CRITICAL THINKING IN

NURSING
Oleh: Nursalam

nursalam -2006
 WHAT DOES CRITICAL
MEAN?
 Critical means requiring careful judgment.
 Thinking means to have an opinion, to reflect
on or ponder, to call to mind or remember to
devise a plan, to form a mental picture of
(image), to reason
TINGKATAN KEMAMPUAN
Ranah Psikomotor
(HARROW)

NATURALIZATION

ARTICULATION Spontan
dan
Akurat otomatis
PRECISION
dan
Lancar cepat
MANIPULATION
dan
Tanpa contoh tepat
IMITATION
Visual
Meniru dapat meniru
dengan
contoh
TINGKATAN KEMAMPUAN
RANAH AFEKTIF ( sikap dan nilai )
(KRATHWOHL)

CHARACTERIZATION

ORGANIZATION
Menjadikan
VALUING pola hidup
Mengatur diri
RESPONDING
menghargai
RECEIVING
menanggapi

menerima
WHAT IS THE DIFFERENCE BETWEEN
THINKING & CRITICAL THINKING?
 CONTROL
 Criticalthinking is controlled, purposeful &
more likely to lead to obvious beneficial
results
 Thinking is basically any mental activity;can
be aimless & uncontrolled; it may serve a
purpose, but we often aren’t aware of its
benefits;we might not even remember our
thoughts at all
WHAT ARE THE CHARACTERISTICS OF
CRITICAL THINKING?

 1. It is rational & reflective.

 2. It involves healthy, constructive skepticism.
 3. It is autonomous.
 4. It includes creative thinking.
 5. It is fair thinking.
 6. It focuses on what to believe & do.
 WHAT ARE ATTITUDES OF
CRITICAL THINKERS?
 They are:
 1. Active thinkers.
 2. Knowledgeable of their biases & limitations.
 3. Fair-minded.
 4. Willing to exert a conscious effort to work in
a planful manner.
 (Con’t)
 5. Good communicators.
 6. Empathetic.
 7. Open-minded.
 8. Independent thinkers.
 9. Curious & insightful.
 10. Humble.
 11. Proactive.
 (Con’t)
 12. Honest with themselves & others, admitting
when their thinking may be flawed or requires
more thought.
 13. Organized & systematic in their approach.
 14. Flexible.
 15. Cognizant of rules of logic
 16. Realistic
 17. Team players.
 18. Creative & committed to excellence.
nursalam -2006
 Critical Thinking in Nursing

 Purposeful, outcome-directed
 Essential to safe, competent, skillful nursing
practice
 Based on principles of nursing process and the
scientific method
 Requires specific knowledge, skills, and
experience
 New nurses must question
 Critical Thinking in Nursing
 Guided by professional standards and ethic
codes
 Requires strategies that maximize potential
and compensate for problems
 Constantly reevaluating, self-correcting,
and striving to improve
 Formula for Critical Thinking
 Start Thinking

 Why Ask Why

 Ask the Right Questions

 Are you an expert?

Aspects of Critical Thinking
 Reflection

 Language

 Intuition
 Levels of Critical Thinking
 Basic

 Complex

 Commitment
 Critical Thinking
Competencies
 Scientificmethod
 Problem Solving
 Decision Making
 Diagnostic Reasoning and Inferences
 Clinical Decision Making
 Nursing Process
Developing Critical Thinking
Attitudes/Skills
 Not easy
 Not “either or”
 Self-assessment
 Tolerating dissonance and ambiguity
 Seeking situations where good
thinking practiced
 Creating environments that support
critical thinking
 Nursing Process
 Systematic approach that is used by all
nurses to gather data, critically examine and
analyze the data, identify client responses,
design outcomes, take appropriate action,
then evaluate the effectiveness of action
 Involves the use of critical thinking skills
 Common language for nurses to “think
through” clinical problems
Nursing Process
 Components Of Critical
Thinking
 ScientificKnowledge Base
 Experience
 Competencies
 Attitudes
 Standards
 Nursing Process
 Traditional critical thinking competency
 5 Step circular, ongoing process
 Continuous until clients health is
improved, restored or maintained
 Must involve assessment and changes in
condition
When using the Nursing Process
 Identify health care
needs
 Determine
Priorities
 Establish goals &
expected outcomes
 Provide appropriate
interventions
 Evaluate
effectiveness
1. ASSESSMENT
 Systemically collects, verifies,
analyzes and communicates data
 Two step process- Collection and
Verification of data & Analysis of
data
 Establishes a data base about client
needs, health problems, responses,
related experiences, health practices,
values. lifestyle, & expectations
Critical Thinking and
Assessment Process
 Brings knowledge from biological,
physical, & social sciences as basis
for the nurse to ask relevant
questions. Need knowledge of
communication skills
 Prior clinical experience contributes
to assessment skills
 Apply Standards of Practice
 Personal Attitudes
Assessment Data
 Subjective Data
 Objective Data
 Sources of Data
 Methods of Data Collection-
Interview
 Interview initiates nurse-client
relationship
 Use open-ended questions
 Nursing health history
2. NURSING DIAGNOSIS
 Statement that describes the client’s
actual or potential response to a
health problem
 Focuses on client-centered problems
 First introduced in the 1950’s
 NANDA established in 1982
 Step of the nursing process that
allows nurse to individualize care
3. PLANNING FOR NURSING CARE
 Client-centered goals and expected
outcomes are established
 Priorities are set relating to unmet
needs
 Maslow’s Hierarchy of Needs is a
useful method for setting priorities
 Priorities are classifies as high,
intermediate, or low
Purpose of Goals and
Outcomes
 Provides direction for individualized
nursing interventions
 Sets standards of determining the
effectiveness of interventions
 Indicates anticipated client behavior
or response to nursing care
 End point of nursing care
 Goals of Care
 Goal: Guideposts to the selection of
nursing interventions and criteria in
the evaluation of interventions
 What you want to achieve with your
patient and in what time frame
 Short term vs. Long term
 Outcome Of Care: What was
actually achieved, was goal met or
not met
NURSING INTERVENTIONS
 Interventions are selected after goals and outcomes
are determined
 Actions designed to assist client in moving from
the present level of health to that which is
described in the goal and measured with outcome
criteria
 Utilizes critical thinking by applying attitudes and
standards and synthesizing data
 Types of Interventions
 Nurse-Initiated

 Physician-Initiated

 Collaborative
Interventions
 Selection Of Intervention
 Usingclinical decision making skills, the
nurse deliberates 6 factors:

 Diagnosis, expected outcomes, research

base, feasibility, acceptability to client,
competency of nurse
Nursing Care Plans
 Written guidelines for client care
 Organized so nurse can quickly
identify nursing actions to be
delivered
 Coordinates resources for care
 Enhances the continuity of care
 Organizes information for change of
shift report
Nursing Care Plans vs Concept
Maps
NCP Concept/Mind Map
 4. IMPLEMENTATION OF
NURSING INTERVENTIONS
 Describes a category of nursing behaviors
in which the actions necessary for
achieving the goals and outcomes are
initiated and completed

 Action taken by nurse

Types of Nursing Interventions
 Standing Orders: Document containing
orders for the use of routine therapies,
monitoring guidelines, and/or diagnostic
procedure for specific condition

 Protocols: Written plan specifying the

procedures to be followed during care of a
client with a select clinical condition or
situation (Pneumonia, MI, CVA)
 Implementation Process
involves:
 Reassessing the client

 Reviewing and revising the existing care

plan

 Organizingresources and care delivery

(equipment, personnel, environment)
5. EVALUATION
 Step of the nursing process that measures
the client’s response to nursing actions and
the client’s progress toward achieving
goals
 Data collected on an on-going basis
 Supports the basis of the usefulness and
effectiveness of nursing practice
 Involves measurement of Quality of Care
Evaluation of Goal
Achievement
 Measures and Sources: Assessment
skills and techniques
 As goals are evaluated, adjustments
of the care plan are made
 If the goal was met, that part of the
care plan is discontinued
 Redefines priorities
nursalam -2006
Critical Thinking SKILLS for
Nurses

Develop your Problem Solving Skills!

Kindred Hospital Louisville
Shannon Ash, RN, BSN
 Objectives
1. Define critical thinking.
2. Identify critical thinking tools to use in nursing
practice.
3. Explain how to integrate the nursing process
with critical thinking.
4. Apply critical thinking processes to solve
patient care situations.
What IS Critical Thinking?
 Critical thinking can be defined several ways.
One definition is “an active, organized, cognitive
process”.
 Another definition is “a process for identifying
underlying assumptions and variables in order to
draw conclusions and make decisions”.
 You could even use the definition “a process used
to explore alternatives to determine what is
important”.
 What IS Critical Thinking?
 No matter which definition you choose,
critical thinking involves the use of several
concepts, including: exploring, analyzing,
prioritizing, explaining, deciding, and
evaluating to identify solutions and
determine a course of action to solve
patient care problems.
 What IS Critical Thinking?
 Exploring encourages you to identify all
the variables within a situation.
 Analyzing is the process of studying each
variable to understand its meaning and its
relationship to the other variables.
 Prioritizing requires you to weigh the
relative importance of each variable to the
others, at a given point in time.
 What IS Critical Thinking?
 Explaining the variables involves the
exercise of amplifying each variable to
understand its meaning in the situation and
to the involved parties.
 Deciding means to choose a specific
course of action.
 Evaluating requires the thinker to assess
how correct the thinking process was, and
if further action is needed.
 Exercise # 1
 Mrs. Vernon, a 67-year old patient who suffers from
COPD has been admitted to your unit from another
facility. Upon admission you note her to be alert,
oriented and appropriate. She provides you with
information to complete her history. After completing
& charting your assessment, you leave her to see to your
other patients. An hour later when you return, you note
that Mrs. Vernon does not seem as alert, and appears to
be confused. On each of the 5 components of critical
thinking, write down what could be going on with your
patient.
 Mrs. Vernon

 Exploring: what could be causing this

previously alert woman to be so suddenly
confused?
 Hypoxia
 Hypotension
 Fatigue
 Infection
 Medications
 Unfamiliar Surroundings
 Stroke
 Mrs. Vernon
 Analyzing: what other information can I
gather to help me narrow down the
possible causes of her confusion?
 Vital Signs
 Oxygen Saturation/ ABG
 Medications taken & last dose time
 Further assessment of confusion level
 Previous history of confusion?
 Potential infection sites & their appearance
 Mrs. Vernon
 Prioritizing/Deciding: is this change
significant to this patient, and do I need to
even look further? This also includes the
decision that is made whether to inform the
physician of the change in their patient’s
status. What would you say?
 Considering that Mrs. Vernon is a new
patient, and that this is a sudden change, it is
potentially clinically significant, and should be
investigated thoroughly, and reported to the
Physician right away.
 Mrs. Vernon
 Evaluating: after reporting the alteration to the
patient’s Physician, he orders the following:
 STAT ABG & STAT Portable CXR
 Blood Cultures
 Urine & Sputum Cultures
 Head CT in the morning if confusion doesn’t resolve
 Discontinue all medications that could cause
confusion
 At this point, the Physician’s orders indicate to you
that he is thinking along the same lines as you did,
and your thinking process was complete
 Mrs. Vernon
 Now the next time you have a patient
who suddenly presents with confusion,
you have a “history” with that
experience, and have a knowledge
base to draw from.
 Other Concepts
 The other concepts of deciding and
evaluating also take part in your
assessment of the situation!
 As you started this exercise, and every
critical thinking episode, you start with
your existing knowledge base. Each time
you are faced with a new situation, you
identify from it what you already know.
 Tools for Critical Thinking
 Ask questions! Sometimes people hesitate
to ask questions because they fear that
asking a question may be interpreted as a
lack of knowledge on their part. However,
the question is a key element of critical
thinking.
 Questions serve many purposes, and only
serve to broaden your knowledge base, and
expand your options.
 Why Question?
 Questioning begins the information-
seeking process.
 All questioning is about seeking
information, re-formulating information to
new situations, and solving nursing
practice dilemmas.
 Can you think of some other examples of
information seeking that you do?
 Information Seeking

 Some examples of information seeking:

1. Looking up lab values
2. Reviewing a policy or procedure
3. Reading instructions about how to operate a
4. piece of equipment
5. Reviewing a patient’s chart
6. Asking a co-worker or resource person.
 Exercise #2
 Mrs. Riley, a 45-year old wife and mother, has just
returned to your nursing unit from the recovery
room after a gastric resection for a malignant
stomach tumor. She has orders for respiratory care,
pain medication, continuous gastric suction,
incision monitoring, and NPO status. Eight hours
postoperatively she develops sudden dyspnea and
decreasing oxygen saturations. On each of the 5
components of critical thinking, write down what
could be going on with your patient.
 Mrs. Riley
 Exploring: what could be causing this
woman to be so suddenly dyspneic and
hypoxic?
 Pneumothorax
 Hemothorax
 Pneumonia
 Pleural Effusions
 Atelectasis
 Electrolyte Disorders
 Mrs. Riley
 Analyzing: what other information can I
gather to help me narrow down the
possible causes of her dyspnea/hypoxia?
 Breath Sounds
 ABG
 Blood Chemistry
 After listening to her breath sounds, you
determine that breath sounds are absent
on the left side.
 Mrs. Riley
 Prioritizing/Deciding: is this change
significant to this patient, and do I need to
even look further? This also includes the
decision that is made whether to inform the
physician of the change in their patient’s
status. What would you say?
 Any significant change in a patient’s
respiratory status should be reported to the
patient’s physician right away.
 Mrs. Riley
 Evaluating: after reporting the alteration to
the patient’s Physician, he orders the
following:
 STAT ABG & STAT Portable CXR
 Equipment for chest tube insertion to be at bedside
STAT
 When the chest x-ray comes back, there is a large
pneumothorax on the left, as well as diffuse
atelectasis. Anesthesia is called to place a chest tube
STAT. Your analysis was right on target!
 Mrs. Riley
 Once the chest tube was placed, Mrs. Riley
had an immediate improvement of her
oxygen saturations, and her dyspnea
resolved. Now a new set of critical
thinking is demanded of you. How does
this chest tube change the care &
assessments you will provide for Mrs.
Riley?
 It’s no accident...
 It’s no accident that the nursing process
mirrors a lot of the critical thinking
process. They are both processes
developed to gather information, look
ahead, plan, and evaluate processes.
 Looking at the two, side-by-side really
illustrates that example.
 Side-by-Side

NURSING CRITICAL
PROCESS THINKING
Assessment Exploring
Diagnosis Analyzing
Planning Prioritizing/decision
making
Implementation Prioritizing and
deciding
Evaluation Evaluating
 Exercise #3
 Mr. Harris is your patient. He is a 18 year old young
man thrown from the van in which he was riding,
when it was hit head on by an oncoming car. He is
unconscious and has a cervical fracture. He has no
movement of his extremities. Suddenly during the
middle of the night, his legs begin to move. On each of
the 5 components of critical thinking, write down
what could be going on with your patient.
 Mr. Harris
 Exploring: what could be causing the
movement in Mr. Harris’ legs?
 SpinalReflexes
 Purposeful movement
 Muscular spasms
 Mr. Harris
 Analyzing: what other information can I
gather to help me narrow down the
possible causes of his movement?
 Are the movements purposeful?
 Can the movements be duplicated?
 How much movement is possible?
 Does the patient report any changes in
sensation?
 Mr. Harris
 Prioritizing/Deciding: is this change
significant to this patient, and do I need to
even look further? This also includes the
decision that is made whether to inform the
physician of the change in their patient’s
status. What would you say?
 With the patient having a stable overall status,
it would most likely be best to report this to the
physician first thing in the morning.
 Mr. Harris

 Evaluating: after reporting the alteration to the

patient’s Physician, he orders the following:
 Spine CT
 Neurological Consult
 Every 4 hour neurological checks
 At this point, the Physician’s orders indicate to you
that he is thinking along the same lines as you did,
and your thinking process was complete
 Critical Thinking
 Critical thinking is essential in nursing
practice. Critical thinking applies to nearly
every aspect of your patient care and
patient assessment.
 The sharper your skills are, the better care
you provide for your patients.
 Developing your problem-solving skills
also help you to provide a high level of
patient care.
 Exercise #4
 You’re doing a routine reassessment on your
patient, Mr. Fisher. You notice that his vital signs
are as follows:
 Temp: 99.9
 Pulse: 144
 Resp: 26
 BP: 90/42
 None of these values are within Mr. Fisher’s
normal range. What are you thinking could be
going on? Write down everything that comes to
mind.
 What to consider?
 Did you consider that there may be an
underlying infection, causing the elevated
temperature, heart rate, and decreased
blood pressure?
 Or is the elevated heart rate the reason for
the low blood pressure?
 The limited information you have should
make you want to get more information, to
help solve the problem.
 Assessment
 You determine that these vital signs
warrant further assessment of his
condition.
 What questions do you want to answer
with your reassessment?
 Write down your answers now.
 I wanna know...
 What potential routes  What medications is he
for infection does he on?
have? An IV, a foley  What is his fluid
catheter, a G-tube, a volume status? What
surgical site, a wound? are his I & O’s like?
How do these areas  Is he diaphoretic?
look?
 Does he complain of
 What are his lung
pain?
sounds like?
 What color is his urine?
 Is his heart rate regular
or irregular?
 Consider the Causes...
 First, you used your previous knowledge to
identify which of the vital sign values were
abnormal.
 Then, you gathered potential reasons for
those abnormalities based on the individual
patient, and decided to look for the
information from your assessment to find
out if one of those potential reasons could
have been the cause.
 Could it be?
 What were some of the potential causes?
 Infection
 Dehydration
 Heart Problem
 Pain
 By searching for more information, you could
narrow down the potential causes!
 Essential Components
 Another essential component of the
decision making process, is the
consideration of determining if the
problem is important.
 For a patient whose urine output is
normally 150cc/hr, is a drop of urine
output to 135cc/hr for 2 hours important?
Probably not.
 Essential Components
 Weigh that against a scenario of a patient who
usually has a normal urine output and who
suddenly has no urine output from his foley
catheter for 8 hours. Is that important?
Absolutely!
 With the above scenario, what are some things
you would want to check right away in that
patient? What would you want to do? Write
down your answers.
 Remember
 Always keep in mind that any affect on one
system is going to affect another system!
 A sudden drop in urine output could be the
result of acute kidney failure; dehydration;
bladder or catheter obstruction; disease, etc.
 Other findings from your assessment may help
you determine which of these situations apply!
 Practice , Practice, Practice
 Remember that with practice, your
problem-solving and critical thinking skills
will get better and better.
 Next time you have a problem, take a
minute, sit down, use the critical thinking
tools presented here to help gather more
information & apply what you already
know to help solve your problem!