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?