CHAPTER 15
KEY OBJECTIVES
1. Explain the relationship between critical thinking and clinical judgment in nursing practice.
Critical thinking is the foundational process of analyzing information logically and reflectively. In nursing, it involves purposeful, self-regulatory judgment.
Clinical judgment is the outcome of critical thinking—it's the decision or conclusion a nurse makes after processing patient data.
Relationship:
* Critical thinking provides the mental framework.
* Clinical judgment is the actionable decision derived from it.
* Example: A nurse uses critical thinking to interpret abnormal vitals → this leads to clinical judgment to notify the physician or initiate intervention.
2. Interpret the value of applying a clinical judgment model in nursing practice.
Using a clinical judgment model (e.g., NCSBN Clinical Judgment Measurement Model) helps nurses:
* Make safe and accurate patient care decisions.
* Prioritize interventions based on evidence.
* Understand the step-by-step thinking process (cue recognition, analysis, hypothesis, action, outcome evaluation).
* Promote consistent care across providers and situations.
Value: Reduces errors, supports reasoning under pressure, enhances outcomes, and improves nursing education and assessment.
3. Examine the components of critical thinking in clinical decision making.
Key components include:
Component
Description
Interpretation
Understanding and explaining patient data
Analysis
Investigating ideas, identifying relationships
Inference
Drawing conclusions based on evidence
Evaluation
Assessing reliability and relevance of info
Explanation
Justifying actions with evidence
Self-regulation
Reflecting on and improving your thinking
Problem-solving
Identifying solutions based on reasoning
4. Contrast the differences between basic problem solving and diagnostic reasoning.
Aspect
Basic Problem Solving
Diagnostic Reasoning
Definition
Straightforward, task-based solutions
Analytical process of identifying a patient problem
Approach
Linear and procedural
Holistic and evidence-driven
Used For
Routine problems
Complex or ambiguous patient situations
Example
Restarting IV when infiltrated
Evaluating new-onset chest pain
5. Explain differences in the levels of critical thinking.
Based on Benner's theory:
Level
Characteristics
Basic
Follows rules/guidelines, relies on experts
Complex
Begins to analyze independently, questions routines
Commitment
Makes choices without assistance, takes responsibility
6. Analyze benefits of clinical experiences that contribute to critical thinking.
Clinical experiences:
* Expose students to real-world variability.
* Encourage reflection-in-action and reflection-on-action.
* Develop pattern recognition, confidence, and prioritization.
* Help apply theory to practice under supervision and feedback.
* Encourage interdisciplinary communication and holistic care.
7. Apply critical thinking attitudes during assessment of a patient condition.
Critical thinking attitudes that enhance assessment include:
Attitude
Application
Curiosity
Asking why symptoms are occurring
Humility
Acknowledging limitations, seeking help
Integrity
Reporting findings honestly
Perseverance
Continuing assessment until cause is found
Confidence
Trusting your findings and actions
Fairness
Avoiding bias, assessing each patient individually
8. Explain when to use intellectual standards.
Intellectual standards (clarity, accuracy, relevance, depth, breadth, logic, significance, fairness) guide evaluation of thought processes.
Use during:
* Assessments (e.g., Is this information accurate?).
* Nursing diagnoses (e.g., Are the findings logically connected?).
* Care planning (e.g., Are interventions relevant and evidence-based?).
* Communication with team or documentation.
9. Evaluate the ability to make accurate clinical decisions.
Indicators of accurate clinical decisions:
* Appropriate prioritization of care.
* Timely, evidence-based interventions.
* Improved patient outcomes.
* Effective collaboration with the health team.
* Reflection that confirms rationale was logical and valid.
To evaluate this ability:
* Use clinical judgment models.
* Seek feedback from peers/preceptors.
* Reflect on outcomes and consider what could be improved.
KEY TERMS
1. Clinical Decision Making
The process nurses use to choose the best actions to meet patient goals based on data, experience, and knowledge.
Example: Deciding whether to administer pain medication or reposition a patient first.
2. Clinical Judgment
The conclusion or decision a nurse reaches after analyzing clinical data. It involves recognizing cues, interpreting them, and acting appropriately.
Example: Deciding to escalate care when a patient’s oxygen saturation drops unexpectedly.
3. Critical Thinking
An active, disciplined process of analyzing, synthesizing, and evaluating information to guide beliefs or actions.
Key Traits: Clarity, logic, fairness, depth, relevance.
Used for: Safe, individualized care decisions.
4. Deductive Reasoning
Using general information to reach a specific conclusion.
Example: All patients with sepsis are hypotensive → This patient is hypotensive → This patient may have sepsis.
5. Diagnostic Reasoning
A specific type of critical thinking involving the collection and analysis of patient data to determine a diagnosis.
Used to: Identify problems and plan effective interventions.
6. Evidence-Based Knowledge
Information derived from research, clinical expertise, and patient values used to guide care decisions.
Foundation for: Evidence-Based Practice (EBP).
7. Inductive Reasoning
Using specific observations to form a general conclusion.
Example: This patient with a urinary catheter has a fever and foul-smelling urine → UTIs are common with catheters.
8. Inference
A logical interpretation made from available evidence or observed cues.
Example: A patient is grimacing and guarding their abdomen → You infer they are in pain.
9. Intuition
A gut feeling or immediate understanding without apparent reasoning, often based on experience.
Example: An experienced nurse senses something is wrong before abnormal signs appear.
10. Knowing the Patient
Understanding a patient’s patterns, preferences, and history to anticipate needs and personalize care.
Helps build: Trust and tailored clinical decisions.
11. Nursing Process
A systematic method of critical thinking used to plan and provide patient care:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
12. Problem Solving
The process of identifying a problem, exploring alternatives, choosing, and implementing a solution.
Example: Solving a clogged IV line by checking for kinks, changing sites, or flushing.
13. Reflection
A process of looking back on and analyzing past actions to improve future performance.
Encourages: Learning from experiences and avoiding repeated errors.
CHAPTER 16
KEY OBJECTIVES
1. Explain the relationships among assessment, clinical decision making, and clinical judgment.
* Assessment provides the foundational data (e.g., vital signs, symptoms, history).
* Clinical decision making uses that data to determine priorities and care needs.
* Clinical judgment is the conclusion or action the nurse takes based on the assessment and decision-making process.
Relationship: Assessment → Clinical decision making → Clinical judgment
Example: You assess increased respiratory rate → decide patient needs oxygen → judge situation as deterioration.
2. Discuss how the two steps involved in nursing assessment are used in practice.
The two steps are:
1. Collection of data (objective and subjective)
2. Interpretation/validation of data
In practice:
* You collect data via interviews, exams, vitals, and labs.
* Then, validate findings (e.g., confirm abnormal heart sound with another nurse or stethoscope check) to ensure accurate nursing diagnosis.
3. Differentiate the types of nursing assessments used in practice.
Type of Assessment
Purpose
Initial/Admission
Baseline data at first encounter
Focused/Problem-Oriented
Assess a specific problem or system
Emergency
Life-threatening situations (rapid, focused)
Ongoing/Reassessment
Evaluates changes during care
4. Examine the components of critical thinking in nursing assessment.
Component
Role in Assessment
Interpretation
Analyze data meaning
Analysis
Recognize patterns in findings
Inference
Draw conclusions (e.g., SOB = respiratory issue)
Evaluation
Determine data accuracy
Explanation
Justify assessment choices
Self-regulation
Reflect and adjust assessment techniques
5. Analyze practice situations to determine the type of nursing assessment to use.
Example Scenarios:
* New patient with multiple comorbidities → Initial assessment
* Complains of chest pain during shift → Focused or emergency assessment
* Monitoring wound healing every shift → Ongoing assessment
* Code blue or trauma → Emergency assessment
6. Explain how experience in performing nursing skills influences patient assessment.
* Experienced nurses notice subtle changes (e.g., restlessness before desaturation).
* They can prioritize better, use intuition, and ask targeted questions.
* Clinical experience allows quicker, more accurate pattern recognition and validation of findings.
7. Examine how the use of critical thinking attitudes and professional standards yields a comprehensive assessment database.
Critical thinking attitudes (e.g., curiosity, perseverance, humility) ensure:
* You question incomplete data.
* You dig deeper (e.g., patient denies pain but is guarding abdomen).
Professional standards (e.g., ANA Standards, Code of Ethics) ensure:
* Accurate documentation.
* Objective, unbiased assessments.
* Respect for cultural, ethical, and individual factors.
Combined, they build holistic, patient-centered databases.
8. Explain the importance of building a nurse-patient relationship when gathering a patient assessment.
* Promotes trust and openness, leading to more accurate data.
* Encourages honesty about sensitive topics (e.g., mental health, pain, lifestyle).
* Patients feel respected and heard, improving satisfaction and compliance.
Example: A patient may disclose substance use only if they feel safe.
9. Apply communication techniques when conducting a patient interview.
Effective techniques include:
* Open-ended questions: “Can you describe your pain?”
* Active listening: Nodding, eye contact, minimal interruptions.
* Clarifying: “When you say dizzy, do you mean lightheaded or spinning?”
* Silence: Allows patient time to think or express emotion.
* Summarizing: “Let me recap what you’ve told me…”
10. Display professionalism during history taking.
Demonstrate by:
* Using neutral, nonjudgmental language
* Ensuring privacy and confidentiality
* Wearing appropriate attire and identification
* Maintaining cultural sensitivity
* Documenting accurately and objectively
11. Explain the assessment process.
The assessment process involves:
1. Collecting Data: From patient, family, records, diagnostics.
2. Validating Data: Confirm accuracy and completeness.
3. Organizing Data: Using frameworks like body systems or Gordon’s patterns.
4. Interpreting Data: Recognizing patterns, making inferences.
5. Documenting: Accurate, clear, and timely notes.
Leads directly into nursing diagnosis and care planning.
KEY TERMS
1. Assessment
The first step of the nursing process, involving the systematic collection and analysis of patient data to determine health status, needs, and priorities.
2. Back Channeling
Verbal or non-verbal cues used by the nurse to encourage the patient to continue sharing information.
Examples: "Go on," "I see," nodding, or saying "Uh-huh."
3. Closed-Ended Questions
Questions that prompt short, specific answers, often “yes” or “no.”
Used for: Clarifying or confirming facts.
Example: “Do you have a fever?”
4. Cue
A piece of information, sign, or symptom gathered during assessment that indicates a potential health issue.
🔍 Example: Grimacing while moving may be a cue for pain.
5. Inference
A judgment or interpretation made based on cues and evidence.
Example: You infer the patient is in pain based on restlessness and facial expression.
6. Nursing Health History
A structured interview focused on the patient’s current health concerns, medical history, lifestyle, and risk factors.
*Collected during initial assessment to guide care planning.
7. Nursing Process
A five-step systematic approach to nursing care:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
8. Objective Data
Observable and measurable facts collected by the nurse through assessment.
Examples: Blood pressure, wound size, respiratory rate.
9. Open-Ended Questions
Questions that invite the patient to share more information in their own words.
Example: “Can you describe how you’ve been feeling?”
10. Review of Systems (ROS)
A systematic approach during health history where the nurse asks about signs and symptoms related to each body system.
Example: Asking about chest pain, SOB, or palpitations during cardiovascular review.
11. Subjective Data
Information reported by the patient that cannot be objectively measured.
Examples: “I feel dizzy,” “I have pain in my leg.”
12. Validation
The process of confirming the accuracy of data collected during assessment.
Example: Rechecking a blood pressure reading that seems abnormally high.