Download - Clinical Reasoning, Assessment, and Documentation Practicum of Health Science Technology 2009 - 2010
Clinical Reasoning, Clinical Reasoning, Assessment, and Assessment, and DocumentationDocumentationPracticum of Health Practicum of Health
Science Technology 2009 - Science Technology 2009 - 20102010
ObjectivesObjectives
At the end of this unit the student At the end of this unit the student will be able to:will be able to:
Analyze findings from physical Analyze findings from physical assessmentassessment
Identify patient’s problemsIdentify patient’s problems Formulate a plan of care for Formulate a plan of care for
patientpatient Document assessment, findings, Document assessment, findings,
and plan of careand plan of care
Identifying Problems and Making Identifying Problems and Making DiagnosisDiagnosis
1.1. Identify abnormal findingsIdentify abnormal findings2.2. Localize these findings anatomicallyLocalize these findings anatomically3.3. Interpret findings in terms of Interpret findings in terms of
probable processprobable process4.4. Make hypothesis about the nature of Make hypothesis about the nature of
the patient’s problemthe patient’s problem5.5. Test the hypothesis and establish a Test the hypothesis and establish a
working diagnosisworking diagnosis6.6. Develop a plan agreeable to the Develop a plan agreeable to the
patient to address identified problempatient to address identified problem
Scientific MethodScientific Method
Refers to techniques for Refers to techniques for investigating phenomenainvestigating phenomena
Method of inquiry based on Method of inquiry based on gathering observable, empirical, gathering observable, empirical, and measurable evidence subject and measurable evidence subject to specific principles of reasoningto specific principles of reasoning
Collection of data through Collection of data through observation, experimentation, and observation, experimentation, and the formulation and testing of a the formulation and testing of a hypothesis hypothesis
Steps to the Scientific MethodSteps to the Scientific Method
1.1. Define the question (Problem)Define the question (Problem)2.2. Gather information and resourcesGather information and resources3.3. Form hypothesisForm hypothesis4.4. Perform experiment and collect dataPerform experiment and collect data5.5. Analyze dataAnalyze data6.6. Interpret data and draw conclusions Interpret data and draw conclusions
that serve as a starting point for a that serve as a starting point for a new hypothesisnew hypothesis
7.7. Publish resultsPublish results8.8. RetestRetest
What is the problem?What is the problem?
Chief ComplaintChief Complaint What brought the patient to What brought the patient to
seek medical care?seek medical care? Signs and SymptomsSigns and Symptoms
Gather Information and Gather Information and ResourcesResources
Patient Medical HistoryPatient Medical History Previous diagnostic testingPrevious diagnostic testing
Form HypothesisForm Hypothesis
What do you suspect is going on What do you suspect is going on with the patient based on the with the patient based on the signs and symptoms, and patient signs and symptoms, and patient medical historymedical history
Perform Experiment and Collect Perform Experiment and Collect DataData
Physical ExaminationPhysical Examination
Analyze Data Analyze Data
Diagnostic Diagnostic interpretationinterpretation
Differential Differential DiagnosisDiagnosis
Interpret data and draw Interpret data and draw conclusions that serve as a conclusions that serve as a
starting point for a new starting point for a new hypothesishypothesis
What is patient What is patient suspected suspected diagnosis?diagnosis?
Publish resultsPublish results
Plan of care to address patient Plan of care to address patient “problem”, chief complaint “problem”, chief complaint
Medical diagnosisMedical diagnosis
RetestRetest
Follow up appointmentFollow up appointment Results of diagnostic testing Results of diagnostic testing
orderedordered Additional testing ordered based Additional testing ordered based
on resultson results New medical plan of careNew medical plan of care
Nursing ProcessNursing Process
AssessmentAssessment DiagnosisDiagnosis PlanPlan ImplementationImplementation EvaluationEvaluation
AssessmentAssessmentThe most critical step in the The most critical step in the
nursing process.nursing process. Answers the question: “What is Answers the question: “What is
happening?”, or “What could happening?”, or “What could happen?”happen?”
Involves collecting, organizing, Involves collecting, organizing, and analyzing information/data and analyzing information/data about the patientabout the patient
Results in Nursing DiagnosisResults in Nursing Diagnosis- Data Collection- Data Collection- Data Analysis - Data Analysis
Data CollectionData Collection
Types of Data:Types of Data: SubjectiveSubjective ObjectiveObjectiveSources of Data:Sources of Data: Primary – the patient; always the Primary – the patient; always the
best sourcebest source Secondary – family members; Secondary – family members;
diagnostic testing; other health diagnostic testing; other health care professionals assessmentcare professionals assessment
Methods of Data CollectionMethods of Data Collection
InterviewInterview Structured form of communicationStructured form of communication Purpose is to provide care specific to Purpose is to provide care specific to
this client’s needs and problemsthis client’s needs and problems Health HistoryHealth HistoryExaminationExamination InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation
Data AnalysisData Analysis
Data ReviewData Review Are data accurate and complete?Are data accurate and complete?
Data InterpretationData Interpretation What are the patient’s actual What are the patient’s actual
and/or potential problems?and/or potential problems? Develop a problem list based on Develop a problem list based on
the datathe data Prioritize the patient’s problemsPrioritize the patient’s problems
PlanPlan
What are you going to do about What are you going to do about this patient’s problem?this patient’s problem?
How can you address this How can you address this problem?problem?
Why do you think this plan will Why do you think this plan will improve the patient’s level of improve the patient’s level of wellness? (rationales)wellness? (rationales)
Nursing DiagnosisNursing Diagnosis
Defined by the North American Defined by the North American Nursing Diagnosis Association Nursing Diagnosis Association (NANDA), as a clinical judgment (NANDA), as a clinical judgment about individual, family, or about individual, family, or community responses to actual, community responses to actual, or potential health problems/life or potential health problems/life processes that requires nursing processes that requires nursing interventionintervention
Nursing DiagnosisNursing Diagnosis
Standardized statement about the Standardized statement about the health of a client for the purpose of health of a client for the purpose of providing nursing careproviding nursing care
Developed based on data obtained Developed based on data obtained during nursing assessmentduring nursing assessment
Provide the basis for selection of Provide the basis for selection of nursing interventions to achieve nursing interventions to achieve outcomes for which the nurse is outcomes for which the nurse is accountableaccountable
Types of DiagnosisTypes of Diagnosis
ActualActual RiskRisk PossiblePossible SyndromeSyndrome WellnessWellness
Actual DiagnosisActual Diagnosis
Statement about a health Statement about a health problem the client has, and the problem the client has, and the benefit from nursing carebenefit from nursing care
Risk DiagnosisRisk Diagnosis
Statement about health Statement about health problems that a patient does not problems that a patient does not have yet, but is at high risk to have yet, but is at high risk to develop in the near futuredevelop in the near future
Possible DiagnosisPossible Diagnosis
Statement about a health Statement about a health problem the patient might have problem the patient might have currently, but there is currently, but there is insufficient information currently insufficient information currently to make an actual diagnosisto make an actual diagnosis
Syndrome DiagnosisSyndrome Diagnosis
Used when a cluster of nursing Used when a cluster of nursing diagnosis are seen togetherdiagnosis are seen together
Wellness DiagnosisWellness Diagnosis
Describes an aspect of the client Describes an aspect of the client that is at a low level of wellnessthat is at a low level of wellness
Structure of Nursing DiagnosisStructure of Nursing Diagnosis
ProblemProblem EtiologyEtiology Medical DiagnosisMedical Diagnosis ManifestationsManifestations
ProblemProblem
Statement of the patient’s risk Statement of the patient’s risk for or actual health condition for or actual health condition that the nurse is licensed and that the nurse is licensed and accountable to treataccountable to treat
EtiologyEtiology
Factors “related to” or Factors “related to” or “associated with” the patient’s “associated with” the patient’s problemproblem
Medical DiagnosisMedical Diagnosis
If knownIf known What you can attribute the What you can attribute the
patient’s current problem topatient’s current problem to Must be determined by Must be determined by
physician, prior to being utilized physician, prior to being utilized in nursing diagnosisin nursing diagnosis
ManifestationsManifestations
““as manifested by”as manifested by” Signs and symptoms of the Signs and symptoms of the
problem identifiedproblem identified Subjective and objective dataSubjective and objective data
PlanPlan What are you going to do about this What are you going to do about this
patient’s problem?patient’s problem? How can you address this problem?How can you address this problem? Why do you think this plan will improve Why do you think this plan will improve
the patient’s level of wellness? the patient’s level of wellness? (rationales)(rationales)
Direction for nursing action designed to Direction for nursing action designed to assist the client and/or significant other assist the client and/or significant other to meet the expected outcomesto meet the expected outcomes
Nursing actions are specific, realistic, Nursing actions are specific, realistic, and individualized for a particular patientand individualized for a particular patient
ImplementationImplementation
Caring out the planCaring out the plan Actual hands on with the patientActual hands on with the patient Physically addressing the Physically addressing the
patient’s problempatient’s problem
EvaluationEvaluation
Determine whether or not plan Determine whether or not plan actually maintained or increased actually maintained or increased patient’s level of wellnesspatient’s level of wellness
If not what needs to be done to If not what needs to be done to change the plan, where it will change the plan, where it will have a positive effect on the have a positive effect on the patient’s level of wellnesspatient’s level of wellness
Nursing Care PlanNursing Care Plan
Universal Self Care RequisitesUniversal Self Care Requisites Nursing DiagnosisNursing Diagnosis Expected OutcomesExpected Outcomes Nursing InterventionsNursing Interventions RationalesRationales Evaluation of OutcomesEvaluation of Outcomes
Universal Self Care RequisitesUniversal Self Care Requisites
The category of self-care The category of self-care requisites that are basic and requisites that are basic and common to all humans and are common to all humans and are constantly present; these needs constantly present; these needs must be met to achieve optimal must be met to achieve optimal health and well-being. health and well-being.
There are eight universal self-There are eight universal self-care requisites:care requisites:
1.1. AirAir
2.2. FoodFood
3.3. WaterWater
4.4. EliminationElimination
5.5. Activity and RestActivity and Rest
6.6. Solitude and Solitude and Social InteractionSocial Interaction
7.7. Prevention of Prevention of HazardsHazards
8.8. NormalcyNormalcy
Self – Care Agency (SCA)Self – Care Agency (SCA)
Assets or abilities of Assets or abilities of an individual to an individual to perform self-careperform self-care
Self – Care Deficit (SCD)Self – Care Deficit (SCD)
Deficit Deficit relationship that relationship that exists when the exists when the demand for self – demand for self – care exceeds the care exceeds the person’s ability to person’s ability to perform self – perform self – care.care.
Nursing Diagnosis (NANDA)Nursing Diagnosis (NANDA)
AirAir WaterWater FluidFluid FoodFood EliminationElimination Solitude – Social Solitude – Social
IsolationIsolation Social Social
InteractionInteraction
Activity/RestActivity/Rest HygieneHygiene Pain/ComfortPain/Comfort HazardsHazards NeurosensoryNeurosensory SexualitySexuality NormalcyNormalcy Teaching/Teaching/
LearningLearning
DocumentationDocumentation
Goal:Goal: Clear, concise, but comprehensive Clear, concise, but comprehensive
report that documents the key report that documents the key findings of your patient findings of your patient assessment and communicates assessment and communicates the patient’s problems in a brief the patient’s problems in a brief and legible format to other health and legible format to other health care providers and members of care providers and members of the health care team.the health care team.
DocumentationDocumentation
Think about:Think about: Order and readabilityOrder and readability Amount of detail neededAmount of detail needed
Checklist for Clear and Accurate Checklist for Clear and Accurate DocumentationDocumentation
Is the order clear?Is the order clear? Make sure that future readers, Make sure that future readers,
including yourself, can easily including yourself, can easily find specific points of find specific points of informationinformation
Make the headings clearMake the headings clear Accent your organization with Accent your organization with
indentations and spacingindentations and spacing
Does the data included Does the data included contribute directly to the contribute directly to the assessment?assessment?
Spell out supporting evidence for Spell out supporting evidence for every problem or diagnosis that is every problem or diagnosis that is identifiedidentified
Be sure there is sufficient detail Be sure there is sufficient detail to support the Assessment and to support the Assessment and PlanPlan
Are possible, and risk diagnosis Are possible, and risk diagnosis specifically described?specifically described?
Often portions of the history or Often portions of the history or examination suggest that an examination suggest that an abnormality might exist or abnormality might exist or develop in that areadevelop in that area
Are there overgeneralizations or Are there overgeneralizations or omissions of important data?omissions of important data?
Data not recorded is data that is Data not recorded is data that is lost!lost!
If you don’t document If you don’t document it, it was not done!it, it was not done!
Is there too much detail?Is there too much detail?
Is there excess repetition of Is there excess repetition of information or redundancy?information or redundancy?
Is important information buried Is important information buried in a mass of detail?in a mass of detail?
Are phrases and short words Are phrases and short words used appropriately?used appropriately?
Omit unnecessary wordsOmit unnecessary words This saves time and spaceThis saves time and space Omit repetitive introductory Omit repetitive introductory
phrasesphrases Use short words instead of Use short words instead of
longer, fancier ones when they longer, fancier ones when they mean the same thingmean the same thing
Describe what you observedDescribe what you observed
Is the written style brief? Is there Is the written style brief? Is there excessive use of abbreviations?excessive use of abbreviations?
Medical records are legal Medical records are legal documents, so they should be clear documents, so they should be clear and understandableand understandable
Using words and brief phrases Using words and brief phrases instead of whole sentences is instead of whole sentences is common, but abbreviations and common, but abbreviations and symbols should be used only if symbols should be used only if they are readily understoodthey are readily understood
Are diagrams and precise Are diagrams and precise measurements included where measurements included where
appropriate?appropriate?
Diagrams add greatly to the Diagrams add greatly to the clarity of the recordclarity of the record
Make sure measurements are in Make sure measurements are in metric units when possiblemetric units when possible
Is the tone of the documentation Is the tone of the documentation neutral and professional?neutral and professional?
You must remain objective!You must remain objective! Hostile, moralizing, or disapproving Hostile, moralizing, or disapproving
comments have no place in the comments have no place in the patient’s medical record.patient’s medical record.
Remember this is a Remember this is a LEGALLEGAL document! document! NEVER use inflammatory, demeaning, NEVER use inflammatory, demeaning,
derogatory, words, penmanship, or derogatory, words, penmanship, or punctuation in documentationpunctuation in documentation
Types of DocumentationTypes of Documentation
Physician progress notePhysician progress note PIE chartingPIE charting SOAP/SOAPIESOAP/SOAPIE
Physician Progress NotePhysician Progress Note ID = Identification of patientID = Identification of patient CC = Chief ComplaintCC = Chief Complaint HPI = History of Present IllnessHPI = History of Present Illness PMH = Past Medical HistoryPMH = Past Medical History Personal HistoryPersonal History Health HabitsHealth Habits Health Maintenance Health Maintenance Family HistoryFamily History Review of SystemsReview of Systems Physical ExaminationPhysical Examination Diagnostic StudiesDiagnostic Studies Plan of CarePlan of Care
PIE ChartingPIE Charting
P = ProblemP = Problem I = InterventionI = Intervention E = EvaluationE = Evaluation
SOAP/SOAPIESOAP/SOAPIE
S = Subjective informationS = Subjective information O = Objective informationO = Objective information A = Assessment A = Assessment P = PlanP = Plan I = ImplementationI = Implementation E = EvaluationE = Evaluation
Principles of Test Selection and Principles of Test Selection and UseUse
ReliabilityReliability ValidityValidity SensitivitySensitivity SpecificitySpecificity Predictive valuePredictive value Positive predictive valuePositive predictive value Negative predictive valueNegative predictive value
ReliabilityReliability
Indicates how well repeated Indicates how well repeated measurements of the same measurements of the same relatively stable phenomenon relatively stable phenomenon will give the same resultwill give the same result
PrecisionPrecision May be measured for one May be measured for one
observer or for more than one observer or for more than one observerobserver
ValidityValidity
Indicates how closely a given Indicates how closely a given observation agrees with “the observation agrees with “the true state of affairs”true state of affairs”
Best possible measure of realityBest possible measure of reality
SensitivitySensitivity Identifies the proportion of people Identifies the proportion of people
who test positive in a group of people who test positive in a group of people known to have the disease condition, known to have the disease condition, or the proportion of people who are or the proportion of people who are true positivestrue positives compared with the compared with the total number of people who actually total number of people who actually have the diseasehave the disease
When the observation or test is When the observation or test is negative in people with the disease, negative in people with the disease, the result is termed the result is termed false negativefalse negative
Good tests have a sensitivity of 90%, Good tests have a sensitivity of 90%, and help rule out disease because and help rule out disease because there are few false negatives there are few false negatives
SpecificitySpecificity Identifies the proportion of people who Identifies the proportion of people who
test negative in a group of people test negative in a group of people known to be without a given disease or known to be without a given disease or condition or the proportion of people condition or the proportion of people who are “true negatives” compared who are “true negatives” compared with the total number of people with the total number of people without the diseasewithout the disease
When the test is positive in people When the test is positive in people without the disease, the result is without the disease, the result is termed, termed, false positivefalse positive
Good test have a specificity of 90% and Good test have a specificity of 90% and help determine disease because the help determine disease because the test is rarely positive when test is rarely positive when disease/condition is absent, and there disease/condition is absent, and there are few false positivesare few false positives
Predictive ValuePredictive Value
Indicates how well a given Indicates how well a given symptom, sign or test result – symptom, sign or test result – either positive or negative – either positive or negative – predicts the presence or absence predicts the presence or absence of diseaseof disease
Positive Predictive ValuePositive Predictive Value
Probability of disease in a Probability of disease in a patient with a positive patient with a positive (abnormal) test, or the (abnormal) test, or the proportion of “true positives” proportion of “true positives” out of the total population out of the total population testedtested
Negative Predictive ValueNegative Predictive Value
Probability of not having the Probability of not having the condition or disease when the condition or disease when the test is negative, or normal, or test is negative, or normal, or the proportion of “true the proportion of “true negatives” out of the total negatives” out of the total population testedpopulation tested
Gold StandardGold Standard
The best or most successful The best or most successful diagnostic or therapeutic diagnostic or therapeutic modality for a condition, against modality for a condition, against which new test or results and which new test or results and protocols are compared.protocols are compared.
Gold StandardGold Standard
9595
True PositiveTrue Positive
1010
False - False - PositivePositive
55
False - False - NegativeNegative
9090
True True NegativeNegative
Gold StandardGold Standard
Numbers related to presence or Numbers related to presence or absence of disease are always absence of disease are always displayed down the table in the displayed down the table in the left and right columnsleft and right columns
PresentPresent = a + c = a + c Absent Absent = b + d= b + d
Gold StandardGold Standard
Numbers related to the test are Numbers related to the test are always displayed across the always displayed across the table in the upper and lower table in the upper and lower rowsrows
Test positive Test positive = a + b= a + b Test negative Test negative = c + d= c + d
Medical TerminologyMedical Terminology
InstructionsInstructions
Define the following terms in your Define the following terms in your interactive note book. Utilize interactive note book. Utilize KIM technique with the K = Key KIM technique with the K = Key word/ key term; I = Information/ word/ key term; I = Information/ Definition; and M = Memory Cue Definition; and M = Memory Cue – something that will help you to – something that will help you to remember the term. Maybe a remember the term. Maybe a picture, word, or phrase.picture, word, or phrase.
TermsTerms
Scientific MethodScientific Method HypothesisHypothesis Nursing Nursing
DiagnosisDiagnosis Actual DiagnosisActual Diagnosis Risk DiagnosisRisk Diagnosis Possible Possible
DiagnosisDiagnosis
Syndrome Syndrome DiagnosisDiagnosis
Wellness Wellness DiagnosisDiagnosis
EtiologyEtiology Medical Medical
DiagnosisDiagnosis RationaleRationale Universal Self Universal Self
RequisitesRequisites
TermsTerms Self – Care AgencySelf – Care Agency Self – Care DeficitSelf – Care Deficit ReliabilityReliability ValidityValidity SpecificitySpecificity SensitivitySensitivity Predictive ValuePredictive Value Positive Predictive ValuePositive Predictive Value Negative Predictive ValueNegative Predictive Value Gold StandardGold Standard
Medical AbbreviationsMedical Abbreviations
Dx – DiagnosisDx – Diagnosis Hx – HistoryHx – History H&P – History and Physical H&P – History and Physical
ExaminationExamination amb – As manifested byamb – As manifested by 22° - Secondary to° - Secondary to aeb – As evidenced byaeb – As evidenced by USCR – Universal Self Care USCR – Universal Self Care
RequisitesRequisites
SCA – Self Care AgencySCA – Self Care Agency SCD – Self Care DeficitSCD – Self Care Deficit NANDA – North American Nursing NANDA – North American Nursing
Diagnosis AssociationDiagnosis Association PIE – Problem, Intervention, PIE – Problem, Intervention,
EvaluationEvaluation SOAPIE – Subjective, Objective, SOAPIE – Subjective, Objective,
Assessment, Plan, Assessment, Plan, Implementation, EvaluationImplementation, Evaluation
VIP of the WeekVIP of the Week
Florence NightingaleFlorence Nightingale
Instructions: Research this person and Instructions: Research this person and write the following in your interactive write the following in your interactive notebook.notebook.
Who is she? Describe her as a person.Who is she? Describe her as a person. What significance did she have to What significance did she have to
medicine, science, or health care?medicine, science, or health care? How can you utilize her contribution How can you utilize her contribution
in your profession?in your profession? How did her contribution affect the How did her contribution affect the
world?world?