05.07 Critical Thinking

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Steps in the Nursing Process 1 (Mnemonic)
Steps in the Nursing Process 2 (Mnemonic)
Steps In The Nursing Process 3 (Mnemonic)
4 Critical Thinking Steps (Cheat Sheet)
Survival Guide for Nurses (Book)


We are going to talk about critical thinking. This is one of my favorite topics not just in nursing, but in general because it is a skill that you must develop. You must develop critical thinking skills, and I'm sure you've been told that over, and over, and over again, but no one tells you how. They tell you, "You have to start thinking critically," but we're going to show you exactly how to think critically and how you can apply it immediately in your practice and just in life in general.

This is our definition of what we believe critical thinking is. We believe it's the ability to recognize a problem, gather information, evaluate possible options, and communicate with others quickly and efficiently to get the best possible clinical outcomes. Recognize, gather, evaluate, communicate, and get the best possible outcomes you can. Now like I said guys, this is something that you can develop now. It's something you already have been doing, but we want to strengthen that muscle. Critical thinking is like a muscle. You can strengthen it. It can become stronger and stronger until eventually it's just completely second nature. So, really it's just the application of the nursing process by instinct. It develops over time. It's like a muscle, but it requires practice. Essentially there's just four steps to critical thinking. We have a cheat sheet on this and I'm just going to introduce it here because we're going to talk about it more in depth as we go on. The first step is suspending all judgment. Notice how I've capitalized all in each of these. That's so important. It's not suspending some judgment, it's suspending all judgment. We'll talk about that. Then it's collecting all information. Then it's balancing all information, and then it's making a holistic decision.

So, the first step is to suspend all judgements. This means that we want to make sure we're being completely objective about the situation. We can't allow ourselves to decide anything to quickly. If you've already made up your mind about a situation you're going to have blinders on, right. [inaudible] your eyeballs and you're going to have blinders on to where you can't see everything that's going on out here. You're seeing such this narrow scope just like you're looking through little tiny binoculars backwards, and all you can see is just this little speck, and you're missing all this beauty of nature. So, make sure you take those blinders off and you suspend every judgment that you can. You got to look beyond the obvious. It might be that one thing that you're looking at 95% of the time or that thing that you're thinking off, but you got to take those blinders off because that 5% of the time you still got to be a nurse and you still got to make good decisions. A nurse who suspends all judgment never ignores a patients complaint. It's going to help you avoid bias, and it's going to help you make good clinical decisions.

Let's use an example patient throughout this lesson to help you guys, and I'm going to tell you another story at the end as well about critical thinking. So, let's say you have a patient who just came back from abdominal surgery. He's complaining of pain repeatedly for the last couple hours. Now the tele monitor is showing a heart rate elevated in the 120s ... whoops ... 120s. If you just assume he's in pain because well that's obvious he just came back from surgery, and he's asked five times in the last two hours for pain meds you'll probably just ignore it until it's time for his pain meds to be due, but let's see what happens though if we apply critical thinking. When we actually suspend all judgment. Okay, so let's go through these and I'm going to talk about that patient as we go.

The next step is to collect all information. We need to consider there may be something else going on. Your patient may be in pain, but there might be something else going on, 'kay?

So, this is called data mining. We ask questions. We go digging. There's this picture that I really like of a guy in a mine. There's a guy here with a pitchfork, and he's chopping away here at this wall inside a mine. Well, he's been digging for a long time. Eventually he gets tired. The next image is of this same guy with the pitchfork over his shoulder because he's given up, but what you see in the next slide is right behind this wall there's just tons and tons of diamonds. One more hit would have given him the diamond mine, would have gotten him all these diamonds.

So, what I want you guys to keep in mind here is that we have to mine for as much data as we can. There might be one piece of information we're missing about our patient that's keeping us from making the right decision. You can't dig forever because we're limited on time and we have to act quickly with our patients, but you got to gather as much information as you can. Assess your patient, not the monitor. Monitors can give us false information, give us false positive, give us false negatives. Make sure you're digging for everything. You're assessing your patient. You're collecting all the information that you possibly can. So, let's go back to that post op patient. Instead of our biases keeping us at the nurses station waiting for his pain meds to be due we go back and we check on him. The patient reports that his pain is 10/10 in the belly. When you look at him he's diaphoretic, he's sweating, right. His heart rate is still in the 120s. What other information should we get? Well we assess his belly. It's hard. It's firm. He's guarding. We assess the blood pressure. It's 80/40. Oh. We check his drains, right. There's frank, bright red blood in there. So, now we're gathering a lot of information than just this pain. We get all these pieces together. Let's look at what we should do for him.

All right let's go to the next one. So, now we start to balance all the information. We've suspended all of our judgment. We've gone back, we've checked on this patient, we collected all the information we can from monitors, from him, from objective data, from subjective data. Now we have all these different pieces of information all over the place. We got to start balancing this and getting this nice lined up set of information so that we can make our decision. We first have to decide what's important. What pieces of information are the highest priority. Which ones mean something, and which ones just don't. Which ones do we not need to make a decision about our patients, and which ones are most important. We have to start lining it all up and we apply a value rank to it. So, this one really matters. This one, maybe. This one just doesn't matter at all. So, let's look at our post op patient. The belly pain is 10/10. His firm hard abdomen, BP 80/40.

Biggest issue here would be the BP. Then we start applying our Maslow's hierarchy of needs to assign a value to each of these pieces. BP, that's a circulation issue. That's ABCs right. Boom. We got our ABCs. He's in pain, but it's not that important. We can wait to give pain meds, but his BP is 80/40. We got to do something about that. Then he has the hard abdomen. He's in pain. He's diaphoretic. If I can fix one thing does it achieve our desired outcome? Ask yourself for each one of these things. If I can fix the pain he'll be out of pain, but can I fix the blood pressure with that? Does it fix what we really need to fix? If I can only fix that one thing can I fix what needs to be fixed? Probably not, so there must be some sort of bigger issue going on with this patient.

If I don't fix one thing what happens? If I don't fix the pain what happens? Well, he's going to stay in pain. If I don't fix this blood pressure what happens? Well we got a profusion issue. We're in trouble [inaudible] circulation issue. If I don't fix this frank blood pouring out of him, what happens? We've got a bigger issue. He could go into shock. He could die. This is a big deal. We got to do something about this. So, I'm lining up all this different information that I have, ranking it, and trying to make a decision from there.

Okay, now we have to make a holistic decision. That means a balanced, fair, complete decision. We suspended judgment. We collect and balanced all the information. It's time to make a decision. We can't sit there forever. We got to do something. We have to think about the patient as a whole not just as a set of symptoms. We got to start thinking about the patient. We got to start balancing all this information. We prioritize ABCs and safety, Maslow's hierarchy of needs, ABCs, safety. Those are the issues that matter most to us right now.

Look at all these pieces. What does a high heart rate, low BP, diaphoresis, 10/10 abdominal pain, and firm abdomen usually mean in a post op surgery patient? He's probably bleeding into his belly. He needs surgical intervention as soon as possible. You've determined that. Now you got to trust this decision and act. Don't be timid about this. You got all this information. This can be the hardest part. You have to trust your gut, call the provider, get this patient to the OR as fast as we can. Imagine if you'd ignored the heart rate because you just assumed it was because of pain. His heart rates 120. Well, that's because he's 10/10 pain, but we don't have any pain meds due. I can't do anything, bomp, done. Then we go back to check on the patient later because his pain meds are due now, and his BPs now 20/10, and the floor is full of blood because all of his drains have drained out, and he's in shock. What do we do, or if you'd just given him morphine we'd tank his blood pressure even more. We didn't gather all the information. You got to gather all that information you did. Now trust your gut, and act on it. Bad stuff does happen. You can think critically, find the route cause of all these different things.
Let's go over the main key points here you guys. Critical thinking is like a muscle that improves over time. It does take practice. I'm not going to talk down to you guys and act like you don't know how to think critically. You do. You've already been doing this in daily life. You wake up, it's raining outside, you don't throw a tank top on. You suspend your judgment, you say, "It could rain today." You collect all that data. You throw on a sweater. You guys already know how to think critically. Combining that critical thinking with clinical judgment is what's going to make you a phenomenal nurse. I know that you can do this so believe yourself that you can do this. First step is suspending all judgment. Second step is collecting all information. These are two pieces that I think are left out so often. Suspending that judgment is hard. Don't decide too quickly, avoid bias, make sure you're data mining, assessing your patient, balance all the information that you have, prioritize what's important, and finally make a decision. Look at the big picture, trust your gut, and act. So important.
Let me tell you guys a story really quick. When I was a brand new nurse I was just kind of on my own. We had this patient come down into the progressive care unit. He was a young African-American male had been in a MVC. He was in pain. He had a splint on his arm, a neck collar. It was a fresh car wreck. I go in his room, and I'm talking to him. We do all of our things. We do our assessments and stuff, and then he starts complaining of pain.

I'm like, "Yeah, well you know the guy was in a car accident. Of course he's in pain," but then I start to assess more. I'm like, "You know what? Let's do a full PQRST pain assessment." He starts telling me about his pain. It's on his chest. It feels crushing. It's intermittent, it's coming back, it's getting stronger. So, I start gathering more, and more, and more data on this guy. Then I call the provider and I push them for an EKG. I said, "You know what, we need to do an EKG on this guy." Guess what happened? His EKG looked like that. This guy was in the middle of an active STEMI: ST-elevation myocardial infarction. So, we transferred him to the ICU, get this guy, I start treating him for a STEMI. We do all of our MONA therapy before I get him over to the ICU. So, we give him some morphine. Get him on some oxygen. Get him a nitrate. Get him an aspirin, and then we get him over to the ICU. Suspending all judgment, collecting more data, balancing that, and realizing this guy was in the middle of a heart attack possibly saved this guys life.

So, even though I was a new nurse I'm proud of that decision that I made as a new nurse to dig a little bit deeper, and you guys can do that too. Trust yourselves. Make sure you check out all the different information with this lecture. We have a cheat sheet on critical thinking. I want you guys to refer to it, and trust yourselves. You can do this. All right, I want you guys to go out and be your best selves today and as always, happy nursing.
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