purpose of this stage is to evaluate progress
toward the goals identified in the previous stages.
• If progress towards the goal is slow, or if regression
has occurred, the nurse must change the plan of
care accordingly.
• Conversely, if the goal has been achieved then the
care can cease. New problems may be identified at
this stage, and thus the process will start all over
again. It is due to this stage that measurable goals
''must'' be set - failure to set measurable goals will
result in poor evaluations.

• type of evaluation, you will need to
conduct an outcome evaluation. This type
of evaluation involves a determination of:
• The patient's response to the interventions
you performed.
• Whether expected outcomes were met,
not met, or partially met.
• 57436Factors affecting the achievement of
the outcomes.
• 57437. Whether to change, modify, or
terminate the plan of care.

• Some of the reasons for failure to meet expected
outcomes include:
• Changes in the patient's condition that
supersede the plan of care.
• The need for more time to see if the outcome
can be met.
• Gaps in assessment data
• Errors in identification of problems or nursing
diagnoses.
• Unrealistic or vague expected outcomes and
plans.
• Lack of patient input in the plan of care.

Thank you
For Listening