chapter4.pdf

Chapter 4 The Art of Diagnosis and Treatment Dr. Asomani  The Art of Diagnosis and Treatment The advanced practice registered nurse’s (APRN’s) unique services Care based on current research—evidence-based practice (EBP) Nursing perspective of the whole person Does more th...

Chapter 4 The Art of Diagnosis and Treatment Dr. Asomani  The Art of Diagnosis and Treatment The advanced practice registered nurse’s (APRN’s) unique services Care based on current research—evidence-based practice (EBP) Nursing perspective of the whole person Does more than diagnose and treat Look at the kind of thinking an APRN utilizes  Clinical Judgment in Primary Care Clinical judgment and the Circle of Caring Medical model and nursing approach Medical diagnosis (ICD-10) and human responses Caring and authentic presence Ability to link patient experience with health, diagnosis, therapeutic choices, and possible outcomes Clinical Judgment in Primary Care (continued_1) Purpose and goal of diagnostic reasoning Problem-solving, opportunity disease prevention, screening, and health promotion Taken seriously and not ignored Complex stories Attend to “By the way, I was wondering…” as lead-in to real concerns  Context of Clinical Judgment in Primary Care Purpose and goal of diagnostic reasoning (continued) Variety of problems Organized approach needed Long-term relationships  Clinical Judgment in Primary Care (continued_2) Unique aspects of primary care Types of patient problems in primary care are unique and illness presentations are different than in other settings Psychosocial problems frequently present with vague, nonspecific somatic complaints Pace is different  Clinical Judgment in Primary Care (continued_3) Uncertainty Increased autonomy and increased uncertainty Uncertainties in aspects of care even with experienced APRNs Some patient problems require lifelong lifestyle adjustments Intellectual honesty and humility balanced with confidence based on experience  Clinical Judgment in Primary Care (continued_4) Nursing and the medical model Both: gain medical domain skills, build new skills based on the nursing frameworks Consider responses to threats, coping, and meaning of illness to patient Approach is individualized  Clinical Judgment in Primary Care (continued_5) Patient-APRN linkages Model Figure 4.1 Clinical judgment happens in dialogue between patient and provider Model includes patient, provider, and environmental factors  Clinical Judgment in Primary Care (continued_6) Johnson (1993), Phases of Discourse Establish agenda Develop plan of care Elicit information Use teachable moment (patient Alert for cues centered) Help problem solve Personalize solutions Physical exam APRN’s high patient satisfaction  Clinical Process and Its Limitations Human memory limitations Information processing model Short-term memory New information Seven bits Clusters and chunks  Clinical Process and Its Limitations (continued_1) Human memory limitations (continued) Long-term memory Vast quantities of information (data and associated emotions) Must be accessible to be able to retrieve information Repetitive exercises Organization structure fact is associated Element of human contact in clinical process  Clinical Process and Its Limitations (continued_2) Critical thinking Critical thinking supports clinical Reflective process judgment Explores all possible avenues Humility Conclusions drawn on evidence Systematic Creative Strengthen of evidence for conclusion (hard and soft) Potential problems and goal development  Clinical Process and Its Limitations (continued_3) Intuition Intuition and clinical judgment Based on long Reminded of past experience experience in setting and what will likely happen Unconscious thought when in new experience process probably based Unable to verbalize data on pattern matching points that lead to conclusion Thinking slows down the process Expert level of practice  Clinical Process and Its Limitations (continued_4) Developing expertise Benner et al. (1996) Differences in clinical judgment based on experience Features of diagnostic reasoning in Benner’s stages See Table 4.1 in text Diagnostic Process Overview Diagnostic reasoning process Data generation and clustering Pattern matching Hypothesis generation Planning Probabilistic reasoning Problem solving Critical reflection  Diagnostic Process Overview (continued_1) Data collection List of possible diagnoses or hypotheses If diagnosis is in first list, higher possibility it is correct Experienced clinicians use hypothesis-driven data acquisition Novice tends to use “shotgun” approach  Diagnostic Process Overview (continued_2) Data collection (continued) Hypothesis-driven seeks data to confirm or disprove hypothesis Competing hypotheses ruled out by seeking nonconfirmatory data Data collection needs to be more than completely symptom driven  Diagnostic Process Overview (continued_3) Hypothesis evaluation Data clustered into meaningful chunks Alert to data that do not fit pattern expected On guard not to ignore discrepant data “Common things occur commonly” “When you hear hoof beats, think horses, not zebras”  Diagnostic Process Overview (continued_4) Hypothesis evaluation (continued) Rare conditions have lower probability Focus on the most serious conditions Diagnoses are frequently interrelated Deal with underlying problem and other problems may not need direct intervention Diagnostic Process Overview (continued_5) Habits that support clinical judgment (Table 4.2) Data acquisition Hypothesis formulation Hypothesis evaluation Problem naming Goal setting Therapeutic option consideration Evaluation  Diagnostic Process Overview (continued_6) Errors in diagnostic reasoning Table 4.3 Data collection Hypothesis generation  Diagnostic Process Overview (continued_7) Reaching a working diagnosis Discussion of a management plan with the patient Honest conversation about patient’s ability and willingness to follow treatment recommendations Inclusion of a follow-up plan Importance of the physical examination Comfort measures and evaluating treatment plan Elements of the Diagnostic Process OLD CART mnemonic (Box 4.1) Onset Characteristics Location Aggravating factors Duration Relieving factors Treatment  Elements of the Diagnostic Process (continued_1) History of present illness Chief complaint: sort out diagnostic possibilities Specific questions: sort out competing diagnoses Open-ended questions Clarify story  Elements of the Diagnostic Process (continued_2) Address what patient thinks is wrong Establish relationship Identify with patient most important/accomplish  Elements of the Diagnostic Process (continued_3) Past medical history Refine hypothesis Suggests risk factors All medications: “brown bag” method Immunizations Allergies and kind of reaction Health maintenance practices  Elements of the Diagnostic Process (continued_4) Family history Part of risk factor assessment Genogram (see Figure 4.2) Social history Work history Functional health patterns  Elements of the Diagnostic Process (continued_5) Review of symptoms Questionnaire: general to specific Functional health patterns Marjory Gordon’s nursing questions Advanced Assessment 4.1 Physical examination Clarify and detect  Elements of the Diagnostic Process (continued_6) Diagnostic tests Confirm, rule out, or screen Vary usefulness: sensitivity, specificity, and predictive value False-positive and false-negative results (Table 4.4) Predictive value and accuracy Consider cost and convenience  Elements of the Diagnostic Process (continued_7) Differential diagnosis Prioritized list of possible diagnoses One approach: “skin in” Diagnosis often involves more than medical problems Nursing Situation: A Nurse Practitioner’s Approach to Differential Diagnosis  Elements of the Diagnostic Process (continued_8) Differential diagnosis (continued) Nursing Situation: An Advanced Practice Nurse’s View of Nursing Versus Medical Problems  Elements of the Diagnostic Process (continued_9) Developing management plan “Presenting the patient” to preceptors Problem list clarified Clinical judgment: how to best manage Broader than prescription medications Different levels of interventions Address functional patterns  Elements of the Diagnostic Process (continued_10) Developing management plan (continued) Brief teaching Brief counseling Life patterns Spiritual support  Elements of the Diagnostic Process (continued_11) The Diagnostic Process in Action Simple encounter for self-limiting acute illness “Sore throat” ▪ Generating a hypothesis ▪ Physical examination ▪ Consideration of treatment decisions  Current Diagnostic Process Trends Evidence-based practice Most up-to-date treatment approaches Justified by clinical trials or case studies Informed choices about treatment Use of guidelines for practice http://www.guideline.gov/ Basis protocol development and peer review  Current Diagnostic Process Trends (continued_1) Shared Decision-Making Patient-centered care model that encourages the patient and family to be involved, informed, and engaged in all decisions Presumes the providers will respect patient preferences, values, and opinions  Current Diagnostic Process Trends (continued_2) Outcome considerations Patient and providers agreement Different settings prompt different sets of outcomes Chronic or reduced quality of life requires sensitivity in outcome determinations  Documentation SOAP format Consists of Subjective, Objective, Assessment, and Plan Concise, compressive, and meaningful Purpose: record data and findings Accuracy essential and actions at next follow-up  Documentation (continued_1) SOAP format (continued) Subjective All data from patient’s report Outline form Make data easily retrievable  Documentation (continued_2) SOAP format (continued) Objective Date from objective means Not limited to numerical data Includes “tired looking,” “worried” Pertinent negatives  Documentation (continued_3) SOAP format (continued) Assessment Active problems being managed Include chronic problems that have an impact on plan Preventive health promotion Ongoing  Documentation (continued_4) SOAP format (continued) Plan Treatment defined in specific detail Includes specific directions Three general sections 1. Diagnostic testing 2. Educational approaches 3. Clear follow-up plans  Documentation (continued_5) SOAP format (continued) Plan Include sense of the goal of treatment Discuss and record goals of therapy for chronic or complex problems Consider whether documentation conveys scope and tone of the visit  Documentation (continued_6) Documentation Systems Usually “invented” by each practice Opportunity for NPs in practice to rectify problems in the records ▪ Claiming credit and billing for care  Reduction of Medical Error Institute of Medicine study: Primary care has largest number of errors Administration: misfiled information, chart not available, lack of documentation Processing laboratory specimens  The Digital Future Increased use of electronic media in health care Records maintained electronically Able to communicate information with public who have access to computers or Internet Many practices send their patients e-mails with health-related information  The Digital Future (continued) Telehealth (telemedicine) Inconsistent laws and policies Next phase of medical innovation: incorporation of smartphones and mobile apps for monitoring and data transfer New field of precision medicine Ethics Every clinical judgment is an ethical judgment Beneficence Autonomy Truth telling Allocation of resources Patient advocate Fidelity Circle of Caring: Relationship potential to enhance patient and nurse