Logic and Critical Thinking

MC103NUR | MRS. MELODY CRISPINA MORALES, MSN

THE NURSING PROCESS  Whenever a healthcare provider intervenes or implements care,
 The nursing process is the essential core of practice for the they must reassess or evaluate to ensure the desired outcome
registered nurse to deliver holistic, patient-focused care. has been met.
 The utilization of the nursing process to guide care is clinically NURSING ASSESSMENT
significant going forward in this dynamic, complex world of  The nursing process is a five-step systematic approach that
patient care. allows you to provide individualized care to a client.
THE STEPS OF THE NURSING PROCESS FIVE-STEP NURSING PROCESS ADPIE
A SSESSMENT
 Subjective data: verbal statements from the patient or caregiver
 Objective data: measurable, tangible data (vital signs, intake and
output, height and weight)
 Data may come from the patient directly or from primary
caregivers who may or may not be direct relation family
members.
 Electronic health records: populate data in and assist in
assessment
D IAGNOSIS
 Formulation of a nursing diagnosis: assists in planning and
implementation of patient care  In the assessment process, the nurse will gather information to
 The North American nursing diagnosis association (NANDA): up identify health problems that contribute to overall health and
to date list of nursing diagnoses well-being.
 Clinical judgment about responses to actual or potential health CRITICAL THINKING APPROACH TO ASSESSMENT
problems on the part of the patient, family or community TWO STAGES OF ASSESSMENT:
 Maslow's Hierarchy of Needs: helps to prioritize and plan care C OLLECTION AND VERIFICATION OF INFORMATION
based on patient-centered outcomes  Primary source: client
P LANNING  Secondary source: family, healthcare providers, medical records
 Goals and outcomes: directly impact patient care based on A NALYSIS OF INFORMATION
evidence-based practice guidelines  Understanding and processing the information within the context
 Patient-specific goals and attainment assist in ensuring a of the patient’s clinical condition
positive outcome DATABASE
 Nursing care plans: P URPOSE OF ASSESSMENT
 Essential in this phase of goal setting  Perceived needs
 Provide a course of direction for personalized care  Identify health concerns
tailored to an individual’s unique needs
 Identify primary problems
 SMART goals R ESULTS OF DATABASE
 Specific
 Form a plan of care
 Measurable or meaningful
 Prioritize problems
 Attainable or action-oriented
 Focus on patient needs
 Realistic or results-oriented
 Timely or time-oriented Critical thinking skills help you to synthesize relevant information
I MPLEMENTATION and use it in a purposeful way.
 Implemented according to the care plan, continuity of care for the
patient during hospitalization and in preparation for discharge PRIMARY AND SECONDARY SOURCES OF DATA
 Involves action and the actual carrying out of nursing SOURCES OF DATA
interventions outlined in the plan of care P RIMARY SOURCE
 Requires nursing interventions: applying a cardiac monitor or  Client (interview, observation, physical examination) the best
oxygen, direct or indirect care, medication administration, and source of information
standard treatment protocols
 Family and significant others (obtain client’s agreement first)
 Documentation record
 Vital signs and diagnostics
E VALUATION
S ECONDARY SOURCE
 Vital to a positive patient outcome
 Healthcare team
 Whenever a healthcare provider intervenes or implements care,
 Medical records
they must reassess or evaluate to ensure the desired outcome
has been met.  Scientific literature
 Frequent reassessment depending upon overall patient condition DATA COLLECTION
 Adaption of plan of care based on new assessment data Subjective data Objective data
IN A NUTSHELL What you are told What you can see or validate
Pain Client states: “I am Nurse sees the client limping
 Assessment includes both subjective and objective data.
having very bad pain in and grimacing when walking.
 A nursing diagnosis assists in the planning and implementation of
my leg.”
patient care.
Fever Mother states: “My child The client’s temperature is
 Patient-specific goals and attainment assist in ensuring a
had a fever.” 38.4°C (101.00°F).
positive outcome. Goals should be created using the SMART
format.
 Implementation involves action and the actual carrying out of
nursing interventions outlined in the plan of care.

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 LOGIC AND CRITICAL THINKING

PROCESS OF ASSESSMENT NURSING DIAGNOSIS

 Collect data. DIAGNOSES TYPES
 Cluster information and identify similarities. M EDICAL DIAGNOSIS
 Collect more information as needed to form a complete clinical  Identification of a disease condition based on specific information
picture. gained from diagnostic evaluations
 Be sure to have supporting cues before making an inference. C OLLABORATIVE PROBLEM
ASSESSMENT APPROACHES  Both providers implement interventions based on the diagnoses,
H EALTH HISTORY such as placing orders and administering treatments, and
 Gathering information that may help you better understand the evaluate outcomes or progress
patient’s current health problems N URSING DIAGNOSIS
H EAD - TO - TOE PHYSICAL ASSESSMENT  Identification of a health risk or alteration in a body system for
 Using assessment skills to recognize abnormalities which interventions and outcomes can be selected to correct the
F OCUSED ASSESSMENT problem(s)
 Looking closely at a particular area of concern WHY NURSING DIAGNOSES?
METHODS OF INFORMATION COLLECTION  Nursing diagnoses allow nurses to practice independently within
 Client-centered interview = an organized conversation with the their scope of practice. The North American Nursing Diagnosis
client Association (NANDA) has developed, refined, and promoted
nursing diagnoses for use by all professional nurses.
 Purpose of the nursing diagnosis:
 Provides precise definitions of client’s problems
 Allows licensed nurses and other members of the
healthcare team to utilize or communicate with a common
language of understanding the client needs
 Provides guidance for developing nursing interventions
NURSING DIAGNOSTIC PROCESS
 Assessment, validation, and interpretation of the client’s health
INTERVIEW TECHNIQUES status
 Ask open-ended questions  Information clustering and identification of defining
 Ask clarifying questions characteristics
 Validate information  Identification of client needs
 Allow the patient to talk without too many interruptions  Formulation of nursing diagnosis and collaborative problems
 Be respectful of cultural and behavioral differences NURSING DIAGNOSTIC STATEMENTS
 Differentiate between subjective vs. objective information  Provide a precise definition of problem, allowing nurses and
NEXT ASSESSMENT STEPS other members of the healthcare team to utilize or communicate
P HYSICAL EXAMINATION with a common language for understanding clients’ needs.
 Allow nurses to communicate what THEY do among themselves,
 Involves techniques of inspection, palpation, percussion,
with other health care professionals.
auscultation, and smell
 Distinguish the nurse’s role from that of the physician or other
 Helps collect valuable objective information
O BSERVATION OF CLIENT BEHAVIOR ( VERBAL VS . NONVERBAL ) healthcare providers.
 Help nurses focus on the scope of nursing practice.
 Gather additional objective information USING CRITICAL THINKING
 Watch client’s level of function: physical, developmental,  Diagnostic process
psychological, and social aspects of everyday living
 Information clustering
D IAGNOSTIC INFORMATION
 Identifying client’s health problems
 Provides you with information needed to develop a plan of care  Formulating diagnosis
 Might include: laboratory values, imaging, focused assessments DATA CLUSTERING
(example: cognitive evaluation)
 Bringing together information in a logical way to form patterns
I NTERPRETING AND VALIDATING ASSESSMENT DATA
with defining characteristics
 Helps when selecting a nursing diagnosis
 Recognize patterns or trends in the clustered data and compare
them with standards
DATA DOCUMENTATION
 It is the professional responsibility of the nurse to ensure that
care gets documented.
 The client record is a legal document.
 Use accurate and approved terminology.
 This must be completed in a timely manner.
IN A NUTSHELL
 The assessment is a multi-step process that requires the INTERPRETATION IDENTIFYING HEALTH PROBLEMS
application of critical thinking.  A nursing diagnosis can be accepted based on the presence of
 Information can be both subjective or objective. certain information, or rejected based on the absence of certain
 A client-centered interview, such as a health history, is an information.
organized conversation with the client with the intent of
gathering more information.
 A strong knowledge of interviewing techniques is essential for
nurses to be able to have respectful, informed conversations
about a client’s health.

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 LOGIC AND CRITICAL THINKING

TYPES OF NURSING DIAGNOSES study rather than the treatment

A CTUAL NURSING DIAGNOSIS or study itself
5. Identify response to the 11. Identify the problem and its cause
 Describes human responses to health conditions or life equipment rather than the to avoid a circular statement.
processes: assessment data are sufficient to establish the equipment itself
nursing diagnosis 6. Identify problems rather than 12. Identify only problem in the
 Example: Impaired skin integrity your problems with nursing care. diagnostic statement
R ISK FOR NURSING DIAGNOSIS  Identify a treatable cause or risk factor rather than a clinical sign
 Describes human responses to health conditions/life processes or chronic problem that is not treatable.
that may develop: do not have defining characteristics because  Identify priority problems
they have not occurred yet  Identify only problem in each diagnostic statement.
 Example: Risk for infection, Risk for falls IN A NUTSHELL
H EALTH PROMOTION NURSING DIAGNOSIS  By learning to make accurate nursing diagnoses, you will
 A clinical judgment of an individual’s motivation, desire, and healthcare problems to other professionals.
readiness to enhance well-being: a person’s readiness is  A nursing diagnosis will ensure that you select relevant and
supported by defining characteristics appropriate nursing interventions and contribute to continuity of
 Example: Readiness for enhanced medication compliance care.
COMPONENTS OF A NURSING DIAGNOSIS PLANNING NURSING CARE
ESTABLISHING PRIORITIES
 Prioritizing diagnoses helps establish a sequence for nursing
interventions
H IGH - EMERGENT
 If untreated, will result in harm
 Priority! Treat first!
 Airway
 Oxygenation
 Circulation
I NTERMEDIATE
 Non-emergent or non-life-sustaining needs
CONSIDERING CULTURE  Pain
 Consider clients cultural diversity when selecting a nursing  Nutrition
diagnosis. L OW
 Ask questions such as:  Long-term health needs that address the future
 How has this health problem affected you and your family?  Rehabilitation
 What do you believe will help or fix the problem?  Disease specific education
 What worries you most about the problem?  Health maintenance and prevention
 Which practices within your culture are important to you? P RIORITIZATION ?
 Cultural awareness and sensitivity improve your accuracy in  Reevaluation of nursing diagnoses
making nursing diagnoses.  Ethical considerations
SOURCES OF DIAGNOSTIC ERROR  Interventions and strategies
 Assessment, validation, and interpretation of the client’s health  Client priorities
status PRIORITIES IN PRACTICE
 Avoid errors by collecting information in an organized
manner and validating information.
 Information clustering and identification of defining
characteristics
 Errors in data collection occur when data are clustered
prematurely, incorrectly, or not at all.
 Identification of client needs
 Formulation of nursing diagnosis and collaborative problems
 Word the diagnostic statement in appropriate, concise, and
precise language using NANDA terminology.

It is not always possible to collect data in an organized way in SMART Goals

real time. You can go back to reorganize and validate  Once the nursing diagnosis is selected, specific goals need to be
assessment data anytime. set to address each diagnosis

DIAGNOSTIC STATEMENT GUIDELINES

1. Identify response, not the 7. Identify problem rather than the
medical diagnosis nursing intervention.
2. Identify a NANDA-I diagnostic 8. Identify problem rather than the
statement rather than the goal of care
symptom.
3. Identify a treatable cause or 9. Make professional rather than
risk factor rather than a clinical prejudicial judgments.
 Scenario: Mrs. Smith is having severe pain in her right leg that is
sign or chronic problem that is limiting her mobility.
not treatable through nursing  Goal: Mrs. Smith’s pain will be controlled to a reported score of
intervention. 5 or less by the end of the shift.
4. Identify the problem caused by 10. Avoid legally inadvisable
the treatment or diagnostic statements

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 LOGIC AND CRITICAL THINKING

GOALS OF CARE
 Client-centered: reflect the client’s highest level of wellness and
function.

CRITICAL PATHWAYS CARE PLANNING

 Critical pathways are evidence-based guidelines that help meet
expected outcomes by detailing specific steps in client care.
 What can be a critical pathway?
 Decreasing length of stay
 Improving pain outcomes
 Decreasing the cost of care
 Always partner with clients when setting their individualized
 Preventing disease specific complications
goals
IN A NUTSHELL
 Able to participate in activities of daily living (ADLs)
 Each nursing diagnosis is accompanied by a goal, expected
 Able to participate in problem – solving
outcomes, and interventions.
 Able to participate decision - making
 A plan of care is essential to defining care, providing consistency
 Able to understand the value of nursing therapies in care, and promoting interdisciplinary practices.
EXPECTED OUTCOMES  Critical thinking is an essential skill in developing quality care
 Each goal will have at least one expected outcome that defines plans and care mapping.
how the goal will be met. IMPLEMENTING NURSING CARE
 Scenario: Mrs. Smith is having severe pain in her right leg N URSING I NTERVENTION
that is limiting her mobility.
 Goal: Client will report a pain score of 5 or less by the end  A nursing intervention is any treatment based on clinical
of shift. judgment and knowledge that a nurse performs to enhance
outcomes for the client or in the community.
 Expected outcome: Client will be able to transfer from the
bed to the chair. CRITICAL THINKING IN IMPLEMENTATION
 Outcomes must be specific and measurable.  Interventions
NANDA and NOC  Medical condition
 To support nursing practice, the Nursing Outcomes Classification  Possible outcomes
(NOC) was developed to accompany each NANDA goal.  Expected response
STANDARD NURSING INTERVENTIONS
G UIDELINES FOR THE SELECTION OF INTERVENTIONS :
 C LINICAL PRACTICE GUIDELINES AND PROTOCOLS
 Guide interventions for specific healthcare problems or
conditions
PLANNING INTERVENTIONS  S TANDING ORDERS
 Nursing interventions are actions that nurses perform to enhance  Prescribed instructions or procedures to be performed in
the health of clients. the event that a medical condition arises or changes
 Know the rationale for the intervention.  NIC INTERVENTIONS
 Possess the psychomotor and interpersonal skills.  Research-based standardized classifications of
 Be able to function within a setting and use the facility's interventions that nurses perform on behalf of clients
resources effectively.  ANA S TANDARDS OF P ROFESSIONAL N URSING P RACTICE
TYPES OF INTERVENTIONS  To be used as evidence of the standard of care
N URSE INITIATED IMPLEMENTATION PROCESS
 Independent: actions that a nurse initiates
 Example: encourage client to walk 100 ft three times daily
 Ambulate client
P HYSICIAN INITIATED
 Dependent: require an order from a healthcare professional
 Example: give PRN blood pressure medicine when systolic blood NURSING SKILLS FOR IMPLEMENTATION
pressure is greater than 160 mm Hg C OGNITIVE SKILLS
 Giving medications as ordered  Application of critical thinking
C OLLABORATIVE I NTERPERSONAL SKILLS
 Interdependent: require combined knowledge, skill, and expertise  Developing trusting relationships and communicating effectively
of multiple healthcare professionals P SYCHOMOTOR SKILLS
 Example: encourage food consistent with dietary needs as
specified by the dietician  Integration of cognitive and motor activities
 Diet or therapies DIRECT CARE VS. INDIRECT CARE
D IRECT CARE
NANDA, NOC, and NIC
 A nursing plan of care is an important part of providing quality,  Treatments performed through interactions with clients
client-centered care.  Assessments
 The nursing care plan…  Medications administration
 …defines the client’s problems.  Risk reduction
 …defines the nurse’s role in the client’s treatment.  Participation in therapy
 …provides continuity of care.  ADLs
 …promotes interdisciplinary practice.  Diagnostics

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 LOGIC AND CRITICAL THINKING

I NDIRECT CARE GOALS OF CARE

 Treatments performed away from the client but on behalf of the  Evaluation competencies from the ANA
client.  Communication results
 Documentation of care  Use criterion-based evaluation measures.
 Communication within the healthcare team  Collaborate
 Care coordination  Be systematic
 Delegation when appropriate  Reassess and revise the care plan as needed.
 Evaluation of care GOALS AND EXPECTED OUTCOMES
 Interdisciplinary care plans SMART GOAL
TEAMWORK AND DELEGATION  A specific statement that describes the desired change in a
 When you delegate aspects of care, you are responsible for client’s condition or behavior
ensuring that each task is assigned appropriately and is E XPECTED OUTCOME
completed according to the standard of care.  End result that is measurable, desirable, and can be observed in
the client’s condition
EVALUATING EFFECTIVENESS OF INTERVENTIONS

ACHIEVING CLIENT GOALS

STEPS FOR EVALUATING OUTCOMES

Steps Examples
1. Review desired outcomes Oxygen saturation will remain
above 90% on room air.
2. Review actual outcomes. Oxygen saturation is 86% on
room air.
3. Compare desired outcomes Actual outcome is not meeting
with actual outcomes. desired outcome.
4. Identify discrepancies. Client oxygen saturation is too
low when on room air
5. Identify barriers and revise Client is not able to properly
care plan. use incentive spirometer
because of delirium.
DISCONTINUING A CARE PLAN
 Discontinuing a care plan when…
 …a client goal was met successfully.
 …the client agrees.
 Document the discontinued plan.
M ODIFYING A C ARE P LAN
 Modifying a care plan when…
 …client care priorities change.
 …interventions are not effective or are no longer
appropriate.
 Document the modified plan.
IN A NUTSHELL
 Desired and undesired evaluations are helpful in developing care
plan.
IN A NUTSHELL  The standards for evaluation as outlined by the ANA should be
used to evaluate if the SMART goals were met.
 Critical thinking is essential when implementing care.
 The evaluation process should be used to decide if a care plan
 Standard interventions can be used as evidence-based
needs to be discontinued or modified.
guidelines for providing client care.
 Both direct and indirect interventions guide the care team toward
achieving set goals.
EVALUATING NURSING CARE
DESIRED AND UNDESIRED EVALUATIONS
P OSITIVE / DESIRED EVALUATIONS
 These occur when desired outcomes or SMART goals are met.
 Interventions were successful.
U NMET / UNDESIRED EVALUATIONS
 These occur when the desired outcomes or SMART goals are not
met.
 Interventions were not successful.

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