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.

What is Critical Thinking?

When I was in nursing school, I didn’t really understand what the professors meant when they said the term critical thinking . I just nodded along and pretended like it made sense to me.

I started to understand a bit more when I got into clinicals and really understood not only what it meant to think critically, but also what it felt like to critically think in the moment.

Critical thinking is something that you will do every single shift as a practicing nurse. Not one day will go by in which you do not think critically.

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!)

Problem

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.

Goal

I need them to get their oxygen saturation back up to 98%, like 3 minutes ago!

Nursing intervention

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.

Evaluation

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.

It worked!

RELATED ARTICLE: 5 Steps to Writing a (kick ass) Nursing Care Plan (plus 5 examples)

The Development of Critical Thinking

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.

NURSING DIAGNOSIS

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.

To come up with your nursing diagnosis, you’ll look at the patient’s subjective and objective data. This can be kind of confusing, especially when you first start looking at it. We have a really great post that helps differentiate between subjective and objective data here.

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.

RELATED ARTICLE: The Ultimate Nursing Care Plan Database

PROBLEM-FOCUSED NURSING DIAGNOSIS

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).”

Becomes

“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.”

becomes

“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.”

Becomes

“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
• Evaluation: what this an appropriate plan?

Alright, so I’ve walked you through some of the really technical, standardized language of the nursing care plan process…

RELATED ARTICLE: 2 Examples of How I Used Critical Thinking to Care for my Patient (real life nursing stories)

Let’s Practice Nursing Care Plans

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.

Problem	Interventions	Goal	How to evaluate
At risk for skin breakdown	Turn q2 Assess thoroughly Promote adequate nutrition Pillow support	No skin breakdown	Was there any skin breakdown during my shift? Y/N?
Fall risk	Bed alarm on Non skid socks EKG Chart Room near nurses station Increase frequency of rounds Reorient PRN Call bell within reach Try not to use meds that may disorient patient	No falls No injuries	Did patient fall? Y/N
At risk for inadequate nutrition	Assess food preferences Encourage oral intake 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 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 you professor’s office hours and really sitting down and talking through this 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 diagnoses 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 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…?

OR

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, 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 verbalized by the patient. So, all is well.. Right?

Wrong!

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?”

YES.

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.

Conclusion

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.

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