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Ahhhh.. chicken and waffles. They don’t sound like they should go together, but they do. They so do.
Apart they are delicious, but together.. they just make sense.
It’s the same with critical thinking and care plans.
Coming up with a nursing diagnosis, nursing interventions, and using your clinical judgment to decide upon the best way to approach how you direct your care for your patient for the day as well as how you navigate obstacles are one in the same.
I will take a second to describe this process, but keep in mind that it occurs much more fluidly than this description.
I liken this to learning how to shoot a layup in basketball. When you’re a beginner, you learn each step and then put them together. It looks and feels very mechanical at the beginning. However, as you get more comfortable with the process, going through it becomes much smoother and more fluid and eventually you’ll be at a point where you’re doing it without even realizing it.
First, you will recognize a problem or issue.
Then you will determine the best solution / nursing intervention.
You’ll then determine if your intervention was successful and if you need to intervene again.
Example: The low oxygen saturation
(More examples at the end of the post!)
You are at the nurse’s station and see your patient’s oxygen saturation is 82%. You go into the room and see your patient is scrunched down in the bed with their nasal cannula is on the bed, labored breathing and coughing weakly.
I need them to get their oxygen saturation back up to 98%, like 3 minutes ago!
You decide to grab a coworker and have them help you boost your patient up so they are sitting straight up. You quickly reapply their nasal cannula. You hear them trying to clear their throat and grab the suction and clear a large amount of sputum that was caught in the back of their throat.
You see their oxygen saturation bounce up to 95%, and then up to 100%, and they are no longer coughing or experiencing labored breathing. They ask you what time lunch trays should arrive.
Learning how to critically think takes time. It is not something you just read in a textbook and can immediately apply. It requires foundational knowledge (like in the previous scenario, knowing what kind of troubleshooting to implement when a low oxygen saturation is occurring) and experiences.
This concept gets introduced in nursing school and you start to see it in action during clinicals. It will be mechanical at first, but eventually you will be critically thinking with the best of them. It just takes time, knowledge, and experience to really know how to see a situation (or multiple situations) and know the best plan of attack.
Practice (Not a game… practice)
(High-five to all of you Allen Iverson fans out there.. 2016 Hall of Famer – what what!)
While it does take time to become a competent critical thinker, you can begin to practice this. Whenever you have one-on-one time with a clinical instructor, physician, NP/PA, or someone else that is experienced in the field, it’s a great idea to practice this in down time. For example, if you are doing your senior year preceptorship in an intensive care unit and you’re working with one ICU nurse, you can being to ask them questions to further develop your knowledge base, learn from their experiences, and test yourself.
If you’re dealing with a septic patient in an intensive care unit, you could ask questions like..
“So what would this patient present like in the emergency department to clue the triage nurse in to the issue of sepsis?”
“If they weren’t responding to treatment, what would that look like… how would we respond?”
“If his blood pressure starts to decrease, what would your first reaction be?”
“When would you start to get concerned?”
“I know antibiotics are important in treatment of a sepsis patient, but how would I know if the ones we’re using aren’t working?”
“What’s the biggest complication we’re facing with this patient… how would I know that’s beginning to occur?”
What are Care Plans?
Note: There are quite a few different confusing resources for this topic floating around out there on the internet. To keep things consistent, the only resource I will use to outline care plans and definitions will come from the NANDA International website.
So now that we’ve talked about what critical thinking practically looks like, let’s chat a little bit about care plans. Going through nursing school, I felt like care plans were the least straightforward aspect of school. It took a long time for me to really feel like I kind of knew what I was doing… and I still wasn’t even sure if I got it.
Care plans are exactly what they sound like: they are a basic plan behind the care you’re going to provide.
What the heck is NANDA, NIC and NOC?
NANDA used to stand for the North American Diagnosis Association until 2002. They are now just officially known as NANDA International (or NANDA-I) because they grew quite a bit and are not limited to North America. They have basically created a standardized list of nursing diagnoses. It’s important that everyone, regardless of facility, is using the same terminology when referring to these kinds of things.
NIC stands for Nursing Intervention Classification. It’s the same concept as NANDA-I… it is a standardized list of nursing interventions.
NOC stands for the Nurse Outcomes Classification. It is a standardized list of nursing outcomes.
So to review.. NANDA-I is for diagnoses, NIC is for intervention, NOC is for outcomes.
It’s extremely helpful to have this massive, research-based, agreed-upon terminology. So if you’re working in New Jersey, you’re using the same terminology as the nurses in Hawaii. This is helpful for staff as well as patients.
There are quite a few textbooks related to nursing care plans and nursing schools may require different ones. They should include the most recent NANDA-I, NIC, and NOC approved terminology. They are the foundation of the care plans. It is imperative we are speaking the same universal language.
But before we can really dig into nursing care plans though,, we need to clearly define and discuss a few frequently used terms that all of your books will refer to over and over again. If you fully understand these, it makes the whole process much clearer.
When we hear the word diagnosis, we tend to assume we know what that means. Try to suspend judgement! I say this because a nursing diagnosis and a medical diagnosis are two completely different things. The medical team will make their medical diagnosis, write their progress notes, their orders, and so forth. Independently from that, the nurse will look at the patient’s medical diagnoses and entire clinical picture and develop their nursing diagnoses. These nursing diagnoses will guide how they provide and prioritize their care.
First let’s talk about what a nursing diagnosis is…
Here is the official definition of the term nursing diagnosis from the NANDA-I website:
A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.
Here is the NRSNG translation of the term nursing diagnosis:
A nursing diagnosis is something the nurse decides is a priority for their patient after they have looked at their entire clinical picture (gathered from assessment, report, and the patient’s chart). These diagnoses will guide the nurse’s care and priorities for the patient.
So now that we are on the same page about what a general nursing diagnosis is, let’s talk about the three kinds of nursing diagnoses. They are problem-focused, health-promotion, and risk nursing diagnoses.
Let’s define each so you fully understand each term.
Please note, the following 3 examples of different nursing diagnosis came directly from the NANDA-I website and can be found here.
Here is the official definition of the term problem-focused nursing diagnosis from the NANDA-I website:
A clinical judgment concerning an undesirable human response to health conditions/life processes that exists in an individual, family, group, or community. In order to make a problem-focused diagnosis, the following must be present: defining characteristics (manifestations, signs, and symptoms) that cluster in patterns of related cues or inferences. Related factors (etiological factors) that are related to, contribute to, or antecedent to the diagnostic focus are also required.
Here is the NRSNG translation of the term problem-focused nursing diagnosis:
A nursing diagnosis that is focused on a problem the nurse identifies after considering the entire clinical picture. Defining characteristics and related factors must be present.
“I see __________ problem (diagnosis) and things that are related to the problem are ______________ (related factors), and I know this problem exists because I’ve observed/measured ____________ (defining characteristics).”
“Anxiety related to situational crises and stress (related factors) as evidenced by restlessness, insomnia, anguish and anorexia (defining characteristics).”
HEALTH PROMOTION NURSING DIAGNOSIS
Here is the official definition of the term health promotion nursing diagnosis from the NANDA website:
A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community. In order to make a health-promotion diagnosis, the following must be present: defining characteristics which begin with the phrase, “Expresses desire to enhance…”.
Here is the NRSNG translation of the term health promotion nursing diagnosis:
This diagnosis focuses on optimizing and promoting the health for that patient. We know this is an appropriate diagnosis because the patient has expressed desire from the patient to improve their health. Defining characteristics must be included.
“This patient is ready to learn more about _________ because they told me they were.”
“Readiness for enhanced self-care as evidenced by expressed desire to enhance self-care.”
RISK NURSING DIAGNOSIS
Here is the official definition of the term risk nursing diagnosis from the NANDA website:
A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. In order to make a risk-focused diagnosis, the following must be present: supported by risk factors that contribute to increased vulnerability.
Here is the NRSNG translation of the term risk nursing diagnosis:
A nursing diagnosis that expresses something the patient is at risk for. Risk factors must be included.
“This patient is at risk for __________ and I know this because of ___________ factors.”
“Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors).”
A FEW MORE IMPORTANT TERMS…
Risk factors: something that would increase the likelihood of something else. These are only in risk diagnoses.
Related factors: something that is related to the nursing diagnosis. Examples of how you may state risk factors in your diagnosis can include “associated with, related to, contributing to,” or other. These must be included focused diagnoses and can be included in health-promotion diagnoses, but are not required.
Defining characteristics: things you can witness yourself or measure that are related to your diagnosis. You observe defining characteristics with your 5 senses (just hopefully not taste..)
Patient goals: what you hope your patient to achieve.. It should be measureable and centered around the patient, specific, and have specified timeline, if applicable.
“Patient will report pain of 4/10 within 60 minutes of medication administration and repositioning”
Interventions (with rationales): what you’re going to do try and achieve your goals and why
Pain medication administration, reposition, pillow support to increase comfort and decrease pain level
Use direct verbiage.. “I will _______” / “patient will _______”
Implementation: did you do this, yes or no?
This may seem like an odd thing to include… but sometimes, you’re not able to complete the interventions you wanted to for a variety of reasons. While you had a goal with specific interventions identified, maybe the patient declined or was discharged or was at a procedure so you could not implement your interventions. That’s why they want you to say whether or not you intervened. Saying you did not does not may you a bad nurse, unless the only reason you did not intervene was because you didn’t feel like it.
Note why something didn’t occur in the evaluation section
Outcome: what happened?
“Patient reported pain scale of 6/10 in 60 minutes of intervention
Let me walk you through how this realistically works…
You are getting report on your patient.
(Please note, this is not full report, rather specific information from report)
Your patient has had a massive stroke and cannot move the left side of his body and doesn’t have the best control with the right side. PT tried to get him up yesterday and he just couldn’t handle it. He has a history of chronic back pain and has had a pretty consistent headache since the stroke. He’s somewhat impulsive and he’s set the bed alarm off a few times. He doesn’t eat much. It’s hard to tell if it’s because he hates his pureed food, if he has no appetite, or if he’s purposefully refusing intake.
So when I hear that in report, I start identifying problems and nursing interventions for him during my shift and some goals to evaluate whether or not my interventions were successful.
He’s had a massive stroke and cannot move the left side of his body and doesn’t have the best control with the right side = risk for skin breakdown (PROBLEM) .. I’ve got to make sure I am on top of turning him at least every 2 hours with lots of pillow support, thoroughly assessing his skin, and making sure he’s got adequate nutrition. (INTERVENTIONS)
Massive stroke + PT tried to get him up yesterday and he just couldn’t handle it + He’s somewhat impulsive and he’s set the bed alarm off a few times = he’s a high fall risk … I’ve got to make sure I’ve got all of my fall interventions in place. That means he’s wearing non-skid socks when he’s up, the bed alarm is on, if possible I’ve got him in a room near the nurse’s station, increase the frequency of my rounds, I reorient him if he becomes disoriented, I make sure the call bell is within reach, and evaluate if I really need any meds that may decrease his alertness.
He doesn’t eat much. It’s hard to tell if it’s because he hates his pureed food, if he has no appetite, or if he’s purposefully refusing intake = he’s at risk for inadequate nutrition (if a patient isn’t getting proper nutrition, it’s pretty difficult for the body to heal). I’ll make sure to get any food preferences that he might have, encourage oral intake, try to figure out why he’s not eating, make sure the food is warm and he consumes it promptly after arrival, and work with the dietician to see if any dietary supplements are necessary/appropriate.
When I get towards the end of my shift, I start to evaluate if my care plan was effective… if my problems and interventions were appropriate and/or successful.
Care plans are something you decide upon at the beginning of the day and implement throughout your shift. Towards the end of your day, you document what they were and if they were progressing or not. You resolve goals that were achieved that are no longer applicable, initiate new ones if needed, and chart on existing ones that are still applicable.
I put this thought process in a chart below. What used to be this vague process in school is now second nature to me now that I do this every single shift. This is basically my thought process, not necessarily what I would document.
How to evaluate
At risk for skin breakdown
Promote adequate nutrition
No skin breakdown
Was there any skin breakdown during my shift? Y/N?
Assess any mental or physical obstacles to adequate intake
Ensure food is as appealing as possible
Work with dietician regarding supplements
Patient consumes 50% of all meals
Initiate dietary supplement (if deemed medically appropriate by dietician and physician)
Did patient consume 50% of meals? Y/N
Was dietary supplement appropriate? Y/N?
If so, was it initiated and consumed? Y/N?
To summarize… I listen to report, check the chart, and assess my patient. Between those actions, I decide what kind of problems exist, what goals I have for the patient, and which nursing interventions would best help me achieve these goals for my patient. Throughout the shift, I implement my nursing interventions and afterwards I will evaluate whether or not we’re progressing towards the goals or if we’re not progressing.
So when you’re creating your care plans for clinical or courses, you’re basically doing the above process in a very specific format with very specific verbiage.
“This now seems straightforward.. but why is this still so difficult for me to understand?”
This is difficult for nursing students because you haven’t seen a ton of patients yet.
If you’ve never cared for patient with heart failure before, it’s hard to pick out the specific nursing diagnoses that would be appropriate for them… as well as the subsequent interventions, goals, and how to evaluate.
So if you’re not experienced with providing nursing care (and you shouldn’t be since you’re a nursing student!) … you don’t know the typical nursing diagnoses, interventions, normal responses, and normal expectations for said interventions. That’s why when you’re opening your care plan book, it looks like a foreign language. That’s why it’s hard to put these pieces together. Learning how to hear about what’s going on with a patient, meeting them, assessing them, and reading their chart and then quickly deciding how you’re going to plan your care for the day takes practice. It’s not something you can study for a few days, take an exam, and know how to do perfectly.
You’re learning in nursing school… and it takes a little while to learn how to develop this skill.
When I think back about my mental thought process during school,, I felt like it was a big performance. Every clinical, every class, every interaction was to show how much I knew… but when I look back, that’s not at all what it is or should be. It’s a time to learn how to do this stuff, not be perfect immediately.
(Sorry if that’s an obvious thing but I’m one of those who always asks “stupid” questions and needs the obvious explained to me kinda person!)
I highly advocate not waiting until the last minute to turn care plans in. They are tough to understand and it may take going to your professor’s office hours and really sitting down and talking through them to understand it.
I say all that to say – don’t think you’re stupid if this doesn’t make sense to you immediately. Please don’t become discouraged and think nursing isn’t for you if this doesn’t click after the first explanation. This takes time because there are a lot of things to think about and consider while forming these care plans.
I also recommend not looking at care plan assignments as something where you’ll get a perfect grade the first time and every time after that. I was pretty hard on myself when I’d miss little things here and there with care plans. Looking back, I really should not have been. There is a natural learning curve so expecting to pick it up immediately and never miss a point is somewhat unrealistic.
Creating a good nursing care plan isn’t just something you do quickly so you can check off you’ve done it. It truly takes time to learn how to do it correctly, which means you’re probably not going to get it right the first few times around.
Care Plans + Critical Thinking = Optimal Patient Care
When you decide upon your nursing diagnosis and start to prioritize your care by having these goals in mind. It orders your steps, in a way. You really have goals in mind to help the patient progress to discharge, rather than just getting them to the next shift.
That is the key,
The goal is for the patient to progress, not for you to complete your shift.
Just because your meds were passed, your patients were assessed and charted on and the medical team rounded, ordered new things and you implemented them doesn’t mean you provided good nursing care.
Imagine you are married to the love of your life… Alex. Oh, Alex. You’re always there. You’re the yin to my yang. The X to my Y. The Pam to my Jim. The chicken to my waffles.
Now imagine they broke their femur in a bicycling accident, had urgent surgery, and are now on an orthopedic floor. . .
(Kinda harsh, I know but bear with me..)
You’ve got Nurse A that walks in, gets report, looks at the chart and gets to work. They pass their meds on time. Give Alex IV pain meds whenever they want… draw labs when they’re ordered… help Alex to the bathroom when they ask…. Although Alex spent about 80% of the day in bed because the pain meds made them really sleepy. Nurse A answers questions when asked, but they don’t really explain anything. At the end of the day, they give the next shift report and they leave.
At the end of the day, Alex still needs pain meds frequently, felt groggy all day, barely got up, and didn’t eat much. He/she needs a decent amount of help getting up and sitting down whenever using the restroom and hasn’t seemed to improve a whole lot.
Dr. Smith, who operated on Alex right upon admission, rounded towards the end of the day, while Alex was sleeping. She wrote the following in her progress note: “Transition to oral pain meds, increase ambulation, discharge in next 72 hours.”
Successful shift… right? Everything was technically done/completed on time… doesn’t that mean they did a good job…?
You’ve got Nurse B who walks in, gets report, looks at the chart and gets to work. After report, Nurse B decides pain management, promoting mobility, and preventing skin breakdown are going to be important today to get your BFF home and doing better ASAP. Nurse B looks closely at all of the orders (meds and nursing intervention orders) to make sure to prioritize this stuff today.
Nurse B starts out the day by letting you and Alex know the plan for the day… “We’re going to try to transition from IV to oral pain meds for better, longer relief. It’s really important to get out of bed as much as possible today so we’ll get at least 2 walks in, but hopefully 3. I also want you out of bed for each meal. And we really want to make sure you’re not sitting on your butt all day because you skin can start to break down, so if you decide to sleep, let’s get some pillows and prop you up on your side, if that’s comfortable.”
Nurse B gave oral pain meds with the rest of Alex’s meds at the beginning of the shift. Nurse B made sure to get Alex up for all 3 meals and walked with him/her twice. When Alex said he wanted to take a nap during the afternoon, Nurse B came in and got him positioned up on his side. He/she slept like a rock for an hour and a half.
Dr. Smith, who operated on Alex right upon admission, rounded towards the end of the day, while Alex was up in the chair and eating dinner. She wrote the following in her progress note: “Continue current plan, discharge tomorrow.”
At the end of the shift, Alex had not needed another dose of IV pain meds despite all of the increased mobility. He/she walked twice, was up to the chair for all of the meals. Getting up the first few times was tough, but it got easier as the day progressed. By the end of the day, Alex was basically walking himself/herself to the bathroom with just the assistance of a walker and someone near by just in case.
So, which nurse had a more productive and successful shift?
They both passed their meds on time… Responded to call lights and needs verbalizing by the patient. So, all is well.. Right?
Nurse A got the tasks done for the shift, but didn’t have a plan. Nurse A did not have discharge in mind. Nurse A just wanted to get to the end of the shift. Nurse A was passive.
Nurse B had a plan. Nurse B had a care plan.
Nurse B thought about the needs of a patient with a fractured femur and prioritized care for the day. Nurse B communicated. Nurse B made sure their patient progressed towards discharge.
So, which nurse do you want caring for your loved one? Your BFF? The chicken to your waffle?
Adding Critical Thinking Back In
So imagine the above situation with Alex, but something goes wrong. Alex starts to get a fever… or gets tachycardic.. Or has sudden increasing pain uncontrollable by previous doses of pain meds…
You will use critical thinking to figure out what’s going on and the best way to address it. You’ll step back, look at the clinical picture and think. Critically, of course.
(Gosh I am on a ROLL people!)
You also use critical thinking to develop your care plan in the first place. Critical thinking enables you to figure out what’s important for this patient … why it’s important … why it’s important … how to get it done … and enables you to look at how it went at the end of the day and where the next shift needs to pick up where you left off.
Yes, This Stuff is An important Part of Being a Safe Nurse – We Promise!
I promise this is all not only important, but will be information you will you use every shift. You know how you’re sitting in class and you think, “Will I really need to know this to get through my shifts?”
Absolutely and unequivocally yes.
Real Life Critical Thinking + Nursing Care Plan Examples
Ok, let’s go through some examples of scenarios that require both critical thinking and care plan implementation!
Example 1: Falling Over You
Your patient is detoxing from alcohol. She has a really unsteady gait when they get up, weak, and have intermittent confusion. You don’t feel comfortable leaving her just sitting in the bed because if she gets up on their own, you think she may fall. You want to do all you can to prevent her from falling.. She is quite frail and you’re pretty sure she’ll break a bone if she hits the deck… So you try to think of all the little things you can do…
Critical thinking: So you make sure the bed alarm is set before you walk out of the room each time, whenever she does get up you make her put on those non-skid socks (even though she hates them), she’s in a room close to the nurse’s station, you always make sure her call bell is within reach, and you make sure to check on her a little more frequently than you technically need to just to ask if she needs to go to the bathroom or anything to drink or eat to prevent her from just getting up on her own.
Nursing diagnosis: high risk for falls related to cessation of alcohol intake as evidenced by unsteady gait, confusion, and weakness.
Patient goals: patient will remain free from falls, patient will remain free from injury, patient will utilize call bell prior to getting out of bed
Interventions: bed alarm on at all times, patient will wear non-skid socks when out of bed, ensure patient is in room close to nurse’s station, increase frequency of rounds,
Implementation: did you do your interventions.. Yes or no?
Evaluation: ⅔ goals achieved (patient did not fall and did not suffer injury), patient did not consistently use call bell despite it being in reach throughout shift. Will remind patient to use as well as reorient. All other interventions successfully implemented and helped to achieve goals.
Example 2: Dry Time
Your patient is has hyperemesis gravidarum and is dehydrated from having severe nausea and vomiting the last 3 months. When you did her assessment, she told you her mouth was really dry, as was her skin when you took her socks off to check her pedal pulses. You start to think about why she might be dry and remember that she can’t keep any food or liquids down.
Critical thinking: You decide to ask her to see if the antinausea meds are working and if the timing of them works out with her meals. You ask her if she enjoys the taste of the various oral liquids she has and if there’s anything different you can try to get her to increase consumption. You notice she has normal saline infusion at 50 ml/hr but decide to touch base with the medical team to see if it would be appropriate to increase that rate until her dry mouth/skin start to improve and she keeps more liquid down.
Nursing diagnosis: fluid volume deficit related to nausea and vomiting as evidenced by dry mucous membranes and skin, minimal oral intake.
Patient goals: patient will consume 50% of each meal, patient will report that antinausea medication regimen is effective, patient will report improvement or resolution of dry mouth
Interventions: Will assess and optimize antinausea medication schedule and time appropriately with meals, will identify 3 liquids and 3 foods the patient verbalizes do not increase nausea and order them from kitchen, discuss increasing intravenous hydration with medical team
Implementation: Zofran was given every 6 hours, Phenergan every 6 hours on an alternating schedule so that patient was receiving medication approximately every 3 hours; meds given approximately 1 hour before meal times to ensure they were at their peak when meals were hot. Three foods and liquids identified; our kitchen did not carry the brand of ginger ale she requested; spoke with partner who will bring it tonight after he gets off work. Discussed IVF with medical team.
Evaluation: Patient reported that administering the antinausea meds before nausea and vomiting became severe was much more effective; she consumed 50% of lunch and breakfast and 75% of dinner. Patient reported that having the specific foods available when meds were at their peak was also effective and increased consumption. Medical team increased ordered IVF to 100 ml/hr at approximately 1300. By shift change, patient reported her dry mouth was beginning to resolve.
Example 3: He’s Gotta Go
Your patient had back surgery 1 week ago. Prior to surgery, he was taking narcotics long-term for pain control and was being seen at a pain management clinic. Your patient has not had a bowel movement since 4 days preoperative. It has been 11 days since his last bowel movement. Post-operatively, he was on a Hydromorphone PCA for 4 days and transitioned to oral pain medications. He is taking 10 mg oxycodone every 6 hours. In report, he said he feels really constipated. He said he has only passed gas a 1-2 times a day since surgery. When you did your assessment, you noted hypoactive bowel sounds. When you looked at his chart, you noted that he was not started on a stool softener or any bowel regimen post-op.
You decide this guy needs to poop! Like, yesterday!
Critical thinking: You decide you probably should talk to the medical team about getting some meds to get his bowels going. You also noticed that he hasn’t been getting up much either. He’s been getting the same amount pain meds around the clock and wonder if he gets up and moves around regularly if he’ll need this many..or if you can mix in a Tylenol instead of so much oxycodone.
Nursing diagnosis: Constipation related to medication regimen, back surgery, and inactivity as evidenced by hypoactive bowel sounds, lack of bowel movements, decreased flatulence, and reported feelings of constipation.
Patient goals: Patient will have a bowel movement, patient will be started on a bowel regimen, patient will report increase of flatulence, patient will get out of bed for all meals and walk twice today.
Interventions: Discuss implementation of a bowel regimen and changes to pain medication schedule with medical team, get patient to chair for all 3 meals, patient will walk twice in hallway.
Evaluation: Medical team ordered 25 mg oral Dulcolax and decreased frequency of oxycodone to every 8 hours and to give 650 mg Tylenol between doses. Scheduled stool softeners were also ordered. Patient was up to the chair for breakfast and dinner and walked once with PT. Patient verbalized that he will be up for all meals and walk twice tomorrow. Patient reported increased of frequency of flatulence. Patient had large, dry, brown bowel movement after digital disimpaction.
Honestly, once you’ve got your job and are off orientation and really feel like you know what you’re doing, you’ll be creating and implementing care plans and critically thinking without even realizing it.
You’ll be helping your colleagues work through critical thinking with their patients. You’ll be critically thinking with physicians.
You’ll learn from experiences and continue to get better and faster at developing care plans critical thinking as you progress in your career.
Welcome to the NRSNG.com Podcast. This is John Haws, RN, CCRN. Today we are talking critical thinking and care plans. Wait, before you turn off this podcast and run away because you hate those two words I want you to give this one a listen. I want you to sit back, I want you to listen to this one.
We’re talking with Katie Cleaver, RN, CCRN with NRSNG.com and Nurseeyeroll.com and we’re talking about what exactly is critical thinking? What are nursing care plans and how to make the two coalesce into one? How to make the two really work for you, and how to have them really make sense. You guys, we have an awesome post about this. It’s about 5,000 words. We have a ton of resources there. Videos, downloads, everything you need to get care plans and critical thinking really working because once you listen to this, you’re going to realize how the two really roll into one. That post is over at NRSNG.com/critical thinking. That’s NRSNG.com/criticalthinking.
I also want to tell you guys there’s actually a thunderstorm going on outside right now while me and Katie are talking on the phone so during the episode you might hear some thunder and a little bit of interruption with that. I apologize you guys for that. I hope it doesn’t get into the way too much, but I really appreciate you guys listening to the show.
Thank you so much for being a part of this NRSNG community. Head over to NRSNG.com/criticalthinking. You guys, this one’s going to blow you away. This whole post you really need to take a minute to head over there, read that entire post when you have some time, take some notes, print the downloads, and watch the videos. It’s really going to help you guys. Without further ado, let’s roll into the episode.
All right. Today we have a really good episode. I’m talking today with Katie Cleaver and we’re going to be talking about critical thinking. I know it’s almost a four-letter word in a nursing school and I remember as a nursing student how annoyed I would get every time an instructor said critical thinking because I feel like it was just left at that. It’s like, You’ve got to critically think as a nurse.” “Okay. I feel like I have a pretty decent brain in my head. Tell me what that means. Why am I not? What am I missing? What’s going on here?”
Today we’re going to talk with Katie. She’s put a lot of research in the last couple weeks into exactly what this means and deconstructing critical thinking and how it applies to nursing specifically so that we could give you guys something better than just saying, “You need to critically think,” or “Make sure you’re critically thinking,” or “It’s really important with nursing.”
What she’s done is she’s really broken it down and she’s going to lay it out for you guys on the NRSNG blog in a series of I think 8 blog posts, several videos, several podcasts just to make sure you guys understand what critically thinking really is. What she uncovered is something really interesting. We’re going to talk about that later is how critically thinking really applies to the other four-letter word in nursing school which is care plans.
Katie, tell us what is critical thinking and what did you discover when doing this?
First of all, I just have to say how much I love that they’re both four-letter words because I felt the same way in nursing school. That critical thinking is the word that they say when they don’t know what to say. The care plans I felt like it was, “This is a task that is just so not straightforward,” and they’re coming up with things that I don’t even know where they’re coming …. I don’t know.
Did you ever get your care plans back and be like, “What?”
WTF. What? Yes, I did because I would spend forever on it, and then turn it in, think it’s great, and then red marks everywhere.
Yeah. “I don’t even know what you’re saying.”
Yeah. You know what I realized especially in nursing school … Not really in nursing school. I didn’t realize this in nursing school, but care plans are not like if you think about some of your other stuff you study for in nursing school, it’s straightforward. I study this and it has this answer.
Even all your other courses, you memorize things and you learn concepts, but creating a care plan is like pulling from every little thing that you know to make this plan for the patient. When you haven’t seen a ton of patients, it is incredibly difficult to do that. It’s not one of those tasks that it takes you 20 minutes and you check it off or even like a paper. I know essays and research papers it takes time and you have to write stuff out, but even that is a lot more straightforward than a care plan.
You have to think critically about what makes the most sense for this patient. One of the things I learned was you do have the two things. You have the critical thinking, which is, “Hey, I notice a problem, and I’m going to think about my nursing knowledge of what the best way to address this problem and consider all things about the clinical picture and what I can do as a nurse before calling the physician and involving others. What can I do? Thinking critically, work through this issue to get the best case scenario for the patient or deal with this.” Then adding that piece with care plans.
There’s a bit of overlap definitely that I noticed that I didn’t realize until I was really researching both of them. When you think about care plans it’s like, “Okay. I have my patient that has this medical diagnosis. I’m not a physician and I couldn’t make the medical diagnosis, but what’s a really important aspect of their recovery and them getting out of the hospital and their discharge plan is me looking at their medical diagnosis. Their issues going on with them, and what are some big priorities for this patient that we have to progress through to get them out of the hospital?”
It takes critical thinking to really figure that stuff out and the best way to address those issues. I realized that care plans and critical thinking is really an aspect of being a successful nurse. Working as a nurse for a while, you work with those nurses that are just trying to get through their shift. They don’t care about getting the patient up to walk even though the doctor wants them to. They don’t care about weaning them off their iv pain meds or meeting goals. They’re just trying to get through the shift.
Technically they got all their meds passed out, they answered questions, but they didn’t progress the patient. You have to have a plan and ways to progress the patient to getting out of the hospital sooner. The way you do that is with a care plan. The way that you come up with a care plan is you think critically.
Absolutely. One thing that you and I have talked about, Katie, as we’ve been talking about this subject is that when you have more time working on the floor and working with the patients, you walk into a patient’s room and within two minutes you know everything that you’re going to do. It’s at that point too that we start to really laugh about how instructors made us do care plans, they’re so pointless, but I think that what we miss is that we’ve actually crossed that line of care plans just come naturally to us at that point.
What is this process? How does somebody get to that point of their critical thinking just flows into planning care and it just happens like that?
Well, it’s something that I think that you have to pay attention to these things. You have a patient that had a hip surgery and, okay, you’re learning in report about your patient or maybe you’re learning the night before because you’re going into clinical the next day. Well, what is going to be really important? Let’s stop and think instead of just go to our medications and go to this, and go to that, let’s stop and think. Just casually, “Hey, hold on. My patient, they broke their hip. You know what? It’s going to be really important that they do not fall because that can mess up their hip replacement or if they had a surgery or whatever. So I’ve got to try to figure out what I can do to keep this guy from falling.”
I think what people get tripped up on is the terminology. One thing I realize is it’s important to have this standardized terminology because I went to a nursing school in Iowa. I practiced in Illinois and in North Carolina. It’s all the same terminology, which is wonderful, but I think in nursing school you get so tripped up on giving it the right words and having it sound perfect, but I think what really can help nursing students understand this more is get your care plan template. A lot of nursing schools I think have their own, but write it out but don’t worry about the words.
“Okay, I don’t want him to fall, so no falls.” Try to just not worry about how fancy it sounds. It’s just, “Okay, I want to prevent this guy from falling. Okay. Breaking your hip hurts. He’s probably going to have some pain.” Just trying to think about it in a way that you’re not getting tripped up about the specific terminology because I think that’s the big hangup and if you can first get to the point where you can identify the issues without necessarily having to use that specific terminology then go back and say, “Okay, so he’s got a bunch of pain, so I think that would probably be a good thing to focus on. All right, so let me go back to my NANDA International book and … Okay, acute pain related to hip fracture as evidenced by self-report of pain, grimacing when walking …” those kind of things. I feel like if you work that way, it helps that come together because I think a lot of this stuff is just common sense, but we don’t realize common sense isn’t common.
You don’t realize you’re doing it. When we get out as nurses, we hate writing our care plans at the end of the shift, but we’ve been doing it the whole shift. Some people still struggle with getting the right words that they need to put in there, but it doesn’t mean they’re not doing it and that’s the challenge is trying. I think think that’s the best way to approach it in nursing school. Think about the patient, but don’t freak out about getting the right words right away.
Think about realistically what is going on and then think about your priority diagnoses or what are the three or four big issues going on with this patient? what does that have to do with it? They’ve got pain, but why do they have pain? ‘He’s a high fall risk, but why is he a high fall risk?” That’s your related-to factor. What are you seeing that is telling you this? Your as evidenced by. “All right. I know he’s in pain because the guy just told me he was. Patient reported pain.”
Those kinds of things if you can try and break it up like that I think it makes it flow a lot smoother, but it is important I think for students to know that it shouldn’t be easy. You haven’t seen a lot of patients. This should be challenging and something that you can’t check off right away because you really have to see a lot of patients, understand, “Hey, I’ve seen a bunch of guys that have had hip fractures. They’re really unsteady on their feet and they really have a lot of pain. They have maybe constipation, or they have anxiety, or whatever.” A realistic expectation of what their normal interventions would be. You’ve got to see a decent amount of those kind of patients before you can get this amazing plan together.
Sure. Your first recommendation is forget about NANDA, forget about NIC, forget about NOT and just go to common sense. Go to even though I don’t have a lot of experience with a hip fracture patient, what would this patient be going through? The pain, or the impaired skin integrity, or risk for impair. Those are the things that you just need to start thinking about first.
You say, “Okay, what would this patient naturally be going through?” Then from there you’re saying, “Can I work backwards? Okay, well how can I prevent that pain? How can I reduce that pain? How can I prevent skin integrity issues?” Then from you just start filling in those blanks. That’s what I would do. “What am I going to do during my shift to do that? What do I hope happens because of that?” Once you’ve done that, you can fill in the boxes on the care plan.
Absolutely. One thing I’ve noticed too just working as a nurse but then looking back at care planning stuff, there’s a few pretty standard common ones that’ll apply to those patients and I’m sure you’ll agree the high fall risk, the skin integrity, fluid imbalance, pain. Those are some big ones that I would argue most patients that are in the hospital are having an issue with some of those so I think it’d be good to familiarize yourself with those.
The ones that are the heavy hitters that it’s like, “Oh yeah, most patients in the hospital are fall risks because maybe they had an injury. Maybe they were confused, and if you get familiar with the interventions. I’m sure you could too name off all the fall risk ones. That was one thing I did not have to look up when I was writing these articles. “Non-skid socks, increase [inaudible 14:10], have a room by the nurse’s station, bed alarm on, call light within reach.” I remember that because all the neuro ICU patients are fall risks. I would really recommend getting familiarized with those very common ones.
Yeah, for sure. To try to help students, let’s talk about maybe what you, as an experienced nurse, would do. Let’s say you walk into a patient’s room who has heart failure. That’s all you know at this point. You walk into the patient’s room who has heart failure. Walk us through your critical thinking and then how that’s going to apply to the nursing care plan.
Katie hasn’t practiced this before. I’m throwing it at her right now. You walk into a heart failure room. Walk us through how this is going to go. Rather than just being that nursing student deer in the headlights, it’s a blank patient. Now you with several years experience, you’re walking in there with all this background information. What does the critical thinking and care plan process look like for you?
What I would normally do if I know this patient is a heart failure patient, it’s really important to know that diagnosis and then one of the things that nurses do is you think of your care plan after you have the pieces in front of you of the puzzle. You go in the room and you do an assessment. You look at your chart and this is after you’ve gotten a report, so you have all these little indicators. It’s like, “Hey, create a care plan for blank patient.”
It’s really important that, before you jump into that, do your assessment first. Talk tot he patient first. Those kinds of things are really important to make sure that you’re doing. That’s what I would do. “Okay, I got a report from John. Let’s see he’s a heart failure patient that …” What do I want to say about him report-wise? That is on a bumex drip and maybe he’s in the ICU or something like that, and has a history of afib. Those kinds of things. I’ll go in the room. I really think if someone has heart failure, they’re probably going to not have great fluid balance.
They have heart failure and what I know about the pathophysiologic about heart failure is there’s too much fluid. I’m going to look at my nursing diagnosis book and I’m going to look at my different diagnoses that have to do with fluid. I’m pretty sure there is one there that is fluid volume overload. I’m pretty sure there’s one. That would probably be my priority nursing diagnosis because the biggest deal, whether I do all the other stuff and the reason this guy’s in the hospital is heart failure, if we can work with whatever the physician has ordered to progress this guy with his heart failure to get him out of the hospital, that’s the biggest impact I’m going to make.
I would probably go with “Fluid volume overload related to heart failure as evidenced by,” and then I would go do my assessment. He probably has abnormal lung sounds. He’d probably have edema. His INOs wouldn’t be equal. He’d probably have 18:00] however many liters. That would be my big one. I would really focus on that and what kind of interventions can I do to make sure that I’m addressing those issues? Make sure I’m giving his meds appropriately. I’m maybe restricting his fluids and educating him appropriately. Those kinds of things.
Evaluating, “Did I do these things or not?” I’m sorry, implementation. “Did I do these things or not?” Then evaluation. “How did it go? Was it really ought to keep this guy restricted on fluids?” Maybe one of my interventions is going to be ambulating frequently to the bathroom to go empty his bladder as frequently as possible if he doesn’t have a Foley catheter or something like that. Those kinds of things.
That’s how I would. It’s really, “Okay, what is the diagnosis? What are some big issues that have to go with that diagnosis?” It’s not easy. You’re going to have to hold onto your pathophysiology knowledge. Your med surge course knowledge. Maybe pulling out those kinds of books and looking at that disease process and what kind of things go along with that.
Like you said in the beginning, I think what makes care plans so frustrating as a student is, you have a very minimal knowledge of heart failure and you’ve maybe only taken care of two patients. Never for a full 12 hour shift and so you don’t even see “What’s the bumex drip going to even do? What’s the end result of that? Why am I restricting? He says he’s really thirsty. Shouldn’t I give him some water?” You don’t see the full course of this stuff and so it’s okay to be frustrated by these care plans.
It’s okay to be really agitated by them because the knowledge that you have at this point is very limited and then your full scope of being able to see everything is very limited in Katie’s situation and why this transition you have to when critical thinking just starts happening naturally. That doesn’t happen because you learn how to think better. It happens because you have a better base knowledge and you start to understand more.
You see that heart failure patient from day one to the day they’re released and so you really start to see this whole picture. I think this critical thinking goes with these care plans so much because it’s getting that full picture together. I’m not just doing some things for some random patient. I’m doing specific things for a heart failure patient that has presented with all those symptoms.
Yeah. One think I compare this to is think about a medical student going through learning how to become a doctor and when they’re trying to figure out, “How am I going to maybe diagnose this patient?” At the beginning it’s really challenging because they haven’t seen a ton of heart failure patients. They haven’t seen a ton of patients with a stroke, or an MI, fractured femur or something. Although that one’s straightforward. It takes a while to look at all the diagnostics, look at the full clinical picture, and then get to this conclusion.
It’s really looking at this big picture and pulling apart the important things and it takes experience to figure out what those important things are. Of course it’s expected at the beginning that this is going to take time and that learning curve is there because you haven’t seen all these patients. I think it’s really important that students know because for me I didn’t know that. I didn’t know.
I thought that it was one of those things like, “You should get this right away. Why don’t you get this?” There was maybe one or two in the classroom that could pick stuff out a little bit easier, but other than that, we all were pretty much struggling with care plans, so I just want to reassure people that that’s the normal progression. It’s going to take some time to get good at this and it’s not a, “Here, do this assignment, and complete it, and then that’s it. Do you know what I mean?
Absolutely. I think that the post that you wrote on this and the subsequent posts are going to be huge helps and then also the care plan template that if they go to this post, read his post. Use that template, and really use the advice that you’re giving them here, it’s not going to happen overnight, but this is going to be a tremendous help. With the way that all this information’s been put together in this post and everything, it’s really going to give them the resource that’s need to make sure you’re on the right path. That you’re not like me and Katie years ago where you get a care plan back and it’s like, “I don’t even know why that’s wrong.” You’ll know where you’re going.
That was my biggest frustration was I would write my care plan, and then it would be really hard for me to come up with my care plan, and then I’d talk to my instructor and they’d be like, “Oh, this, this, this.” It’s like, “How did you come up with that?” I feel like that’s this random thing for you to pull out of it, but you realize that stuff after experience. Right now it doesn’t seem obvious, but eventually it will be. Those are encouragement that if you’re frustrated, that’s okay and that’s normal.
I guess one other thing I’d say too is that you’re not even going to notice it happening. You really won’t because we honestly had to go back and think about care plans in nursing school to be able to figure out how to put this information into a post and a podcast because it just happens. When you, Susan, and I all got together, we were like, “We should teach people about care plans,” and we all said, “We don’t even use care plans anymore,” and we’re like, “Wait, no, we do, we just don’t even realize it.” The thinking is all there.
It’s happening systematically, exactly like those boxes appear on a care plan, but it just happened
You just transition to that.
The care plan, we do it so fluidly you don’t even think about it when you go back to the care plan because that was always that frustrating thing with work. I’m doing this work all day and I have to go back and have to turn in my care plan. It’s frustrating because it’s challenging still sometimes to put into words. The right words, the fancy words, the stuff that I just do automatically because I know how to take good care of this patient and what my goals should be because I’ve had experience at this point. I know what I need to do for my stroke patients, my seizure patients, my cabbage patients. I know what the normal post-op progression is because I’ve had experience with it. Now I have to go back and put in the work. That’s the frustrating thing, but it takes time.
Sure. I think one last thing I would leave with people too is in this post you talk about two different nurses on the same shift. One nurse that gives their meds on time, does what they’re supposed to do, makes sure the patient gets their meal, charts, leaves on time. Then the other nurse who listens to the patient, responds to the patient’s needs, realizes, “Okay, the patient’s sill on iv morphine, but they’re supposed to go home tomorrow. We need to start transitioning to norco and having that discussion with the patient, with the physician. It takes them a little longer to get things done and they leave a few minutes late. Which nurse really had the more successful shift? I don’t know if you want to talk about that for just a minute.
Yeah. When you think about that, who do you want taking care of your loved one? When, you’re learning how to be a nurse, you can technically have a shift where you got everything done, but did you really provide excellent care to that patient where they’re progressing, where they can go home sooner? I don’t think nursing students, and I know I didn’t, realize how big of an impact the proactive nurse has on patient stays. If you have proactive nurses, they significantly can reduce patient stays. How many times have you gotten a report where it’s like, “Why didn’t somebody address this three days ago?”
Even something as simple as, “Last bm was last Thursday.” That’s a small thing, but that’s, “Are they on [inaudible 26:24]?” “I don’t know.” Should we check on that?
Right. You’ll run into nurses and they’ll just do what they’re supposed to but they’re not looking at all of the orders. They’re not looking at the big picture. They’re not having a plan behind their shift. That’s the thing. That’s the difference. That’s why care plans are important because it truly is your plan of attack, your plan for the shift of how are you going to progress that patient. Like that heart failure patient, it gives you that priority. When they say priority nursing diagnosis, it’s not just, “Okay, this is the most important.” It’s like, “No, it really is [for that guy 27:01].
That’s what really needs to happen today.
Let’s say that’s your grandpa. That’s your dad. He’s got a priority. That should be the priority to the nurse and while they might have gotten their Colace late, their fluids weren’t restricted like they were supposed to be. I think that’s the really important thing to see is that while they’re frustrating doing these care plans, if you take this seriously and understand that you have to have a plan behind the care that you provide in a 12 hour shift, that you can make this huge impact on this patient’s stay.
I think a lot of people go into it thinking, “Well, that’s the doctor’s job. They should tell me what to do,” and it’s like, “Well, sometimes the nurses aren’t even looking at the order.” I work in the ICU in a critical care setting and we get patients up on ventilators. It’s like, “Oh, well they put in to get them out of bed, but they’re on a ventilator so they can’t.” Yeah they can, but it’s up to the nurse to take that initiative.
The doctor’s there for five minutes a day and they give them these orders, but it’s up to the nurse to progress the patient and that’s what the basis of these care plans and how big a of a difference that you can make and bringing it back to, “Would you want that nurse taking care of your family?”
My father-in-law was in the hospital for a stroke four years ago and I could tell there were a couple of nurses that really had that care plan mindset because they were trying to progress him, and then there were those nurses. There was a nurse that was trying to give, he said he had a mild headache, trying to give him a milligram of dilaudid. Uh, no
You need to [inaudible 28:45] that order and get him some [inaudible 28:48] or some Tylenol. That kind of stuff. Having that mind to look at the big picture and what’s important because you have the power to do that because you are the nurse.
We’re trying to wrap up here, but you touched on a lot of things that I could go on for hours about. I’ll try to be as succinct as I can here. My take-away from what Katie’s saying and something I always try to say is, don’t be the nurse that just checks boxes. There’s so many boxes we have to check as a nurse and we have to check them every 15 minutes, but don’t be the nurse that’s doing their job just to check the box.
What happens, and you’ll see this a lot, is that a lot od hospitals will start to come out with new policies, new protocols, new this, new that because something happened. For those nurses that are critically thinking, that are really understanding what they’re doing, and really diving in, and learning, and trying to be the best nurse they can, you’ll find that … I don’t want to say this, those protocols are really for those nurses that just check boxes because they’re just trying to get through a shift and get out the door and so a new thing has to be added on because of they’re finding ways that these people are cutting corners.
Also I want to say that we get it, care plans are annoying. They suck, they’re hard, they’re tedious when you’re in nursing school, but I think what we’re trying to let you guys see is that learning how to incorporate these into the way that you are a nurse is going to help you be a better nurse. It’s going to help you think faster. It’s going to help you take better care of your patients, it’s going to just help you be a more well-rounded, a more holistic, a more caring nurse.
Lastly I want to say going along with not being a nurse that checks boxes and things like that, it can be very frustrating when you have given your all during your shift. You have a new add in the middle of the night who’s a trauma add. You get them intubated, you get everything done, but you forget to take the trash out before the day shift comes in and the nurse shows up and they neglect everything that you’ve done for this patient. “Well, the trash is still in there. You need to take the trash out.”
It’s like, “Are you kidding me? Forgive me for neglecting that there was a full garbage can when you can see that I have eight drips going, I have a new ventilator going, the doctor’s still in the room. We just finished CPR. Yeah, the garbage is there and it’s obviously not because I was trying to ruin your life.” Don’t just worry about those things like, “That’s the rule. You have to take the garbage out before you go home.” Don’t get so much into those things and really get that critical thinking tied into taking care of the patient and just don’t be the that nurse that’s just checking boxes. Be that nurse that actually cares.
I 8 million percent agree with hat. Absolutely. That’s the thing. When you realize what’s important and what’s important are care plans. What’s important are taking critical thinking and seeing those big pictures. Yeah there’s those little ticky-tack things which are really frustrating when you’ve done this great shift where you really notices all that important stuff and you forgot that stupid little thing and someone chews you out for it.
It’s like, “You know what? If that is what matters to this nurse, then there’s some real big learning deficits that are there,” but that’s why it’s important that you guys as nursing students learn this now and that this is the priority of us both speaking as critical care experienced nurses are saying, “Yes, these are important.” Absolutely, they’re tough but they’re worth getting used, to and getting your feet wet, and understanding. That’s where I’m at with that.
Agreed. When you guys get a minute, go to the post. It’s about 5,000 words long. There’s some downloads there. There’s some videos. Sorry, there’s a thunderstorm guys right now. It’s pretty big. Spend some time, dive into those resources, those videos, and really try to embrace this because we want everybody in our NRSNG family to be that nurse that gives a damn. That’s not just working for a paycheck because there is so many other jobs you could do that are a lot easier than a nurse.
You guys, I hope that was helpful. I hope that you can now see how much we really believe in critical thinking and care plans and how we understand care plans and critical thinking can be really annoying. I understand you hear it all the time, but listen, understanding how to do them, how to make them work, the process to them is going to make a huge difference not just in nursing school, but throughout your entire career as a nurse. Again, head over to NRSNG.com/criticalthinking. That’s NRSNG.com/criticalthinking. All right, guys. You know what time it is now. It’s time to go out and be your best self today. Happy nursing.