State of Nebraska Transition Grant
Critical Thinking/Clinical Reasoning for the Newly Licensed Practical Nurse Education Module
Copyright 2011
Title: Clinical Reasoning/Critical Thinking Learning Objectives: Upon completion of this communication module, the newly licensed practical nurse will: Discuss the importance of prioritization of patient care. Apply principles of time management in patient care. Draw conclusions from patient data. Differentiate priority and non-priority patient needs. Prepare organizational tools that will be utilized on a regular basis. Interactive Exercises: 1. View the following content with your preceptor. 2. Brainstorm with your preceptor, possible situations that could occur during a shift and how to anticipate patient needs. 3. Prioritize patient needs from highest to lowest. 4. Distinguish which patient data would need to be reported to a physician, licensed provider and/or registered nurse. 5. Develop a tool to help you organize your day (or utilize one already prepared by your facility). 6. Discuss with your preceptor, the scheduled activities during a typical shift (meal times, etc.). 7. While listening to report, create a plan for your day and at the end of each day evaluate your plan with your preceptor.
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Transition to Practice: Critical Thinking Clinical Reasoning Prioritizing nursing care may be based on Maslow’s Hierarchy of Needs. We must meet the physiological needs such as oxygenation, before we can move up the pyramid and meet the other needs of the patient.
Prioritization of Nursing Care – nurses need to recognize what are immediate needs and what issues can wait. It does not mean they are not important, but they are not the highest priority. A = airway – has the highest priority. We cannot live without oxygen, which enters our airway. B = breathing – is the next highest priority. Oxygen enter the body by breathing. C = circulation – is the third highest priority. Oxygen must be moved to the tissues where it is needed, in order for the cells to survive. Prioritization practice begins with assessment. The assessment must be performed quickly and nurses must respond quickly with appropriate interventions. Prioritization Practice # 1 A patient is brought into an outpatient department with chest pain and dyspnea. What is the highest priority action for the nurse? Obtain vital signs and check the percentage of oxygen saturation Obtain a complete history 3
Draw blood for lab tests Start an intravenous infusion Prioritization Practice # 2 On your next assessment of this patient you note the temperature is 101.7 F (38.7 C), respiratory rate is 32/minute, apical pulse is 116/minute and SaO2 is 89% on room air. Assuming all of the following interventions were ordered, place the following interventions in order of priority: Obtain a sputum culture Administer an antibiotic Administer an antipyretic Administer oxygen therapy Prioritization Practice # 3 Which of the following assessment data, collected on a patient with chronic obstructive pulmonary disease (COPD) would be the most important to report to the physician? SaO2 90% on room air Apical pulse of 98/minute Blood pressure of 146/86 Clubbing of fingers and circumoral cyanosis Prioritization Practice # 4 Your patient is receiving a blood transfusion and complains of itching and hives are noted. Place the following interventions in the priority order. Maintain the IV infusion with normal saline Assess vital signs and airway patency Stop the blood transfusion Notify the primary care provider Prioritization Practice # 5 You are assigned a patient with type 1 diabetes mellitus who has an order for blood glucose monitoring before meals. In what order would you perform the following interventions? Complete a head to toe assessment Check vital signs Teach patient about diabetes Obtain finger stick for blood glucose level Administer insulin injection Assist patient with breakfast Time management and organizational skills are important for the nurse. Time may be wasted by some of the following activities. Try to think of other time wasters. Keep an activity log for one of your shifts, to determine how you spend your time and review it with your preceptor. Identify time wasters and how to eliminate them. Telephone calls Lack of prioritization and organization Lack of planning Lack of knowledge Failure to make appropriate assignments Ineffective communication Unscheduled meetings 4
Time Management Practice Activity: Take out a piece of paper and divide it into two one-hour increments. Indicate patient meal times. Include when medications are scheduled. Are patients scheduled for any tests, therapy, etc.? When do most of the physician’s make rounds? Time Management Tips: Arrive early for your shift and organize your day. Try to anticipate the unexpected. Listen carefully during shift report and note critical information. Review your assignment and note any patients who might need extra time. Consider tasks which could be assigned to the unlicensed team members. Make sure you have time management tools readily available – pen, scissors, stethoscope, small notebook, watch, etc. Be flexible; expect and plan for interruptions. Do not leave documentation until the end of the shift. Plan to do it throughout the shift. At the end of your day, take a few minutes to plan for the next day. Prioritization Practice # 6 You are assigned the following patients – how would you plan your day? Patient A had a colon resection yesterday and is scheduled for a dressing change Patient B had a hip replacement 2 days ago and is scheduled for physical therapy at 0900 Patient C is an insulin dependent diabetic who needs his blood sugar tested before breakfast Patient D was admitted yesterday evening and puts on the call light complaining of chest pain Prioritization Practice # 7 The nurse is preparing to begin the shift after listening to report. Which of the following patients should the nurse see first? A patient 4 hours post-cardiac catheterization with mild discomfort at the access site A patient diagnosed with diabetes mellitus who needs reinforcement of sick day management guidelines A patient who arrived on the unit 30 minutes ago from the post-anesthesia care unit A patient with pneumonia who has received 2 doses of intravenous antibiotics and has an oxygen saturation of 91%
Check your answers to the prioritization practice questions on the next page. Review your answers with your preceptor.
Prioritization Practice # 1 Based on the information given related to the ABCs, the appropriate answer is to obtain vital signs and check the percentage of oxygen saturation. Prioritization Practice # 2 The following would be the correct order: 5
Administer oxygen therapy Administer an antipyretic Obtain a sputum culture Administer an antibiotic Prioritization Practice # 3 The answer is clubbing of fingers and circumoral cyanosis, which should be reported. Prioritization Practice # 4 The following would be the priority order of interventions: Stop the blood transfusion Maintain the infusion with normal saline Assess vital signs and airway Notify the primary care provider Prioritization Practice # 5 The following would be the correct order of the interventions. If you are administering rapidacting insulin, the client should eat within 30 min of receiving the insulin. The administration of the insulin injection would be dependent upon the patient’s blood glucose result. Take vital signs Obtain finger stick for blood glucose level Administer insulin injection Complete a head to toe assessment Assist patient with breakfast Teach patient about diabetes Prioritization Practice # 6 First you should assess patient D’s chest pain which may require immediate intervention The second patient to assess should be patient C’s blood sugar The third patient to assess should be patient A due to yesterday’s surgery and the need to perform a dressing change The fourth patient would be patient B – even though they are scheduled for physical therapy, their needs at this time would be the lowest priority Depending upon the severity of the patient’s chest pain, it may be necessary to ask another staff member (who can legally perform this function), to access patient C’s blood sugar. Discuss this with your preceptor. Prioritization Practice # 7 The answer to the previous slide would be the patient who arrived 30 minutes ago from the postanesthesia care unit. References Brunt, B. (2005). Critical thinking in nursing: An integrated review. Journal of Nursing Education, 45 (2), 60-67. Burrows, C. (2007). Time management: A health care perspective. Wound Care Canada, 5 (2), 36-40. Cox, S. (2006). Better time management: A matter of perspective. Nursing, 36 (3), 43.
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Fero, L. et al (2009). Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing, 65 (1), 139-148. Forneris, S., Peden-McAlpine, C. (2009). Creating context for critical thinking in practice: The role of the preceptor. Journal of Advanced Nursing, 65 (8), 1715-724. Forneris, S., Peden-McAlpine, C. (2007). Evaluation of a reflective learning intervention to improve critical thinking in novice nurses. Journal of Advanced Nursing, 57 (4), 410-421. Hill, S., Howlett, H. (2009). Success in practical/vocational nursing. St. Louis: Saunders. Huckabay, L. (2009). Clinical reasoned judgment and the nursing process. Nursing Forum, 44 (2), 7278. Kuiper, R., Pesut, D. (2004). Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory. Journal of Advanced Nursing, 45 (4), 381391. Lisko, S., O’Dell, V. (2010). Integration of theory and practice: Experiential learning theory and nursing education. Nursing Education Perspectives, 31 (2), 106-108. Lunney, M. (2008). Current knowledge related to intelligence and thinking with implications for the development and use of case studies. International Journal of Nursing Terminologies and Classifications, 19 (4), 158-162. Pandey, K (2010, August 13). Critical thinking in nursing. Retrieved September 5, 2010 from http://www.buzzle.com/articles/critical-thinking-in-nursing.html Pearce, C. (2007). Ten steps to managing time. Nursing Management, 14 (1), 23. Pierce, P (n.d.). Retrieved September 5, 2010 from http://www.ceufast.com/courses/112/112.htm Quan, K. (2010, May 30). Time management and organizational skills in health care. Retrieved September 5, 2010 from http://www.suite101.com/content/time-management-andorganizational-skills-in-health-care-a242772 Riddell, T. (2007). Critical assumptions: Thinking critically about critical thinking. Journal of Nursing Education, 46 (3), 121-126. Siviter, B. (2004). ABC of time planning. Nursing Standard, 19 (4), 31. Vacek, J. (2009). Using a conceptual approach with concept mapping to promote critical thinking. Journal of Nursing Education, 48 (1), 45-48. Walsh, C., Seldomridge, L. (2006). Critical thinking: Back to square two. Journal of Nursing Education, 45 (6), 212-219. Waterworth, S. (2003). Time management strategies in nursing practice. Journal of Advanced Nursing, 43 (5), 432-440. Zurmehly, J. (2008). The relationship of educational preparation, autonomy, and critical thinking to nursing job satisfaction. Journal of Continuing Education in Nursing, 39 (10), 453-460.
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