Nursing Process and Critical Thinking

THE NURSING PROCESS

The nursing process is a way of thinking and acting based on the scientific method (a step-by-step process with observable results used by scientists to solve problems). The nursing process is a tool for identifying patients’ problems and an organized method for meeting patients’ needs. It was developed in the 1950s to describe the independent role of the nurse in providing patient care. Nurses are taught to use this framework consistently and methodically (Figure 4-1).

The five components of the nursing process are assessment (data collection), nursing diagnosis, planning, implementation, and evaluation. Box 4-1 provides a brief explanation of each component. The goals of the systematic, dynamic process are to explore patients’ health status, identify actual or potential health care problems, determine desired outcomes (results of actions), deliver specific nursing interventions to solve the problems and promote health, and evaluate care given to determine whether outcomes have been achieved. The components often overlap as the nurse continually assesses and evaluates effects of actions. The role of the LPN/LVN is shown in Table 4-1 on p. 50 as set by the LPN/LVN Standards described by the National Federation of Licensed Practical/Vocational Nurses (NFLPN). The LPN role is explained more fully in Chapters 5 and 6.

The construction of a plan of care for the patient is a collaborative process among the nurse, the patient, and other health team members. Patient input during the planning stage results in more success with the plan of care. Registered nurses are officially responsible for the initiation of nursing care plans for each patient, but the LPN/LVN assists with each part of the care plan. The LPN is often responsible for data collection to assist the RN with the assessment phase. The nursing process allows for constant alterations in the plan of care as patients’ conditions change.

The nursing process is similar to other methods used to organize tasks in daily life. In planning a week’s meals at home, the goal is to supply each family member with good nutrition. The assessment or data collection phase involves deciding what might be served and surveying the supplies on hand needed for the food preparation. These data are analyzed to determine what must be purchased at the store, to plan specific menus, and to plan for deviation from normal meals, such as school lunches or quick dinners before a child’s basketball game. Implementation includes shopping, preparing and serving the meals, and cleaning up afterward. Evaluation is performed to determine whether the plan was successful: Did the family members eat what was served? Was there too much left over? Should something have been prepared differently? Was the expected outcome of balanced nutrition for each family member met? If not, how could the plan be altered for next week? This is not a new way of thinking and doing; the process is just being applied in a nursing context.

CRITICAL THINKING

It is necessary to think critically to use the nursing process successfully and to develop good clinical judgment. What does this mean? Critical means requiring careful judgment. Thinking, in this context, means to reason. Critical thinking is directed, purposeful, mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are decided. Critical thinking is necessary to make reliable observations regarding health status and to draw sound conclusions from the data obtained. Critical thinking is needed for creative problem solving and for the production of new ideas and solutions. It is essential for the evaluation of information received from others as well. Critical thinking is the keystone of good clinical decision making and the development of clinical judgment.

PRIORITY SETTING AND WORK ORGANIZATION

Critical thinking is applied to setting priorities for patient care. Nurses must also be able to prioritize the tasks assigned to them. A priority is more important than something else at that time. Priority setting (prioritizing) involves placing nursing diagnoses or nursing interventions in order of importance. Life-threatening problems are of a high priority. Problems that threaten health or coping ability are of a medium priority. Low-priority problems are ones that do not have a major effect on the person if not attended to that day or even that week. Prioritizing patient problems is usually based on the adaptation of Maslow’s hierarchy of needs (see Figure 2-3). Setting these priorities will be discussed in Chapter 5.

Priority setting for work organization requires consideration of several factors. As a student, you begin by prioritizing care for one patient. After graduation, you will need to prioritize care for many patients. When beginning your shift (or clinical day), go over your patient assignment worksheet, the Kardex, or the computer patient care plan and determine what needs to be done in the next hour. These items are of a high priority. Some tasks that may need to be done are vital signs, daily weights before breakfast, blood sugar readings before eating, morning insulin injections, preoperative assessments, and administration of medication for pain control.

When looking at prioritizing such tasks, you must consider what will happen if the task is not done on time. The recovering patient whose vital signs have been stable for the past 24 hours probably will not suffer a bad consequence if you do not take her vital signs right at 8 A.M. The diabetic who is hospitalized to control her disease really needs to have her blood sugar checked and her insulin given and may suffer an alteration in her health status if these tasks are not completed on time.

Other factors to be considered are the surgery schedule, degree of stability of each patient in your care, amount of time it will take to perform each task for each patient, availability of help, medication orders, unforeseen problems that occur, and physicians making rounds who ask you to do a task on a patient who isn’t yours. Knowledge, critical thinking, and clinical judgment will help you prioritize the tasks of your workload.

When all tasks have a rather high priority and there is no way you can do them all alone, you must assign some tasks to others. After prioritizing your tasks for the first hour, consider priorities for the rest of the shift. Figure 4-3 shows one type of work organization sheet.

Priorities constantly change because patient needs and conditions change frequently. To maintain organization with your workload, you must be flexible and you must frequently reorder your tasks. You should reconsider your work organization plan at least every 2 hours during your shift, reprioritizing as needed.

APPLICATION OF PROBLEM SOLVING AND CRITICAL THINKING

The emergency room is a good place to observe how nurses prioritize care and solve problems. When the emergency room nurse is faced with three patients seeking help, the problem of how to deal with all three patients and quickly make a decision about who is treated first must be solved. The first patient complains of severe chest pain; the second has a fever and a very bad cough; the third has a laceration on her chin and is bleeding. The problem: Which patient to treat first?

There are six possibilities for the order of treatment. When considering the possible outcome of choosing each alternative, the nurse looks at the consequences of placing each patient first, second, or third. If the woman with the laceration is chosen to be first, the outcomes might be (1) she will stop bleeding; (2) the man with chest pain may be having a heart attack and may die, or he may be diagnosed with severe indigestion; and (3) the woman with the fever and cough may become angry and cause a commotion. If the man with the chest pain is chosen to be first to be treated, the outcomes might be (1) his life may be saved, or it may be determined he has severe indigestion; (2) the woman with the laceration may lose more blood, or the bleeding may stop by applying pressure while she is waiting to be treated; and (3) the woman with the cough and fever may cause a commotion or may be courteous about waiting.

Considering the likelihood of each outcome occurring is the next step. The nurse looks at the three patients and estimates that the man with chest pain has at least a 65% chance of it being a life-threatening heart attack and a 35% chance that he has indigestion; the chance of the woman with the fever and sore throat causing a commotion is about 5%, and the chance of this woman courteously waiting about 95%. If you choose the man with the chest pain to be treated first, the chance of the woman with the laceration losing a serious amount of blood is about 20% while the chance of stopping the blood with pressure while awaiting treatment is about 80% or better. Since the chance of a bad outcome is highest for the man with the chest pain, you choose to have him treated first. The goal is to avoid having your decision cause injury to anyone.

Besides ordering treatment for emergency room patients, you must decide many things each day, such as what size needle is best to use for an injection, what to tell the patient or her family about her prognosis, which tasks to assign and which to do yourself, which staff to assign to which patients, and which nursing diagnosis has the highest priority for a patient on a particular day. With critical thinking skills, you can weigh many factors and skillfully solve problems, making good decisions a majority of the time. No one makes perfect decisions all the time. Learning to apply the nursing process well will assist you to gain clinical judgment and to follow logical processes automatically when solving problems and making decisions. Operating in a critical thinking mode while pursuing your nursing studies will help you develop the clinical judgment necessary for safe nursing practice.

The nursing process is a way of thinking as well as organizing. In this dynamic process, the nurse is constantly gathering data and evaluating. The next two chapters explain the components of the nursing process more thoroughly. The bibliography for this chapter identifies resources for the student who wishes to enhance learning by improving critical thinking skills.

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