Critical Thinking Skills for

Nurses
Develop your Problem Solving
Skills!
Kindred Hospital Louisville
Shannon Ash, RN, BSN

Objectives
1. Define critical thinking.
2. Identify critical thinking tools to use
in nursing practice.
3. Explain how to integrate the nursing
process with critical thinking.
4. Apply critical thinking processes to
solve patient care situations.

What IS Critical Thinking?

Critical thinking can be defined several
ways. One definition is an active,
organized, cognitive process.
Another definition is a process for
identifying underlying assumptions and
variables in order to draw conclusions
and make decisions.
You could even use the definition a
process used to explore alternatives to
determine what is important.

What IS Critical Thinking?

No matter which definition you
choose, critical thinking involves the
use of several concepts, including:
exploring, analyzing, prioritizing,
explaining, deciding, and
evaluating to identify solutions and
determine a course of action to solve
patient care problems.

What IS Critical Thinking?

Exploring encourages you to identify
all the variables within a situation.
Analyzing is the process of studying
each variable to understand its meaning
and its relationship to the other
variables.
Prioritizing requires you to weigh the
relative importance of each variable to
the others, at a given point in time.

What IS Critical Thinking?

Explaining the variables involves the
exercise of amplifying each variable to
understand its meaning in the situation
and to the involved parties.
Deciding means to choose a specific
course of action.
Evaluating requires the thinker to
assess how correct the thinking process
was, and if further action is needed.

Exercise # 1
Mrs. Vernon, a 67-year old patient who suffers from
COPD has been admitted to your unit from another
facility. Upon admission you note her to be alert,
oriented and appropriate. She provides you with
information to complete her history. After
completing & charting your assessment, you leave
her to see to your other patients. An hour later
when you return, you note that Mrs. Vernon does
not seem as alert, and appears to be confused. On
each of the 5 components of critical thinking, write
down what could be going on with your patient.

Mrs. Vernon
Exploring: what could be causing this previously
alert woman to be so suddenly confused?
Hypoxia
Hypotension
Fatigue
Infection
Medications
Unfamiliar Surroundings
Stroke

Mrs. Vernon
Analyzing: what other information can I
gather to help me narrow down the possible
causes of her confusion?
Vital Signs
Oxygen Saturation/ ABG
Medications taken & last dose time
Further assessment of confusion level
Previous history of confusion?
Potential infection sites & their appearance

Mrs. Vernon
Prioritizing/Deciding: is this change significant to
this patient, and do I need to even look further?
This also includes the decision that is made
whether to inform the physician of the change in
their patients status. What would you say?
Considering that Mrs. Vernon is a new patient, and
that this is a sudden change, it is potentially
clinically significant, and should be investigated
thoroughly, and reported to the Physician right
away.

Mrs. Vernon
Evaluating: after reporting the alteration to the
patients Physician, he orders the following:
STAT ABG & STAT Portable CXR
Blood Cultures
Urine & Sputum Cultures
Head CT in the morning if confusion doesnt resolve
Discontinue all medications that could cause confusion
At this point, the Physicians orders indicate to you that
he is thinking along the same lines as you did, and
your thinking process was complete

Mrs. Vernon
Now the next time you have a patient
who suddenly presents with confusion,
you have a history with that
experience, and have a knowledge
base to draw from.

Other Concepts
The other concepts of deciding and
evaluating also take part in your
assessment of the situation!
As you started this exercise, and every
critical thinking episode, you start with
your existing knowledge base. Each
time you are faced with a new
situation, you identify from it what you
already know.

Tools for Critical Thinking

Ask questions! Sometimes people
hesitate to ask questions because they
fear that asking a question may be
interpreted as a lack of knowledge on
their part. However, the question is a
key element of critical thinking.
Questions serve many purposes, and
only serve to broaden your knowledge
base, and expand your options.

Why Question?
Questioning begins the informationseeking process.
All questioning is about seeking
information, re-formulating information
to new situations, and solving nursing
practice dilemmas.
Can you think of some other examples
of information seeking that you do?

Information Seeking
Some examples of information
seeking:
Looking up lab values
Reviewing a policy or procedure
Reading instructions about how to
operate a piece of equipment
Reviewing a patients chart
Asking a co-worker or resource person.

Exercise #2
Mrs. Riley, a 45-year old wife and mother, has
just returned to your nursing unit from the
recovery room after a gastric resection for a
malignant stomach tumor. She has orders for
respiratory care, pain medication, continuous
gastric suction, incision monitoring, and NPO
status. Eight hours postoperatively she
develops sudden dyspnea and decreasing
oxygen saturations. On each of the 5
components of critical thinking, write down
what could be going on with your patient.

Mrs. Riley
Exploring: what could be causing this woman
to be so suddenly dyspneic and hypoxic?
Pneumothorax
Hemothorax
Pneumonia
Pleural Effusions
Atelectasis
Electrolyte Disorders

Mrs. Riley
Analyzing: what other information can I

gather to help me narrow down the possible

causes of her dyspnea/hypoxia?
Breath Sounds
ABG
Blood Chemistry
After listening to her breath sounds, you
determine that breath sounds are absent on
the left side.

Mrs. Riley
Prioritizing/Deciding: is this change
significant to this patient, and do I need to
even look further? This also includes the
decision that is made whether to inform the
physician of the change in their patients
status. What would you say?
Any significant change in a patients
respiratory status should be reported to the
patients physician right away.

Mrs. Riley
Evaluating: after reporting the alteration to the
patients Physician, he orders the following:
STAT ABG & STAT Portable CXR
Equipment for chest tube insertion to be at
bedside STAT
When the chest x-ray comes back, there is a
large pneumothorax on the left, as well as
diffuse atelectasis. Anesthesia is called to
place a chest tube STAT. Your analysis was
right on target!

Mrs. Riley
Once the chest tube was placed, Mrs.
Riley had an immediate improvement
of her oxygen saturations, and her
dyspnea resolved. Now a new set of
critical thinking is demanded of you.
How does this chest tube change the
care & assessments you will provide
for Mrs. Riley?

Its no accident...
Its no accident that the nursing
process mirrors a lot of the critical
thinking process. They are both
processes developed to gather
information, look ahead, plan, and
evaluate processes.
Looking at the two, side-by-side
really illustrates that example.

Side-by-Side
NURSING
PROCESS
Assessment

CRITICAL
THINKING
Exploring

Diagnosis

Analyzing

Planning

Prioritizing/decision
making
Prioritizing and
deciding
Evaluating

Implementation
Evaluation

Exercise #3
Mr. Harris is your patient. He is a 18 year
old young man thrown from the van in
which he was riding, when it was hit head
on by an oncoming car. He is unconscious
and has a cervical fracture. He has no
movement of his extremities. Suddenly
during the middle of the night, his legs
begin to move. On each of the 5
components of critical thinking, write down
what could be going on with your patient.

Mr. Harris
Exploring: what could be causing the
movement in Mr. Harris legs?

Spinal Reflexes
Purposeful movement
Muscular spasms

Mr. Harris
Analyzing: what other information can I
gather to help me narrow down the possible
causes of his movement?

Are the movements purposeful?

Can the movements be duplicated?
How much movement is possible?
Does the patient report any changes
in sensation?

Mr. Harris
Prioritizing/Deciding: is this change
significant to this patient, and do I need to
even look further? This also includes the
decision that is made whether to inform the
physician of the change in their patients
status. What would you say?
With the patient having a stable overall
status, it would most likely be best to report
this to the physician first thing in the morning.

Mr. Harris
Evaluating: after reporting the alteration to the
patients Physician, he orders the following:
Spine CT
Neurological Consult
Every 4 hour neurological checks
At this point, the Physicians orders indicate to you
that he is thinking along the same lines as you did,
and your thinking process was complete

Critical Thinking
Critical thinking is essential in nursing
practice. Critical thinking applies to
nearly every aspect of your patient care
and patient assessment.
The sharper your skills are, the better
care you provide for your patients.
Developing your problem-solving skills
also help you to provide a high level of
patient care.

Exercise #4
Youre doing a routine reassessment on your
patient, Mr. Fisher. You notice that his vital signs
are as follows:
Temp: 99.9
Pulse: 144
Resp: 26
BP: 90/42
None of these values are within Mr. Fishers
normal range. What are you thinking could be
going on? Write down everything that comes to
mind.

What to consider?
Did you consider that there may be an
underlying infection, causing the
elevated temperature, heart rate, and
decreased blood pressure?
Or is the elevated heart rate the reason
for the low blood pressure?
The limited information you have should
make you want to get more information,
to help solve the problem.

Assessment
You determine that these vital
signs warrant further assessment
of his condition.
What questions do you want to
answer with your reassessment?
Write down your answers now.

I wanna know...
What potential
routes for infection
does he have? An IV,
a foley catheter, a Gtube, a surgical site,
a wound? How do
these areas look?
What are his lung
sounds like?
Is his heart rate
regular or irregular?

What medications is
he on?
What is his fluid
volume status? What
are his I & Os like?
Is he diaphoretic?
Does he complain of
pain?
What color is his
urine?

Consider the Causes...

First, you used your previous knowledge
to identify which of the vital sign values
were abnormal.
Then, you gathered potential reasons for
those abnormalities based on the
individual patient, and decided to look for
the information from your assessment to
find out if one of those potential reasons
could have been the cause.

Could it be?
What were some of the potential
causes?
Infection
Dehydration
Heart Problem
Pain
By searching for more information,
you could narrow down the potential
causes!

Essential Components
Another essential component of
the decision making process, is the
consideration of determining if the
problem is important.
For a patient whose urine output is
normally 150cc/hr, is a drop of
urine output to 135cc/hr for 2
hours important? Probably not.

Essential Components
Weigh that against a scenario of a
patient who usually has a normal urine
output and who suddenly has no urine
output from his foley catheter for 8
hours. Is that important? Absolutely!
With the above scenario, what are some
things you would want to check right
away in that patient? What would you
want to do? Write down your answers.

Remember
Always keep in mind that any affect on one
system is going to affect another system!
A sudden drop in urine output could be the
result of acute kidney failure; dehydration;
bladder or catheter obstruction; disease,
etc.
Other findings from your assessment may
help you determine which of these
situations apply!

Practice , Practice,
Practice
Remember that with practice, your
problem-solving and critical thinking
skills will get better and better.
Next time you have a problem, take a
minute, sit down, use the critical
thinking tools presented here to help
gather more information & apply what
you already know to help solve your
problem!