BACHELOR OF SCIENCE IN NURSING

NCMA 113 (Fundamentals of Nursing)

COURSE MODULE COURSE UNIT WEEK
1 4 4
Critical Thinking and Assessment: Foundation of Quality Nursing Care

ü Read course and unit objectives

ü Read study guide prior to class attendance
ü Read required learning resources; refer to unit terminologies for jargons
ü Proactively participate in classroom discussions
ü Participate in weekly discussion board (Canvas)
ü Answer and submit course unit tasks.

Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts,
process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition
Seaback, Wanda (2007) Nursing process: concepts & application Singapore, Delmar Learning, 2nd
edition

At the end of the course unit (CM), learners will be able to:
Cognitive
ü Discuss the relationships among the nursing process, critical thinking, the problem-solving
process, and the decision-making process.
ü Discuss the nursing process as a therapeutic framework and describe how it can be used as
a tool for promoting multidisciplinary collaboration.
Affective
ü Describe the significance of developing critical-thinking abilities in order to practice safe,
effective and professional nursing care.
Psychomotor
ü Explain how critical thinking an important element of the nursing process is.

Critical Thinking - a discipline specific, reflective reasoning process that guides a nurse in
generating, implementing, and evaluating approaches for dealing with client care and professional
concerns
Problem Solving - a process that involves clarifying the nature of the problem and suggesting
possible solutions.
Decision Making - a critical thinking process for choosing the best actions to meet a desired goal.
Nursing Process - A critical thinking five-step process that professional nurses use to apply the
best available evidence to caregiving and promoting human functions and responses to health and
illness.
Assessment – A reflective analysis of information to form an inference as a basis for further
actions.

Critical Thinking in nursing process is a discipline specific, reflective reasoning process that
guides a nurse in generating, implementing, and evaluating approaches for dealing with client care
and professional concerns (National League of Nurses). This is important in ensuring that the
nurse delivers safe, competent and skillful practice. In doing so, an excellent quality of care is
received by the client.

Uses of critical-thinking skills among nurses

§ Making inferences about the client’s information based from various sources of knowledge. In
dealing with human responses, nurses must be keen in applying a holistic approach. Thus,
drawing meaningful information from areas, other than nursing, is essential in planning effective
interventions.
§ Making quick discernment. Healthcare is a rapidly changing profession. Clients may manifest
common conditions differently. Condition changes at a very unexpected pace. Routine actions
may therefore be inadequate. Critical thinking enables the nurse to recognize important cues,
respond quickly and adapt interventions to meet specific client needs.
§ Decision-making. Nurses make important numerous decisions during work hours. With critical
thinking, relevant data can be collected and interpreted, which is important in decision-making.
Decisions may include actions such as prompt referral, reassessment or carrying out of routine
activities.
Questioning and Reasoning Techniques in Critical Thinking
1. Socratic Questioning – this is a technique that helps to delve on information beyond what can
be seen instantly. With the use of this technique, inconsistencies are searched, varying points of
views are examined and deeper approach to situations are observed.
2. Inductive Reasoning – This is the technique used in forming generalization from a set of facts or
observations. For example, during assessment the nurse observes that the patient’s eyes are
sunken, skin turgor is poor, and the client’s urine is dark amber in color. By putting the facts
together, the nurse may conclude that the patients is dehydrated.
3. Deductive Reasoning – This is the technique used in getting specific facts or observations from
a generalized premise. For example, the client mentioned that he is not well and might be
suffering from an illness, then the nurse will look at different cues that may be suggestive of an
illness.

These three techniques are used in critical thinking. Decisions are made from facts taken from interview
and assessment procedures. Relevant facts are gathered by means of employing socratic questioning.
A nurse may start with a general inference that will be used to identify areas that must be explored.
With that facts are gathered, and a valid generalization may be concluded.

Problem solving is a process that involves clarifying the nature of the problem and suggesting
possible solutions. In nursing, client’s condition is observed over time to ensure its initial and continual
effectiveness. However, during observation, nurses may encounter similar problems that require
alternative solutions. Commonly used approaches to problem solving include trial and error, intuition,
the research process, and the scientific/modified scientific method.

Decision making is a critical thinking Comparison of the different steps of the nursing process and
process for choosing the best actions to decision-making process
meet a desired goal. Nursing Process Decision-Making Process
Assess Identify the purpose
The decision-making process and the Diagnose
nursing process share similarities, and the Plan Set the criteria
nurse uses decision-making in all phases Weight the criteria
of the nursing process. It is essential that Seek alternatives
the nurse use critical thinking in each step Project
or phase of these processes so that Implementation Implement
decisions and care are well considered and Evaluation Evaluate the outcome
delivered with the highest possible quality. *taken from Kozier, et al., (2008)

Nursing Process is a five-step critical thinking and decision-making process that the nurse may utilize
in order to provide individualized patient care.
The steps of the nursing process are built upon each other, overlapping previous and subsequent
steps. The nursing process may be used with clients throughout their life span and in any setting where
care is provided to clients.

Importance of Nursing Process

§ Promotion of improved quality and continuity of care
§ Increased client involvement and participation
§ Providing an organized, continuous and systematic delivery of care and problem solving
§ Efficient utilization of time and resources
§ Delivery of care that meets expectations of both the health care consumer and standards of the
nursing profession.
§ Holds the nurses accountable and responsible for assessment, diagnosis, planning,
implementation and, evaluation of client care.

Five Phases of the Nursing Process

1. ASSESSMENT. This is the deliberate and systematic collection of information about a patient to
determine the patient’s current and past health and functional status and his or her present and
past coping patterns. (Carpenito-Moyet, 2013)
2. DIAGNOSIS. This is the phase by which the nurse analyzes gathered data and identifies health
problems, risks and strengths. The nurse will then make a clinical judgement based from
identified problem.
3. PLANNING. This involves prioritization of problems, formulation of goals and desired outcomes
and selection of nursing interventions.
4. IMPLEMENTATION. This is the actual implementation of the planned interventions. Also, this
involves continuous monitoring and reassessment and documentation of the client’s responses
and needs for assistance.
5. EVALUATION. Determination of improvement of patient’s condition or well-being after the
application of the first four steps of the nursing process.

The nursing process is not only aimed towards promoting a systematic approach in the nursing practice
but is also promotes collaboration. As the client enters the health care system, individual professional
responsibilities of the health care providers begin. Collaboration with the physician, nursing
professionals, and other disciplines is often necessary to coordinate care and promote health.

ASSESSMENT
§ This is the systematic and continuous collection, organization, validation, and documentation of
data.

Types of Data
1. OBJECTIVE Data, also referred to as signs or overt data. These are information detectable by
an observer or can be measured or tested against an accepted standard. This information may
be gathered during physical examination.
 2. SUBJECTIVE Data, also referred to as symptoms or covert data. These are information
apparent only to the person affected and can be described or verified only by that person. This
information are gathered through interview.

Types of Assessment
§ INITIAL ASSESSMENT provides an in-depth, comprehensive database, which is critical for
evaluation changes in the client’s health status.
§ PROBLEM-FOCUSED ASSESSMENT, the nurse determines whether the problem still exists
and whether the status of the problem has changed (i.e. improved, worsened, or resolved)
§ EMERGENCY ASSESSMENT takes place in life-threatening situations in which preservation of
life is the top priority
§ TIME-LAPSED or ONGOING ASSESSMENT takes place after the initial assessment to
evaluate any changes in the client’s functional health.

Assessment Process

Collection of Organizing Validating Documenting

Data Data Data Data

Assessment Process

A. Collection of data

Sources of Data
§ Client
§ Support People
§ Client Records
§ Health Care Professionals
§ Literature

Data Collection Methods

Assessment data may be collected by three important methods: (1) Observation, (2) Interview, and (3)
Examination. Observation occurs whenever the nurse is in contact with the client or support persons.
Interviewing is used mainly while taking the nursing health history. Examining is the major method used
in the physical health assessment.

Observation is a method that makes use of the senses in gathering data. It is a conscious, deliberate
skill that is developed through effort and with an organized approach. It involves two important aspects:
(a) noticing the data, and (b) selecting, organizing, and interpreting the data. Nursing observations must
be organized so that nothing significant is missed.
An interview is a planned communication or a conversation with a purpose. It can be: (a) directive – a
highly structured interview that elicits specific information; or (b) non directive – an unstructured
interview that provides flexibility on how the nurse directs the focus of the conversation.

Main classification of interview questions

1. Closed ended questions, are questions that is restrictive that requires specific answers such
as a “yes”, a “no” or any particular factual information.
2. Open-ended questions, are questions that encourage discovery, exploration, elaboration,
clarification or illustration of the client’s experiences, thoughts or feelings.

Examination is the process by which the nurse makes use of his/her senses to gather relevant
information from the client. Unlike, interview, by which information is taken from the responses of the
client, examination is a more accurate way of gathering relevant data from the patient.

Examination techniques
1. Inspection is the deliberate, purposeful, observations in a systematic manner. Nurse use the
physical senses: visualizing, hearing, and smelling
2. Palpation is the technique that uses the sense of touch. The hands and the fingers are the
most sensitive tool that a nurse has.
3. Percussion is the act of striking one object against another to produce a sound. The tones
produced during percussion are used to assess location, shape, size and density of a tissue.
4. Auscultation is the act of listening with a stethoscope to sound produce within the body. Pitch,
loudness, quality and duration of the sound are being assessed during auscultation.

Ways of examination
a. Cephalocaudal- “head to toe approach” This is an examination of the client that follows the
head-neck-thorax-abdomen-extremities-toes sequence of assessment.
b. Body System- This type of examination focuses on the structures and functions of a specific
body system: respiratory system, circulatory system, nervous system, etc.
c. Screening examination- “review of systems” This manner of examination gives emphasis on
the client’s chief complaint and its associated signs. This is also a brief review of essential
functioning (nursing admission assessment form)

B. Organizing Data
• The nurse use an organized assessment framework

11 Typology of Functional Health Pattern (Gordon)

1. Health perception/ Health Management-describes the clients perceived pattern of health
and well-being and how health is managed.
2. Nutritional/ Metabolic Pattern-describes client’s pattern of food and fluid consumption.
3. Elimination Pattern-describes pattern of excretory function (bowel, bladder and skin).
4. Activity-Exercise Pattern-describes pattern of exercise, activity, leisure and recreation.
5. Sleep-Rest Pattern-describes pattern of sleep, rest and relaxation
6. Cognitive-Perceptual Pattern-describes sensory-perceptual and cognitive patterns.
 7. Self Perception/ Self Concept Pattern-describes client’s self concept and perception of
self pattern (self-worth, comfort, body image, feeling state).
8. Role-relationship Pattern-describes pattern of participation and relationship.
9. Sexuality-reproductive Pattern-describes client’s pattern of satisfaction and
dissatisfaction with sexuality patterns; describes reproductive patterns.
10. Coping/ Stress- tolerance Pattern-describes client’s general coping pattern and
effectiveness of pattern in terms of stress tolerance.
11. Values-beliefs Pattern-describes patterns of values, beliefs and goal that guide the
client’s choices or decisions.

Abraham Maslow’s Hierarchy of Needs

Self-actualization
Self esteem
Love and belongingness
Safety and Security

C. Validating Data- double checking or verifying data to ensure that it is accurate and factual
*differentiate CUES from INFERENCES!

CUES- are subjective or objective data that can be directly observed by the nurse
INFERENCES-are the nurse’s interpretation or conclusion based on the cues

D. Documenting Data
• data are recorded in a factual manner and not interpreted by the nurse.
• for example, the nurse must record the client’s intake as “coffee 240 ml, juice 120 ml, 1
egg and 1 slice of toast” rather than as “appetite good” or “normal appetite” a judgment.

Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts,
process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition
Seaback, Wanda (2007) Nursing process: concepts & application Singapore, Delmar Learning, 2nd
edition
Weber, Janet R. Kelley, Jane H. (2013) Health Assessment in Nursing Lippincott Williams and
Wilkins, 5th edition

Lakhanigam, S. (2017, December 14). Critical Thinking: A Vital Trait for Nurses. Retrieved from Minority
Nurse: https://minoritynurse.com/critical-thinking-vital-trait-nurses/
Nurse Journal.org. (n.d.). The Value of Critical Thinking in Nursing + Examples. Retrieved from Nurse
Journal: https://nursejournal.org/community/the-value-of-critical-thinking-in-nursing/
Papathanasiou, I. V., Kleisiaris, C. F., Fradelos, E. C., Kakou, K., & Kourkouta, L. (2014). Critical Thinking:
The Development of an Essential Skill for Nursing Students. Acta Informatica Medica, 283-286.
doi:10.5455/aim.2014.22.283-286
Science Direct. (2019). Nursing Process. Retrieved from science Direct:
https://www.sciencedirect.com/topics/nursing-and-health-professions/nursing-process
Toney-Butler, T. J., & Thayer, J. M. (2019). Nursing Process. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK499937/

• Critical Thinking and Assessment

A. Create a 500-word essay on the topic “Application of critical thinking, problem

solving and decision making in every phase of the nursing process”

B. George is a 49-year old recently retired engineer with a history of irritable bowel
syndrome that causes frequent diarrhea and rectal bleeding. His wife is a
schoolteacher. It is mid-December when he comes to the hospital complaining about
“not feeling good”. You conclude he is having a reoccurrence of his intestinal problem.
1. What questions would you ask yourself to check your assumptions?
2. How would you demonstrate that you are using critical thinking attitude?
3. How would you apply Socratic questioning? Deductive reasoning? Inductive
reasoning?
4. What are the key areas of information to obtain regarding his past history?
5. Which physiological systems are the most important for data collection?
6. Which other sources of data might be appropriate to access in his case?