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 patients
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

patients Physician, he orders the following:
STAT ABG & STAT Portable CXR
Blood Cultures
Urine & Sputum Cultures
Head CT in the morning if confusion doesnt resolve
Discontinue all medications that could cause
confusion
At this point, the Physicians 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:

Looking up lab values
Reviewing a policy or procedure
Reading instructions about how to
operate a piece of equipment
Reviewing a patients chart
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 patients
status. What would you say?
Any significant change in a patients
respiratory status should be reported to the
patients physician right away.
 Mrs. Riley

Evaluating: after reporting the alteration to

the patients 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?
 Its no accident...

Its 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?
Spinal Reflexes
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 patients
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

patients Physician, he orders the following:
Spine CT
Neurological Consult
Every 4 hour neurological checks
At this point, the Physicians 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

Youre 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. Fishers
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 What medications is

routes for infection he on?
does he have? An What is his fluid
IV, a foley catheter, volume status?
a G-tube, a surgical What are his I & Os
site, a wound? How like?
do these areas look? Is he diaphoretic?
What are his lung Does he complain of
sounds like? pain?
Is his heart rate What color is his
regular or irregular? urine?
 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!