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Medical-Surgical Nursing

6.1 Critical Thinking in Assessment

Medical-Surgical Nursing6.1 Critical Thinking in Assessment

Learning Objectives

By the end of this section, you will be able to:

  • Define critical thinking
  • Discuss the importance of critical thinking in nursing practice
  • Explain the expansion of critical thinking to clinical judgment

Nurses use critical thinking skills every day, from one-on-one patient encounters in clinical settings, to the professional interactions they have with colleagues and the broader health care systems in which they work. Thinking critically means objectively considering and analyzing information and figuring out how to use it efficiently. According to the American Nurses Association (ANA), “critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills” (ANA, 2024, para 3). It’s a complex skill that incorporates education and training, experience, and available data. Critical thinking enables the nurse to make decisions that are well-informed, evidence-based, and patient-centered, which are decisions made with respect for the patient’s interests, needs, culture, values, and preferences.

This section defines critical thinking and explains why it is a foundation of nursing practice. The section will also tie critical thinking to another skill necessary for effective nursing practice—clinical judgment.

Critical Thinking Defined

Critical thinking allows the nurse to use rational standards to analyze information, interpret values/assessments, and ask questions about the data they obtain about a patient as part of a comprehensive health assessment and physical exam. Critical thinking is a skill nurses constantly use, and a skill that evolves with experience. Every decision the nurse makes is rooted in critical thinking. A nurse must combine assessment skills using the evidence of the physical exam to understand the patient’s health concerns and help them achieve a positive outcome.

Critical Thinking in Nursing

The ability to think critically about information helps nurses make all kinds of decisions—from the day-to-day ones to the life-or-death ones. The nurse must consider all aspects of the data they have collected on a patient, whether it’s going through current medications to check for potential interactions or assessing a patient’s lifestyle risks. The nurse also needs to be aware of, and sensitive to, the different cues that patients give based on cultural diversity, gender, race, age, and ethnicity. There are also times when critical thinking can be more challenging, often because gathering data or being confident in those data may not be straightforward: for example, if a patient can’t communicate clearly or if a nurse is contending with their own bias about a patient’s situation. A nurse with critical thinking skills can make a split-second decision based on the health assessment that could save a patient’s life. Even if not lifesaving, critical thinking skills help the nurse ensure positive patient outcomes.

Real RN Stories

Nurse: Sandy, BSN
Years in Practice: Eight
Clinical Setting: Primary care office
Geographic Location: A rural community in the Midwest

About a month ago, I had one of those “could have been worse” moments with a patient who showed up to the clinic for a routine annual physical, but ended up in the ER. Mrs. Kline is a 64-year-old patient at our office who was simply coming in for a check-up. We’re in a rural town, so it can sometimes be hard to get our patients to keep up with their annual screenings and visits since transportation can be a major issue. But Mrs. Kline always shows up like clockwork, remembers to bring her meds, is cheerful, compassionate, and always eager to update us on her grandchildren. She’s one of those patients who is a joy to be around, really. So, when I came into the room to get her vitals and update her chart and saw her looking pretty downtrodden, my hackles went up.

“How are things going, Mrs. Kline?”

I was taken aback when she hesitated to answer—usually, she’d start chatting the moment I turned the doorknob. But on that day, she seemed discombobulated and uncomfortable. When she did start to talk, it seemed labored, like she couldn’t catch her breath. She barely got out, “Oh, about the same as always, dear.”

Well, clearly not!

“Mrs. Kline, how are you feeling right now?”

She winced a little, and her hand almost subconsciously touched her chest. “Oh, I’m just a little tired. I didn’t sleep well last night.”

I nodded, encouraging her to tell me a little more about what was wrong.

“Oh, I just had bad indigestion,” she said. “But that’s what I get for having a second bowl of rocky road!”

She tried to give me a smile, but I could see she was feeling pretty lousy. She was pale and appeared a little clammy. I asked her to tell me more about her symptoms, and she said that she’d been “feeling pretty nauseous” since last night and “had some gas up in her chest.” I asked her to be a little more specific about that feeling, and she said it was “uncomfortable pressure.”

I took her vitals, and her temp, RR, and O2 were normal, but her BP was a bit lower than I would have expected, and her heart rate was a little up.

I knew I still needed to do med reconciliation and ask her about any other changes, but it seemed like whatever was going on with her today needed to be the priority. As I was documenting the findings in her chart, Mrs. Kline started to get out of the chair, “I’m sorry, I think I need to use the restroom. . .” but as she stood, I could see how unsteady she was on her feet.

“Mrs. Kline, I’m very concerned about your symptoms,” I said, helping her back to her chair. “I think we need to put your annual check-up on the backburner for now.”

“I’m fine,” Mrs. Kline insisted, “I think I just caught a little bug. . .”

“Could be, but I’d feel a lot better if we had Dr. Richards come in now,” I said, reaching for the phone. I called up to the front desk and let them know I needed Dr. Richards to patient room 2, and she appeared just a moment later. She knew Mrs. Kline as well as I did, and the minute she looked at her, she also could tell something was really wrong. I gave her report quickly and she did a quick exam. Then, she said, “Mrs. Kline, I’m concerned that you could have having symptoms of a heart attack. I’m going to have Sandy call an ambulance to take you to the ER.”

Mrs. Kline almost laughed, but painfully grimaced as she spoke. “Don’t make a fuss over me,” she said, “If you’re worried, I could just drive. . .”

“Mrs. Kline, the nearest ER is 40 minutes away,” I said gently, “And we want to get you there ASAP. The ambulance is the fastest and safest way.”

She sighed, but almost seemed relieved. “Well, I guess I don’t want to risk getting a ticket, right?”

Dr. Richards and I tried to give her a reassuring smile, but we were both nervous. By the time EMS arrived for transport, Mrs. Kline had started trembling and felt like she was going to pass out. As we sent her off, we wondered if she’d make it.

It was a few hours before we knew anything, but Dr. Richards came to the break room around lunch time to let me know that Mrs. Kline had an NSTEMI.

“I’m glad she came in for her annual,” Dr. Richards said, “If she’d just been at home today, she probably just would have kept writing it off as indigestion. But I’m also glad that you did her intake—even though she wasn’t a high-risk patient, you put the pieces together and probably saved her life.”

While I did feel relief and a little bit of pride knowing that I’d done the right thing for the patient, I didn’t let it go to my head. As nurses, we make quick but well-informed decisions every day, and yes, sometimes they’re life or death. But it was really a team effort, from the coordination in our office to the EMS crew and the ER staff.

Critical thinking can be defined as habitually using a set of rational standards to guide decision-making (University of Tennessee Chattanooga, n.d.). Critical thinking skills allow nurses to gather a more complete picture when they are assessing and examining a patient. At times, what a patient is saying may not match what the nurse observes. The misalignment does not always mean the patient is lying. While critical thinking skills can help nurses identify when a patient is being untruthful or has limited health literacy, these skills are also crucial for helping the nurse identify barriers that can make it harder to get an accurate and cohesive picture of a patient’s health. Patients may not understand why they need to share certain information with their health care providers or the consequences of withholding that information. They may struggle to recognize or remember information that would be useful for them to share during a visit. Patient factors, such as cognition, communication, social stress, mental health, cultural background, personal beliefs, and health literacy level, also affect how they communicate with the health care team.

For example, consider a scenario where the nurse is talking to a patient with dementia. Due to their cognitive condition, the patient may give answers to the nurse’s assessment questions that don’t line up with what the nurse is observing or expecting. The patient is not lying intentionally, but they are unable to be a reliable historian/informant about their own health. A patient with dementia may state that they do not take any medications, but the nurse can see in the patient’s chart that they are prescribed several drugs to manage multiple chronic conditions, and the nurse may also know that the patient was administered a medication earlier that day. A patient with dementia may not recall any of their current health conditions and may not be able to describe their present state of health or concerns. The patient may say they feel “great,” but the nurse may question that statement if they note an elevated temperature and heart rate.

To ensure a holistic picture of the representation of the patient, the nurse uses critical thinking skills during the comprehensive health assessment and physical examination to explore a patient’s whole person needs. A comprehensive assessment and physical examination include not only details about physical state of health, but also the emotional, social, psychological, spiritual (Ambushe et al., 2023), cultural, sexual, energetic, and environmental aspects of a person’s life (ANA, 2019). These factors impact the health and well-being of the individual and are important in planning care for current health problems and preventative care (Figure 6.2).

Healthcare professional examining older patient
Figure 6.2 Older adult patients with cognitive decline or neurological diseases, such as dementia, may not be reliable historians. (credit: Mass Communication Specialist Seaman Apprentice Joshua Adam Nuzzo/U.S. Navy, Public Domain)

Critical Thinking in Clinical Judgment

Integrating nursing knowledge and experience with the data collected and analyzed to make informed decisions about patient care is called clinical judgment. Clinical judgment will evolve with experience. Over time, nurses also develop a degree of intuition, or a “sixth sense” of knowing that largely comes from years of education and problem-solving in real-world patient situations. But even experienced nurses who have a sense of intuition must still call on their critical thinking skills; they would not simply rely on intuition alone.

One framework that explains how to transition from critical thinking to clinical judgment is the Clinical Judgment Measurement Model (CJMM). The process outlined in the model has several components (NCLEX, 2024):

  1. Recognizing cues: The nurse will acquire data from different sources, including the patient and medical records. They will identify specific facts or details within the data from assessments, patient conversations, and records to look for cues that will inform how they will approach caring for the patient.
  2. Analyzing cues: The nurse will take the patient’s needs into account and use the data to identify problems and create priorities. This includes organizing and analyzing the data to look for outliers or trends.
  3. Prioritizing hypotheses: The nurse uses the data and analysis to set priorities based on the possible causes of the patient’s condition and making sure that the most important problems are addressed first. They will work with an interdisciplinary team who is involved in the patient’s care to set goals.
  4. Generating solutions: The nurse will come up with possible interventions based on the patient’s needs, interests, and evidence-based practice (EBP) from current literature.
  5. Taking action: The nurse will objectively look at the interventions and assess how effective they are for the patient. They do research and seek insights from the interdisciplinary team to improve the patient’s care plan. Ultimately, the overall goals and steps taken are nurse driven.
  6. Evaluating outcomes: The nurse will look back on the clinical judgment process and identify areas of strength and weakness. They ask for feedback from colleagues to help them get an objective view of their skills, decision-making, and judgment.

Real RN Stories

Nurse: Mina, RN
Years in Practice: Ten
Clinical Setting: Renal department of a hospital
Geographic Location: Southeastern region of the United States

I’ve worked in the medical renal department for about 10 years now, but I still have moments when I feel like a nursing student solving a textbook patient puzzle! Recently, I cared for a 54-year-old male, Mr. Chen, who was admitted for shortness of breath. Mr. Chen had a history of diabetes and hypertension. During the assessment, he reported that he hadn’t been able to walk down his driveway to get the mail and had gained two pounds in the last three days. He also reported weakness, lack of motivation, and trouble sleeping. In my thinking-it-through process, I paid attention to these subjective statements or “cues” the patient was giving me.

As I was entering data in his chart, I noticed that Mr. Chen took blood pressure medication, insulin, and a diuretic. I did medication reconciliation to confirm that he was still taking these prescriptions as directed. As I was doing the assessment on Mr. Chen, I noted swelling in both of his feet and a respiratory rate of 24 breaths/minute at rest. When I put my fingers against the bottom of his legs by his ankles, they left an indentation. These objective findings got added to my subjective cues from earlier. I started to piece together what I knew about Mr. Chen from his medical record, what he’d told me, and what I was observing based on the physical exam. Once I had all the data gathered, it was time to think about what it might be trying to tell me. Putting it all together, I realized that this patient’s presentation could have been a textbook example of acute kidney injury or heart failure; either way, I knew Mr. Chen needed to be the provider’s priority.

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