Think Like a Nurse

This is about nursing process, critical thinking, and clinical judgement.  Information comes from Davis Advantage for Fundamental Nursing Care by Marti Burton and David Smith

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Welcome back to Nursing Together. I am your host, Dr. Michelle Hoehn, and today we are going to be talking about something that can feel overwhelming when you are first beginning nursing school. It is something that you will hear over and over again. Use your nursing process. You may hear it on a lecture, you may see it on your care plans, you may hear it in your clinical instructors asking you about it and eventually you will find yourself using it without even realizing you're doing it. But here is the most important question. What does it actually mean to think like a nurse? Because nursing isn't simply about completing a list of tasks. It's not give the medicine, take the vital signs, help the patient to the bathroom, document it, done. Nursing requires you to constantly be asking, "What am I seeing? What does that mean? What's most important right now? What should I do about that?" And perhaps more importantly, "Did what I see actually help the patient?" That is where critical thinking, critical judgment, and the nursing process come together. So today we are going to take something that can seem very academic and turn it into something practical, something that you can actually use when walking into a patient's room. Let's get started with the big picture. Imagine this. You arrive for clinicals. Your nursing instructor gives you your patient assignment. You look at the patient's name, and you know the medical diagnosis. Maybe you even know a few of the orders, but you've never met the patient, and now someone says, "Go take care of your patient." You might think, "Okay, but what am I supposed to do?" That is actually a good question because nurses routinely care for patients they have never met before, the nurse may initially know very little about the patients. The nurse has to gather the information, determine what matters, develop a plan, carry out the interventions, and then determine what interventions work. That is the purpose of the nursing process. The nursing process provides nurses with a framework for making decisions about patient care, and there is a simple way to remember it. It's A-D-P-I-E, ADPIE A is for assessment, D is for diagnosis, P is for planning, I is for implementation, E is for evaluation. You may even memorize those five letters. But you always want to go a step further. Don't just memorize ADPIE understand it, know it, and understand the thinking behind it. So critical thinking. Don't just go on automatic pilot. Let's talk about critical thinking. The chapter describes critical thinking as using reasoning and logic thought to determine whether a belief or an action makes sense. In nursing, this means you don't simply accept information without thinking about it. Don't jump to conclusions. Don't make a decision based on assumptions. You validate your information. Let me give you an example. Suppose you receive an order to administer IV antibiotics. You look at the patient's chart. You notice that the patient has an allergy to another medicine in the same antibiotic family. What do you do? You don't say, "Well, there's an order. I guess I'll just give it." No. You stop. You check the allergy information. You ask the patient what medication caused the previous reaction and what happened. Then you communicate the concerns to the appropriate healthcare provider. That is critical thinking. You don't ignore the order. You don't independently change the order. You use your nursing knowledge to recognize potential safety problems and validate the information before proceeding. And the major lesson for an LPN student is don't become a task-completing machine. Think, pause, question, validate, then act. Step one, the assessment. Let's move right into it. The first step is assessment. Assessment is where you gather information about your patient. And here's something important. Assessment is more than just taking vital signs. The assessment includes interviewing the patient, asking questions, listening, observing, performing the appropriate Physical assessment, reviewing the medical records, looking at all of the lab results, reviewing the diagnostic tests, listening to what the patient and the family are telling you. Interviewing, focused physical assessment, and reviewing laboratory and diagnostic results as an important source of assessment information. Now, let's make it practical. Suppose your patient says, "I'm having pain." That is a subjective data. The patient is telling you what they are experiencing. Now, support what you observe. The patient is pale, their skin is moist, they're grimacing, their heart rate is elevated. Those are objective findings. You can see, hear, feel, and measure them. So remember, subjective is what the patient tells you. Objective is what you can measure or observe. And here's where critical thinking comes in. You cannot simply assume what the patient is feeling. For example, if your patient is crying, you might think she's sad, but that's not necessarily true. Maybe she is relieved. Maybe she just received some great news. Maybe she is frightened. The important nursing principle is, don't confuse an observation with an assumption. This specifically emphasizes validating assumptions before acting on them. That is critical thinking. Next, listen to your patient. Another important part of an assessment is nursing interview. When you walk into the room, don't immediately start firing questions at your patient like you're reading from a checklist. First, establish a rapport. Introduce yourself, explain your role, explain what you're gonna be doing, and listen. Nurses should listen carefully and ask follow-up questions rather than simply collecting minimal answers from a form. Here's an example. You ask, "Have you ever been hospitalized before?" The patient says, "Yes, twice." Okay. A task-oriented nurse might check a box and move on. A thinking nurse asks, "What were you hospitalized for?" Now, you may discover one hospitalization involved surgery. That leads to another question. "What type of surgery did you have?" And suddenly, one simple question has opened the door to important assessment information. That is why nursing assessment isn't just about asking questions. It's about recognizing when an answer deserves another answer. Medical diagnosis versus nursing diagnosis. Now, let's clear something that confuses many beginning nursing students. A medical diagnosis identifies a disease or medical condition. For example, pneumonia, cardiac artery disease, appendicitis. A nursing diagnosis, however, focuses on the person's response, need, or problem related to the condition. That is an important distinction. The medical diagnosis tells you what disease does this patient have? The nursing process asks, "How is this patient responding to it, and what nursing care does the patient need?" Nursing diagnosises focus on patient needs and problems rather than simply labeling the disease. So if a patient has pneumonia, don't stop at thinking at the patient has pneumonia. Ask, is the patient having difficulty clearing secretions? Is the patient short of breath? Is activity causing significant symptoms? Is the patient weak? What does the patient need from nursing?" That is where your nursing thinking begins. Priorities, what comes first. Now, we have arrived at one of the biggest challenges in nursing school, prioritization. Your patient may have several problems. Which one matters most? Maslow's hierarchy of human needs is a tool for determining priority. Physical needs come first because they are necessary for survival. Then come safety and security, followed by higher levels of needs. So imagine if a patient has two problems, ineffective airway clearance and low self-esteem. Both are important, but which ones comes first? Airway clearance. Why? Because the ability to breathe takes priority over the physical, social concern. This is the beginning of learning prioritization. When you're faced with multiple problems, ask yourself: What could harm my patient fastest? What threatens life or safety? What needs my attention first? Those questions will help you begin developing mindset of a nurse. Planning. What are we trying to accomplish? Once the problem has been identified, we move into planning. Planning means deciding what you want to accomplish and what nursing actions we'll need to get the patient there. One of the most important parts of planning is developing expected outcomes, and nurses sometimes struggle with this. Here's an easy way to think about it. An outcome should tell you what will the patient do, how much or how well, and by when. For example, instead of saying, "The patient will improve mobility," that's vague. How do we know what improve means? The more specific outcome might say, "Patients will ambulate thirty feet in the hallway with a walker before discharge." Now we have something measurable. The patient either did or did not do it. Expected outcomes should be realistic, specific, measurable, and defined timeframe. And notice something else. The outcome is about the patient's action, not the nurse's action. That is important. Implementation. Next comes implementation. This is where your plan becomes action. You perform nursing interventions. But before you jump into action, stop. Safety-oriented sequences includes checking the healthcare provider's orders when applicable, reviewing facility procedures, gathering supplies, performing hand hygiene, identifying the patients using required methods, and explaining the procedure, providing privacy, and using standard precautions, assessing the patient's ability to tolerate the intervention, and continuing to observe the patient. That means implementation isn't, "I have an order, so let's do it.", Rather it's: "Is it still appropriate for the patient?" The little question can make a huge difference because patient changes, orders may be updated, and the patient's conditions may change. And what may be appropriate an hour ago may not be appropriate now. Independent, dependent, and collaboration interviews. Another important concept is to understand the difference between different types of nursing interventions. Independent interventions. These are actions that the nurse can initiate within the nursing scope of practice and without healthcare provider orders. For example, implementing intake and outtake monitoring based on the assessment findings. Dependent interventions require a healthcare provider order. Examples can be prescribed medicines, certain treatments, IV therapy, diagnostic testing, or changes to activities or diets, depending on the situation and the applicable policy. Collaborative interventions. These involve working with other members of the healthcare team. Think about physical therapy, respiratory therapy, social services, and other nursing. Good nursing care is not a solo sport. Healthcare is a team Don't give cookie-cutter care. There's an idea I really want you to remember. Your patient is not the pneumonia in room four. Your patient is a person. Two patients can have the same medical diagnosis and still need very different nursing care. The cookie-cutter care because standard interventions may fail to address the individual patient's need. A great example. Imagine two patients both need an increase in their fluid intake. You offer patient A iced tea. They say, "I hate iced tea." Okay. Do we document patient refused fluids, or do we critically think and ask, "What would you like to drink?" The patient tells you that they prefer grape juice, orange juice, lemonade, coffee now, you can learn something important. The goal wasn't get the patient to drink iced tea. The goal was improve the patient's fluid intake. That's individualizing care. The intervention still fits the patient, not simply a care plan template. Evaluation. Did it work? Now comes the final part, evaluation, and this is where nurses become dynamic. Evaluation means asking, "Did my intervention work? Did the patient improve? Was the goal realistic? Was the priority correct? Did the patient's condition change?" Nurses evaluate the accurate diagnosis, goals, priorities, interventions, and changes the patient's condition. And here's an important part. Evaluation can send you right back to assessment. That's because nursing isn't a straight line, it's a circle. Assessment, decide, plan, act, evaluate, then assess again. Let's see that happen. A patient initially has decreased activity tolerance. The plan is to gradually increase activity, but later the patient develops left calf pain, warm, redness, swelling. What happens? Do you say, "Well, our care says we should increase activity. Let's keep going."? Absolutely not. You need to reassess. The patient's condition has changed. Further testing confirms they had a Thrombophlebitis Now, the nursing diagnosis changes, the intervention changes, expected outcome changed. The entire plan changes. This is a crucial lesson. A good nurse does not stubbornly follow the old plan when the patient has a change. A good nurse recognizes that the patient has changed and changes the plan accordingly Critical judgment, when critical thinking becomes an action. Now let's take this one step further. You may be thinking, "Okay, I understand the nursing process, but what happens when something unexpected occurs?" That is where clinical Judgment comes in. Clinical judgment is taking your critical thinking and turning it into a nursing action. Imagine you walking into a patient's room. The patient is lying flat. They are having difficulty breathing. Their lips look bluish. Their oxygen mask is lying on the bed next to them. What do you do? You don't stand there thinking, "Hmm, I wonder which chapter this is in." You recognize the clues. You understand that the patient may not be adequately oxygenated. You take immediate actions within your role and scope. You raise the head of the bed. You ensure the prescribed oxygen is correctly applied and functioning. You rapidly assess the patient. You look at the respiratory rate. You listen to the lungs. You check the oxy-oxygen saturation. When you evaluate the response and notify the appropriate supervisor or healthcare professional, that is clinical judgment in action. Notice how quickly the nursing process happened. You assessed, you identified the problem, you determined what needed to happen first. You immediately jumped into an intervention. You evaluated the response. All of that happened very quickly. That's what nurses mean when we talk about think on your feet. What does this mean for you as an LPN? Let's talk specifically about your role. The RN is responsible for the full nursing process, including assessment, nursing diagnosis, outcome identification, planning, implementation, and evaluation. The LPN, LVN participates directly in planning interventions and evaluations, while assessing findings are shared with and, when applicable, confirming with the RN. The LPN also contributes significantly to development of the nursing diagnosis. Always practice according to your state's nursing practice act, fac-facility policies, and your defined scope. So please don't interpret That as, "I'm an LPN, so I don't assess." You absolutely need your assessment skills. You need to recognize abnormal findings. You need to collect meaningful information. You need to communicate what you find. You need to participate in planning and providing appropriate interventions. You need to evaluate your patient's response. Your scope of practice matters. Your facility's policies matters. Your state's nursing practice act matters. And your relationship with your team members matter. Why do your instructors make you do care plans? Seems silly, but let's go ahead and address this one. You may think, "Why do I have to write all these care plans? Am I really going to do this one day when I become an LPN?" Probably not to the same detail and format that you're doing right now, but the care plan is a learning tool. It focuses you to connect the medical diagnosis, the assessment findings, the patient's problems, the nursing diagnosis, the expected outcomes, the interventions, and the evaluations. Students' care plans help students connect these elements and sharpen critical thinking and nursing decision-making. So don't think your care plans are busy work. Think of it as a nursing brain training. You're learning how to connect the dots. Concept maps. See the connection. Another tool you may encounter is a concept map. Think of a concept map as a visual picture of your patient's problems and how it connects. Put the reason for the hospitalization in the middle. Then connect the patient's nursing problems around it. Add your supporting assessment findings, connect related problems, then identify interventions and outcomes. Concept mapping helps you visualize seeing the relationship between the assessment data, nursing diagnosis, interventions, and outcomes. And honestly, if you're a visual learner, it can help tremendously. Instead of looking at a page of disconnected information, you'll begin to see the patient's story. Patient is the center of the process. Let's bring everything together. Imagine you're preparing for clinicals. You are given information about a patient with coronary artery disease. You know that the patient has experienced chest pain. The patient has activity restrictions. The patient is scheduled for a coronary angiogram. The patient is anxious about the procedure. You begin researching. You consider possible nursing diagnosis. You develop expected outcomes. You think about interventions, and then you arrive at clinicals, and suddenly the patient is not exactly the person you expected. He's pale, he is shaky, his blood pressure is elevated, his pulse is irregular. He has diaphoresis with exertion, and he's worried about the procedure. He is worried about what the procedure might reveal. He has a history of smoking, and now you have new assessment information, and that information matters. You reassess your thinking. You decide whether your previous priorities remain appropriate. You implement your interventions, and then you evaluate the results. The patient ultimately undergoes the procedure and receives two stents. He understands what to expect because you prepared him. He feels better. Now, additional teaching is needed for discharge. That entire experience demonstrates something that is very important. The nursing process isn't a worksheet, it is a way of thinking Let's go ahead and take some final takeaways. Number one, assess before you assume. Gather the facts, listen, observe, ask the questions, validate. Number two, prioritize what matters most. Look at safety and physical needs first. Ask yourself, "What could harm my patient?" Number three, individualize your care. Your patient is not simply a diagnosis. Find out what is that particular person's needs. Number four, evaluate everything you do. Don't just ask, "Did I do it?" Ask, "Did it help?" And number five, be willing to change your plan. Patients change. Their conditions change. Your assessment may reveal something new. Your nursing care must change with them and here's the thought I want you to take away with you. Being a nurse is not about knowing every answer immediately. It's about knowing how to think when you don't have all the answers. It's about recognizing important clues. It's about asking the right questions. It's about knowing what requires your attention first. It's about taking safe action, and it's about looking at your patients after asking, "Did that work?" That's nursing. That's critical thinking. That's clinical judgment. And it's how you begin to move from a nursing student who performs tasks to becoming the nurse who is thinking about the patient behind every task. So next time you walk into your patient's room, don't just ask, "What do I need?" Ask yourself, "What is my patient telling me? What am I seeing? What matters most? What should I do?" And finally, "Did it work?" Keep those questions. Keep practicing. Keep connecting the dots. Because every time you use your nursing process, you aren't just completing an assignment. You're learning how to think like a nurse. I'm glad you joined me for another episode of Nursing Together. Until next time, keep learning, keep questioning, keep critical thinking, and most importantly, keep putting the patient at the center of everything that you do.