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CRITICAL THINKING AND THE NURSING PROCESS

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Presentation on theme: "CRITICAL THINKING AND THE NURSING PROCESS"— Presentation transcript:

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

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Critical Thinking Skills for Nurses

Nov 08, 2012

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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.

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Presentation Transcript

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, andevaluating 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. • Decidingmeans 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: • Looking up lab values • Reviewing a policy or procedure • Reading instructions about how to operate a piece of equipment • Reviewing a patient’s 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 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

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 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.

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

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!

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• Preferences

The Nursing Process: Critical Thinking - PowerPoint PPT Presentation

The Nursing Process: Critical Thinking

The nursing process: critical thinking & assessment. amy c. chavarria, rn, msn, mba, hcm, cce ... restrictive or blocking to conversation ... – powerpoint ppt presentation.

• Amy C. Chavarria, RN, MSN, MBA, HCM, CCE
• Critical analysis
• Inductive and deductive reasoning
• Making valid inferences
• Differentiating facts from opinions
• Evaluating the credibility of information sources
• Clarifying concepts
• Recognizing assumptions
• Independence
• Fair-mindedness
• Intellectual humility
• Intellectual courage
• Perseverance
• Essential for safe, competent, skillful nursing practice
• Rapid and continuing growth of knowledge
• Make complex and important decisions
• Draw meaningful information from other subject areas
• Work in rapidly changing, stressful environments
• Recognize important cues, respond quickly, and adapt interventions
• Things change
• Sicker clients
• More consumer involvement
• Need to move from one setting to another
• Need for new learning and workplace skills
• Requirement for evidence of benefits, efficiency, and results
• New problems cant be solved with old ways of thinking
• Thinking skills needed to deal with todays world
• Possible to improve thinking
• Difference between success and failure
• Critical thinking underlies each step of the nursing, problem-solving, and decision-making processes
• Method of planning and providing individualized care
• Modified problem-solving process
• Assess, diagnose, plan, implement, evaluate
• Clarify the nature of a problem and suggests possible solutions
• Evaluate solutions and choose best one to implement
• Commonly used approaches
• Trial and Error
• Research process
• Scientific method
• Choosing the best actions to meet a desired goal
• Identify purpose
• Set and weigh criteria
• Seek and examine alternatives
• Project, implement, and evaluate outcome
• Rigorous personal assessment
• Analysis of thinking processes and attitudes
• Cultivation of critical thinking abilities
• Attendance at conferences
• Awareness of own thinking-while thinking
• Create environments that support critical thinking
• Nursing Process is synonymous with the __________________ solving approach.
• Before Nursing Process, proof of care was loosely structured and unorganized.
• Nursing Process introduced in 1955 by Lydia Hall but wasnt used extensively until the ___________s.
• Started with a _____ step process.
• Social Policy Statement (1980) The ANA identified diagnosis of ______________ and potential health problems as part of nursing practice.
• The actual development of nursing process as a _____ step model, which is used today, was introduced by the ANA in 1991 and includes Outcomes.
• Your text has a 5 step (phase) model.
• Is one better than the other?
• Why different models?
• What did the leave out?
• Outcome Identification
• Implementation
• Implementing
• ______________________ problem-solving approach to giving individual nursing care.
• It is a model used to make decisions about client ______________.
• Serves as a ______________ for professional nursing practice.
• It requires ________________ thinking skills.
• The nursing process has unique characteristics that enable responsiveness to the __________________ health status of the client.
• Cyclic (____________ itself) and dynamic (ever ______________________)
• Client ________________ using client strengths not nurse or physician centered
• Focuses on problem solving and decision making
• In every ________________ of the process
• Allowing nurses to be creative and use all their skills and ________________________
• This facilitates ________________________ of client care
• Interpersonal and collaborative -- involves communication with
• ________________________
• Others in the health care team
• Universal applicability
• Appropriate throughout _______________
• Can be used in ___________ settings
• Use of critical thinking
• See page 261 of text TABLE 16-2
• Looks at _________________ person
• ___________________ AND SYSTEMATIC
• Framework for CARE to individuals, families and communities
• Each phase interacts and is influenced by _____________ phases.
• As condition ________________, the nurse gathers and incorporates information into __________ plan of care.
• ________________ knowledge based of basic sciences and humanities.
• Ability to communicate in _________________.
• Ability to ______________.
• Professional Relevance
• Systematic, organized way of providing nursing care for any client in ____________ situation
• Focuses on clients unique problems
• Recognized as a ____________________ of care
• Professional Relevance (cont.)
• Recognized _________________________ as method of practicing nursing
• ________________ bound to use NP by Nurse Practice Act
• Ensures __________________ nursing care
• Professions require a sound scientific base
• Nursing requires a __________________ system to provide a structure for nursing practice.
• Our system is the Nursing Process
• Is the _____________________, organizing, validating, and documenting of client data.
• It is systematic and ___________________
• What is data? _______________________
• You assess throughout the entire nursing process (all the phases/steps)
• All phases of the NP depend on accurate and ___________________ data collection.
• To establish a database about the clients
• ___________________ to health concerns or illness.
• Their ability to manage health care _______________.
• Establish a database
• Obtain a nursing health _____________________.
• Conduct a _____________________ assessment.
• Review client ______________________.
• Review nursing __________________________.
• Consult ___________________________ persons.
• Consult health professionals.
• Update data as ____________________.
• ___________________ data.
• ____________________ data.
• Communicate/____________________ data.
• States (the professional nurse will) _________ (a) systematic approach to provide individualized, __________-directed nursing care by performing a __________________ assessment regarding health status of the client.
• _____________ assessment
• Problem-_________________ assessment
• __________________ assessment
• _______________-lapsed reassessment
• Initial - 1st client _____________________
• Comprehensive nursing history physical exam.
• Performed within specified time after ______________________.
• Purpose is to establish a complete database for problem identification, reference, and future _________________.
• Problem focused assessment - ____________ scope
• Ongoing process integrated with nursing care
• To determine the status of a ________________ problem identified in an earlier assessment.
• To identify _________ or overlooked problems.
• Hourly assessment of clients IO in and ICU.
• Assessment of clients ability to perform ADLs.
• Time lapsed - ongoing assessment
• Done several months ______________ initial assessment.
• Purpose is to compare the clients current status to _____________________ data previously obtained.
• Such as reassessment of a clients functional health patterns in a
• Home care setting
• Outpatient setting
• Hospital setting
• Shift change
• Emergency - may be initial for ____________-threat ening problems
• Done during any physiologic or psychologic ______________ of the client.
• Purpose is to identify life-threatening problems.
• Rapid assessment of a persons airway, breathing status, and circulation during a cardiac arrest.
• Assessment of suicidal tendencies or potential for ______________________.
• Also called ______________ or covert data.
• Only things the client can ______________ that we cannot test or see.
• Clients sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation.
• Also called ______________ or overt data.
• You can see, smell, heart, taste, feel, or _______________.
• Wound size, color and drainage
• Blood pressure, temperature, _________
• Primary source - the ______________
• Secondary sources -
• Family-significant others (____________ people)
• Past and current health ______________
• _______ test and diagnostic procedures
• Reports from other health members
• Reviewing literature
• Should be scheduled so client is not _____________, hungry or in pain.
• Should provide ___________________.
• Allow family to ___________ if client desires.
• Reviewing general information - primary and secondary data.
• Considering _______________ language, beliefs, values
• ____________________ the client and environment.
• _________________ for seeking healthcare.
• What types of things are we going to assess?
• ______________
• Activity and Exercise
• Nutrition and Metabolism
• Elimination
• _____________ and rest
• What types of things are we going to assess? (cont.)
• ________________ and perception
• Self-perception and self-_______________
• Roles and relationships
• ___________________ and stress tolerance
• Sexuality and reproduction
• Values and __________________
• Observation using your _____________
• Smell (body or breath odor)
• ____________________
• Overall appearance
• Body ____________
• General ___________________
• Signs of distress or discomfort
• ____________ and body gestures
• ____________ color or lesions
• Abnormalities of ________________
• _________-verbal demeanor
• Signs of anger or anxiety
• ________________ or cultural artifacts
• Lung and heart ________________
• _________________ sounds
• Ability to communicate
• Language spoken
• Ability to ______________ when spoken to
• __________________ to time, place and person
• Thoughts and feelings
• About self, others and health status
• Skin temperature and ____________
• ____________ strength hand grips
• Pulse rate, rhythm, and __________
• Palpatory lesions lumps, masses, nodules
• Interviewing - planned or conversation with a purpose
• 2 approaches
• _________________
• Gets _________________ information
• _______________ controls the purpose
• Non-direct-
• ___________________ building interview
• _______ controls the purpose, topic and pace
• Interviewing continued
• Types of interview questions
• Close-ended
• Answer with ____________ words
• Used in directive interviews
• Restrictive or blocking to conversation
• Usually beings with when, where, who, what, does or is
• Highly ______________ or people who have difficulty communicating like close-end questions
• Types of interview questions (cont.)
• Used with nondirective interview
• Invites client to ________________ on thoughts, feeling or information
• Invites ________________ answers
• Begin with what or how or tell me
• See BOX 16-2 on page 267 of text.
• Maintenance Phase
• Keep focused
• Encourage client to talk
• Concluding Phase
• Explain action to client
• Review goals and plans for action
• Preparatory Phase
• Review chart
• Evaluate Data
• Assess your own feelings
• Plan for quiet time
• Introductory Phase
• When nurse and client meet
• Establish rapport
• Client is _______________________
• There will be ________ interruptions
• When the client will feel comfortable and unhurried.
• Well-_______________, well-ventilated
• Moderate size room
• ____________ of noise, movement and interruption
• A place where others cannot overhear or ______________ the client is desirable
• Without barriers between nurse and client
• Nurse __________ client on same eye level
• Sit at a ______ degree angle to clients bed
• Sit on their bed
• ___________ and look down at the client
• Stand at the ___________ of the bed
• Neither too _____________ or too far
• Most people feel comfortable with a distance of __________ feet
• _______________ will dictate appropriate distance
• Accepted distance between individual in conversation varies with ethnicity.
• About 8-12 inches in Arab countries
• _______ inches in the US
• _______ inches in Britain
• _______ inches in Japan
• Men of all cultures usually require ____________ space than women.
• Anxiety increases the need for ________________.
• Direct eye contact ? the need for space.
• In East Asian and Scandinavian countries, direct eye contact is considered __________________.
• Physical contact is used _____________ if it has a therapeutic purpose.
• Touch can be misinterpretedespecially between persons of opposite _______________.
• Language - See Practice Guidelines Communication during an Interview, page 268
• Failure to communicate in language the client can communicate is a form of discrimination.
• Dont using _________________ terms.
• Interpreters (from hospital preferred) or Language Line (ATT 24-7)
• Written documents-make sure client can __________
• Inspection - ______________ inspection of the client done in a methodical deliberate manner.
• Palpation - use of ______________-fingertips and palms to determine size, shape and configurations of underlying structures.
• Percussion - both hands used to ____________ body surface to produce a sound for denseness or hollowness.
• Uses fingers and hands to _________ on area of the client to produce sound
• Resonance - The degree to which the sound _________________ (magnifies the sound)
• Type of percussion tone is determined by the _____________ of the medium through which sound is traveling
• Use fingers of both hands - requires practice and repetition.
• Auscultation - listening to body sounds with a stethoscope place on a body surface to ___________________ sounds
• Listening to the sounds of ________________ within the body
• Stethoscope collects and transmits sounds
• The Bell detects _________-pitched sounds
• The Diaphragm detects _______-pitched sounds
• Heart listen for moving __________
• Lungs listen for moving ______
• Abdomen for movement of GI ________________
• Properties of sound
• _______________ - measure of vibration
• Intensity _____________ of the sounds
• Quality -musical characteristics blowing, squeaking, ________________
• Duration - ____________ of the sound
• PHYSICAL- body __________________ evaluation (cephalocaudal)
• PSYCHOLOGICAL - intellect self- concept ___________________
• SOCIAL relationships ___________________ with family and friends
• SPIRITUAL belief in a higher being personal interpretation of meaning of life attitudes on moral decisions.
• GORDONS FUNCTIONAL HEALTH FRAMEWORK Evaluates persons mind, body, and environment in relation to their ability to perform tasks of daily living.
• HEAD TO TOE FRAMEWORK System for collecting data in an organized manner, starting at the head -proceeding systematically downward to the toes.
• BODY SYSTEMS FRAMEWORK Focuses on pathophysiology involved within specific body systems
• See text pages 270-273.
• Systematically recorded and become a _______________ part of the client record
• _________________________
• Double _________________
• _____________________ to confirm that it is accurate and factual
• Validating helps the nurse complete the following tasks
• Ensure that assessment information is ___________________.
• Ensure that objective and related subjective data _______________.
• Obtain additional information that may have been overlooked.
• Validating tasks (cont.)
• Differentiate between cues and inferences.
• Cues are subjective or objective data that can be directly __________________ by the nurse
• What the client says or
• What the nurse can see, hear, feel, smell, or measure.
• Inferences are the nurses _______________________ or conclusion made based on the cues
• Avoid jumping to conclusions and focusing in the _______________ direction to identify problems.
• Not ______ date requires validation.
• Height, weight, birth date, and most laboratory studies.
• The nurse validates when there are discrepancies between data obtained in the nursing interview and the physical examination, or when the clients statements ___________ at different times in the assessment.
• See TABLE 16-6 in text page 274.

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