How to Develop your Critical Thinking Skills

Critical thinking skills for nurses and healthcare providers

“Enquiring Minds want to know”

Nursing is an honorable profession, and nurses are the heart and soul of the healthcare system. Furthermore, nurses are at the front-lines of administering and evaluating treatment. The nurse is the patient’s advocate and the patient relies on the nurse to be his or her advocate. It is the nurse that the patient spends the most time during his/her stay in the hospital.

Clinical experiences are important throughout a nurse’s career – students or experienced – nurses require a road-map to patient care decisions. Without a road-map, nurses are unable to function with Critical Thinking Skills.

Critical Thinking is the ability to think clearly and rationally about what to do.

Nurses with critical thinking skills are able to understand the logical connections of patient adversities and treatment. The Critical Thinking nurse has curiosity. We often have said curiosity killed the cat. Yet, the nurse with curiosity may save lives. Much like a detective of a crime scene, the nurse must first identify the crime or for the nurse, the adversity. The crime scene, like the adversity, have connections between what has or is occurring with the evidence that exist. The evidence gives a road-map to determining the reason for the crime, the contributing factors for the crime, and the cover-ups for the crime.

The first step in critical thinking is to identify the adversity.

The adversity may be simply be not knowing the connection between two concepts. In the past, we had to make our way through volumes of textbooks to arrive at an answer. Textbooks are written with intensity and complexity. In today’s world we have a quicker way to arrive at the unknown. That is the Google search. With Google, we can research our unknown efficiently. There are volumes of reading materials available for research to acquire the answer to the unknown.

After identifying the adversity and then researching, we must then dismiss any information that doesn’t have relevance. All of this began with curiosity. The nurse that is curious is the nurse that will develop Critical Thinking Skills. Critical thinking is the intellectual disciplined process of actively and skillfully conceptualizing the unknown and then applying the rational.

The Trauma Nurse

For example in the Trauma unit, the nurse must anticipate injuries according to the Mechanism or Injury. If the patient sustained an injury on his/her left side, the nurse must have knowledge of what organs are present on the left side of the body. This is basic knowledge for the Trauma Nurse and requires Basic Thinking. Next, he/she must then determine the adversities that may exist with injuries of those organs. He/she may determine the liver has been injured. Then he/she must determine the significance of a liver damage.

The Critical Thinking nurse must think about the functions of the liver, the signs and symptoms of liver damage and what diagnostics will assist his/her to arrive at the subtleties of liver damage. You can see, Critical Thinking begins with basic knowledge and then with curiosity, he/she will be able to Critically Think the dynamics of liver damage.

The ER Nurse

For the ER Nurse, the nurse must have an awareness of compensatory mechanisms that keep the body alive. Those compensatory mechanisms include: a heart rate that speeds up in order to deliver more blood to organs; respiratory rate speeds up to compensate the delivery of more oxygen to the organs; and the peripheral blood is shunted to the core of the body to conserve the existing blood supply. Therefore, the heart rate and respiratory rate need to remain high. These compensatory mechanisms must remain in place until the etiology of the problem is defined.

When these compensatory mechanisms can no longer keep the body alive, the blood pressure (BP) will drop. The BP is the deciding factor for the patient to be stable or unstable. The nurse that has been able to critically think the dynamics of compensatory mechanisms is better able to understand the dynamics of a sick patient.

The Pediatric Nurse

For the Pediatric Nurse, the nurse must have an understanding of these compensatory mechanisms. If the child has increased work of breathing, increased respiratory rate, and increased heart rate, then the child has respiratory distress.

Is the child getting better or worse if their work of breathing, heart rate, and respiratory rate decrease? Most nurses will respond with “the child is getting worse.” But the child may be getting better. How would you determine if the child is getting better or worse?

The nurse must have critical thinking skills to arrive at this answer.

The pediatric nurse must explore more evidence such as the oxygen saturation. Does the child need more supplemental oxygen to keep the oxygen saturation within normal limits? If the oxygen saturation is dropping, the child is getting worse. If the oxygen saturation is within normal limits, the child will be determined to be getting better.

Children’s appearance provides more evidence. Children are unique with their appearance. They either “look good” or “look bad.” If the child looks good, they have good tone and interact with their parents with good eye contact. If the child looks bad, the child will have poor tone, will not interact with his/her parent and will have a glassy stare.

The nurse that explores more evidence is the nurse with critical thinking skills. The child may have respiratory distress which is the “window of opportunity” to “fix” the child before he/she goes into respiratory failure. If the child goes into respiratory failure, the outcome will be bleak.

EKG Interpretation

Most nurses require EKG Interpretation to critically think the adversities of the body. This skill is most often difficult for nurses. Yet, the nurse with curiosity will tackle this skill with determination. With this skill the ER nurse will be able to determine if the patient is having a heart attack. In addition, the nurse will then be able to determine the area of the heart attack and ultimately determine what to anticipate for the patient.

EKG Strip: Second Degree Heart-Block Mobitz 2

Can you interpret this EKG rhythm? Hoover over the image to reveal the answer

The patient that has damage to the Left Lateral Wall will have diminished cardiac output. Moreover, the patient that has damage to the Inferior Wall will have diminished ventricular refilling. The patient that has damage to the Septal Wall will have conduction defects. The nurse will learn that ischemic changes are the forerunner of a heart attack. Therefore, the nurse must be able to determine those ischemic changes to avert damage to the myocardium. Remember, this began with curiosity and then progressed to determination.

The Telemetry Nurse must have an understanding of Premature Contractions.

Some premature contractions are benign and some are life threatening. Premature Contractions that originate in the atrium are not life-threatening (PAC’s). Those that originate in the AV node are not life-threatening. (PJC’s). But those that originate in the ventricles (PVC’s) have the propensity to be life-threatening.

Premature Ventricular Contractions or PVC’s do not “kick out” much cardiac volume. Therefore, the more PVC’s the greater the concern. PVC’s may originate from several foci in the ventricle’s. Multi-focal PVC’s are more dangerous than uni-focal PVC’s. PVC’s that have patterns such as quadrigeminal, trigeminal, and bigeminal become a greater concern. PVCs that land on a T wave can be catastrophic. Remember, this began with curiosity and then progressed to determination and ultimately to critically thinking..

Even the Labor and Delivery nurse is not exempt from the EKG Interpretation.

When Premature contractions occur the machine reads this premature contraction as an increase in heart rate. Usually premature contractions create a pause after the premature beat and the machine indicates a decrease in heart rate. Therefore, when observing the baseline of a fetal heart rate, the L/D nurse will assess a spike upward followed by a spike downward. This indicates a premature beat has occurred.

In understanding this, the critical thinking nurse will then delve into the ramifications of premature beats. A serious ramification includes diminished cardiac output which results with poor perfusion to the fetus. Remember, this began with curiosity and then progressed determination and ultimately critically thinking skills.

Code Teams & EKG Interpretation

The nurse that responds to a “Code Call” must understand which ventricular rhythms are life-threatening and which ventricular rhythms are dangerous because the interventions are different. Polymorphic Ventricular rhythms are life-threatening and require defibrillation. Monomorphic Ventricular rhythms are dangerous and may require cardioversion, medications or defibrillation, depending on the pulse and blood pressure. This is basic knowledge for the nurse that responds to a Code Call and this nurse must have Critical Thinking skills. This nurse began with curiosity and determination that progressed to critical thinking.

12-Lead EKG Interpretation

Most often, once the nurse has acquired Basic EKG Interpretation, he/she becomes inspired to learn 12-lead EKG. He/she has developed that curiosity as well as the need to become empowered. An empowered nurse is one that is stronger and more confident in his/her nursing practice. With skills in 12-lead, he/she can determine the EKG changes that occur with Pericarditis vs Acute Myocardial infarction. Both have the chest pain, and both have ST segment elevation but the manner in which the ST segment elevation presents itself on the EKG are different. Next, he/she can then determine the appropriate intervention.

12 Lead EKG Interpretation The Contiguous_Leads

12 Lead EKG Contiguous Leads

The 12-lead EKG interpretation can uncover congenital defects that put the patient in harm’s way, especially on the soccer fields where young people suddenly go into cardiac arrest. Once the child goes into cardiac arrest, the outcome is often bleak. If this defect is discovered prior to the arrest, the child may be armed with an implanted automatic defibrillator which will save the child’s life.

In addition, nurses have known for years that one cannot determine an Acute MI with a Left Bundle Branch Block. Now you can. Have I peeked your curiosity? The nurse in today’s world can use the Sgarbossa Criteria to determine if an Acute MI is hiding behind that Left Bundle Branch Block. Are you curious?

Critical Thinking often begins with becoming inspired.

Management of Assaultive Behavior is an interesting course to determine why a person “acts out” to get their way. As a child did you “throw a temper tantrum” to get your way? Did it work? If that behavior worked as a child, the adult may act out in the same way. As a teenager, did you use manipulation as a way to get your way? Did it work? If that behavior worked as a child, the adult may act out in the same way. Did crying get you what you wanted?

The nurse that observes assaultive behavior is then able to determine why the adult acts inappropriately. Is the nurse going to “coddle” the crying adult? Or, is the nurse going to “give in” to the adult that is having a temper tantrum? Is the nurse able to determine if the patient is trying to manipulate her? Understanding these responses will allow the nurse to intervene more appropriately with Critical Thinking Skills. Have I sparked your curiosity?

Stroke Care

Stroke Care is a convoluted science and requires a great deal of patience to understand. To begin this journey, start with the brain’s anatomy. If the stroke has affected the occipital lobe, the patient will have visual disturbances. Next, if the stroke has affected the frontal lobe, the patient will have intellectual difficulties. Then, if the stroke has affected the parietal lobe the patient will have emotional difficulties. If the stoke has affected the temporal lobe, the patient will have hearing problems. Moreover, if the stroke has affected the Cerebellum, the patient will have posture and balance problems. Lastly, if the stroke has affected the Brain Stem, sh#+ happens!!

The Brain Stem is vital to body functions. The hypothalamus is in the brain stem and the hypothalamus controls the temperature of the body. The body may become poikilothermic in which the body becomes the temperature of the room. If you like the temperature of your room to be 72ᵒ that would be the temperature of your body if your hypothalamus fails to work adequately. Your body should have a temperature of 98.6. That’s a far cry from 72ᵒ

The Stroke Scores will enable the nurse to anticipate the outcome for his/her patient.

For an example the CHAD score enables the nurse to determine the risk factors for a stroke. The Cincinnati and the Los Angeles score will enable the nurse to determine if an Ischemic stroke has occurred. The Fisher score enables the nurse to determine vaso-spasms in the sub-arachnoid space. The NIHSS score determines the acuity of the stroke.

Time is of essence in caring for the stroke victim.

The time of the stroke is determined when the patient was last known to be normal. The physician must assess the patient within 10 minutes of arrival, the team must assess the patient within 15 minutes upon arrival, the CT scan must be interpreted within 45 minutes upon arrival and the drug must be administered within 60 minutes upon arrival. This provides the patient the best chance of survival of a stroke event. Knowing these guidelines are basic skills and but knowing “why” requires critical thinking.

Caring for the patient after a stroke with regards to hypertension is essential. Clinicians will often allow a BP remain high. This is called Permissive Hypertension. Why would a clinician allow a BP to remain 220/120? Have a sparked your curiosity?

Clinicians may choose a Low Molecular Weight Coumadin rather than a High Molecular Weight Coumadin. How did scientist turn a High Molecular Weight Heparin into a Low Molecular Weight Coumadin? What advantages are there for a Low Molecular Weight Coumadin?  Have a sparked you curiosity?

There are many pain medications that can prescribed for the stroke patient. What pain does the stroke patient experience? Did you know the stroke patient often has Central Stroke Pain? Do you what that encompasses? Have I sparked your curiosity? “Inquiring minds want to know.”

Blood Gas Interpretation

Blood Gas Interpretation is the responsibility of the physician, RT as well as the nurse. Interpreting Blood Gas is also convoluted. Did you try and then give up? Determination is another facet of the critical thinking nurse. I too, gave up many times. Then I became determined to understand Blood Gas Interpretation. I began with a simple equation. Each component has an acid side and an alkaline side. Arrows going either up or down didn’t work for me. The ROME method didn’t work for me neither did the Tic-tac-toe method. I found a way that allows me to understand acidotic and alkalotic situations. Determination made me work harder to understand and that is another facet of a critical thinking nurse.

Mechanical Ventilation Management

Mechanical Ventilation Management is the responsibility of the Respiratory Therapist. The nurse is not allowed to change ventilator settings. But don’t you want to know why the RT has turned up the pressure setting? Why the RT has changed the respiratory rate? Why the RT changed the Tidal volume? With these changes in settings, do you want to know what to expect for the patient? Inquiring minds want to know. Inquiring minds have curiosity and then determination to learn.

In conclusion, to become a critical thinking nurse starts with basic knowledge and then curiosity to understand and finally determination to understand. When you become a critical thinking nurse, you will become empowered.

Jane Carsrud, RN

Educational Director of Nurses Educational Opportunities














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