1. Clinical Reasoning, Assessment, and Documentation Practicum of Health Science Technology 2009 - 2010

2. Objectives At the end of this unit the student will be able to: Analyze findings from physical assessment Analyze findings from physical assessment Identify patient’s problems Identify patient’s problems Formulate a plan of care for patient Formulate a plan of care for patient Document assessment, findings, and plan of care Document assessment, findings, and plan of care

3. Identifying Problems and Making Diagnosis 1. Identify abnormal findings 2. Localize these findings anatomically 3. Interpret findings in terms of probable process 4. Make hypothesis about the nature of the patient’s problem 5. Test the hypothesis and establish a working diagnosis 6. Develop a plan agreeable to the patient to address identified problem

4. Scientific Method Refers to techniques for investigating phenomena Refers to techniques for investigating phenomena Method of inquiry based on gathering observable, empirical, and measurable evidence subject to specific principles of reasoning Method of inquiry based on gathering observable, empirical, and measurable evidence subject to specific principles of reasoning Collection of data through observation, experimentation, and the formulation and testing of a hypothesis Collection of data through observation, experimentation, and the formulation and testing of a hypothesis

5. Steps to the Scientific Method 1. Define the question (Problem) 2. Gather information and resources 3. Form hypothesis 4. Perform experiment and collect data 5. Analyze data 6. Interpret data and draw conclusions that serve as a starting point for a new hypothesis 7. Publish results 8. Retest

6. What is the problem? Chief Complaint Chief Complaint What brought the patient to seek medical care? What brought the patient to seek medical care? Signs and Symptoms Signs and Symptoms

7. Gather Information and Resources Patient Medical History Patient Medical History Previous diagnostic testing Previous diagnostic testing

8. Form Hypothesis What do you suspect is going on with the patient based on the signs and symptoms, and patient medical history What do you suspect is going on with the patient based on the signs and symptoms, and patient medical history

9. Perform Experiment and Collect Data Physical Examination Physical Examination

10. Analyze Data Diagnostic interpretation Diagnostic interpretation Differential Diagnosis Differential Diagnosis

11. Interpret data and draw conclusions that serve as a starting point for a new hypothesis What is patient suspected diagnosis? What is patient suspected diagnosis?

12. Publish results Plan of care to address patient “problem”, chief complaint Plan of care to address patient “problem”, chief complaint Medical diagnosis Medical diagnosis

13. Retest Follow up appointment Follow up appointment Results of diagnostic testing ordered Results of diagnostic testing ordered Additional testing ordered based on results Additional testing ordered based on results New medical plan of care New medical plan of care

14. Nursing Process Assessment Assessment Diagnosis Diagnosis Plan Plan Implementation Implementation Evaluation Evaluation

15. Assessment The most critical step in the nursing process. Answers the question: “What is happening?”, or “What could happen?” Answers the question: “What is happening?”, or “What could happen?” Involves collecting, organizing, and analyzing information/data about the patient Involves collecting, organizing, and analyzing information/data about the patient Results in Nursing Diagnosis Results in Nursing Diagnosis - Data Collection - Data Analysis

16. Data Collection Types of Data: Subjective Subjective Objective Objective Sources of Data: Primary – the patient; always the best source Primary – the patient; always the best source Secondary – family members; diagnostic testing; other health care professionals assessment Secondary – family members; diagnostic testing; other health care professionals assessment

17. Methods of Data Collection Interview Structured form of communication Structured form of communication Purpose is to provide care specific to this client’s needs and problems Purpose is to provide care specific to this client’s needs and problems Health History Health HistoryExamination Inspection Inspection Palpation Palpation Percussion Percussion Auscultation Auscultation

18. Data Analysis Data Review Are data accurate and complete? Are data accurate and complete? Data Interpretation What are the patient’s actual and/or potential problems? What are the patient’s actual and/or potential problems? Develop a problem list based on the data Develop a problem list based on the data Prioritize the patient’s problems Prioritize the patient’s problems

19. Plan What are you going to do about this patient’s problem? What are you going to do about this patient’s problem? How can you address this problem? How can you address this problem? Why do you think this plan will improve the patient’s level of wellness? (rationales) Why do you think this plan will improve the patient’s level of wellness? (rationales)

21. Nursing Diagnosis Defined by the North American Nursing Diagnosis Association (NANDA), as a clinical judgment about individual, family, or community responses to actual, or potential health problems/life processes that requires nursing intervention Defined by the North American Nursing Diagnosis Association (NANDA), as a clinical judgment about individual, family, or community responses to actual, or potential health problems/life processes that requires nursing intervention

22. Nursing Diagnosis Standardized statement about the health of a client for the purpose of providing nursing care Standardized statement about the health of a client for the purpose of providing nursing care Developed based on data obtained during nursing assessment Developed based on data obtained during nursing assessment Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

23. Types of Diagnosis Actual Actual Risk Risk Possible Possible Syndrome Syndrome Wellness Wellness

24. Actual Diagnosis Statement about a health problem the client has, and the benefit from nursing care Statement about a health problem the client has, and the benefit from nursing care

25. Risk Diagnosis Statement about health problems that a patient does not have yet, but is at high risk to develop in the near future Statement about health problems that a patient does not have yet, but is at high risk to develop in the near future

26. Possible Diagnosis Statement about a health problem the patient might have currently, but there is insufficient information currently to make an actual diagnosis Statement about a health problem the patient might have currently, but there is insufficient information currently to make an actual diagnosis

27. Syndrome Diagnosis Used when a cluster of nursing diagnosis are seen together Used when a cluster of nursing diagnosis are seen together

28. Wellness Diagnosis Describes an aspect of the client that is at a low level of wellness Describes an aspect of the client that is at a low level of wellness

29. Structure of Nursing Diagnosis Problem Problem Etiology Etiology Medical Diagnosis Medical Diagnosis Manifestations Manifestations

30. Problem Statement of the patient’s risk for or actual health condition that the nurse is licensed and accountable to treat Statement of the patient’s risk for or actual health condition that the nurse is licensed and accountable to treat

31. Etiology Factors “related to” or “associated with” the patient’s problem Factors “related to” or “associated with” the patient’s problem

32. Medical Diagnosis If known If known What you can attribute the patient’s current problem to What you can attribute the patient’s current problem to Must be determined by physician, prior to being utilized in nursing diagnosis Must be determined by physician, prior to being utilized in nursing diagnosis

33. Manifestations “as manifested by” “as manifested by” Signs and symptoms of the problem identified Signs and symptoms of the problem identified Subjective and objective data Subjective and objective data

34. Plan What are you going to do about this patient’s problem? What are you going to do about this patient’s problem? How can you address this problem? How can you address this problem? Why do you think this plan will improve the patient’s level of wellness? (rationales) Why do you think this plan will improve the patient’s level of wellness? (rationales) Direction for nursing action designed to assist the client and/or significant other to meet the expected outcomes Direction for nursing action designed to assist the client and/or significant other to meet the expected outcomes Nursing actions are specific, realistic, and individualized for a particular patient Nursing actions are specific, realistic, and individualized for a particular patient

35. Implementation Caring out the plan Caring out the plan Actual hands on with the patient Actual hands on with the patient Physically addressing the patient’s problem Physically addressing the patient’s problem

36. Evaluation Determine whether or not plan actually maintained or increased patient’s level of wellness Determine whether or not plan actually maintained or increased patient’s level of wellness If not what needs to be done to change the plan, where it will have a positive effect on the patient’s level of wellness If not what needs to be done to change the plan, where it will have a positive effect on the patient’s level of wellness

37. Nursing Care Plan Universal Self Care Requisites Universal Self Care Requisites Nursing Diagnosis Nursing Diagnosis Expected Outcomes Expected Outcomes Nursing Interventions Nursing Interventions Rationales Rationales Evaluation of Outcomes Evaluation of Outcomes

38. Universal Self Care Requisites The category of self-care requisites that are basic and common to all humans and are constantly present; these needs must be met to achieve optimal health and well-being. The category of self-care requisites that are basic and common to all humans and are constantly present; these needs must be met to achieve optimal health and well-being.

39. There are eight universal self- care requisites: 1. Air 2. Food 3. Water 4. Elimination 5. Activity and Rest 6. Solitude and Social Interaction 7. Prevention of Hazards 8. Normalcy

40. Self – Care Agency (SCA) Assets or abilities of an individual to perform self-care Assets or abilities of an individual to perform self-care

41. Self – Care Deficit (SCD) Deficit relationship that exists when the demand for self – care exceeds the person’s ability to perform self – care. Deficit relationship that exists when the demand for self – care exceeds the person’s ability to perform self – care.

42. Nursing Diagnosis (NANDA) Air Air Water Water Fluid Fluid Food Food Elimination Elimination Solitude – Social Isolation Solitude – Social Isolation Social Interaction Social Interaction Activity/Rest Activity/Rest Hygiene Hygiene Pain/Comfort Pain/Comfort Hazards Hazards Neurosensory Neurosensory Sexuality Sexuality Normalcy Normalcy Teaching/Learni ng Teaching/Learni ng

43. Documentation Goal: Clear, concise, but comprehensive report that documents the key findings of your patient assessment and communicates the patient’s problems in a brief and legible format to other health care providers and members of the health care team. Clear, concise, but comprehensive report that documents the key findings of your patient assessment and communicates the patient’s problems in a brief and legible format to other health care providers and members of the health care team.

44. Documentation Think about: Order and readability Order and readability Amount of detail needed Amount of detail needed

45. Checklist for Clear and Accurate Documentation Is the order clear? Make sure that future readers, including yourself, can easily find specific points of information Make sure that future readers, including yourself, can easily find specific points of information Make the headings clear Make the headings clear Accent your organization with indentations and spacing Accent your organization with indentations and spacing

46. Does the data included contribute directly to the assessment? Spell out supporting evidence for every problem or diagnosis that is identified Spell out supporting evidence for every problem or diagnosis that is identified Be sure there is sufficient detail to support the Assessment and Plan Be sure there is sufficient detail to support the Assessment and Plan

47. Are possible, and risk diagnosis specifically described? Often portions of the history or examination suggest that an abnormality might exist or develop in that area Often portions of the history or examination suggest that an abnormality might exist or develop in that area

48. Are there overgeneralizations or omissions of important data? Data not recorded is data that is lost! Data not recorded is data that is lost! If you don’t document it, it was not done! If you don’t document it, it was not done!

49. Is there too much detail? Is there excess repetition of information or redundancy? Is there excess repetition of information or redundancy? Is important information buried in a mass of detail? Is important information buried in a mass of detail?

50. Are phrases and short words used appropriately? Omit unnecessary words Omit unnecessary words This saves time and space This saves time and space Omit repetitive introductory phrases Omit repetitive introductory phrases Use short words instead of longer, fancier ones when they mean the same thing Use short words instead of longer, fancier ones when they mean the same thing Describe what you observed Describe what you observed

51. Is the written style brief? Is there excessive use of abbreviations? Medical records are legal documents, so they should be clear and understandable Medical records are legal documents, so they should be clear and understandable Using words and brief phrases instead of whole sentences is common, but abbreviations and symbols should be used only if they are readily understood Using words and brief phrases instead of whole sentences is common, but abbreviations and symbols should be used only if they are readily understood

52. Are diagrams and precise measurements included where appropriate? Diagrams add greatly to the clarity of the record Diagrams add greatly to the clarity of the record Make sure measurements are in metric units when possible Make sure measurements are in metric units when possible

53. Is the tone of the documentation neutral and professional? You must remain objective! You must remain objective! Hostile, moralizing, or disapproving comments have no place in the patient’s medical record. Hostile, moralizing, or disapproving comments have no place in the patient’s medical record. Remember this is a LEGAL document! Remember this is a LEGAL document! NEVER use inflammatory, demeaning, derogatory, words, penmanship, or punctuation in documentation NEVER use inflammatory, demeaning, derogatory, words, penmanship, or punctuation in documentation

54. Types of Documentation Physician progress note Physician progress note PIE charting PIE charting SOAP/SOAPIE SOAP/SOAPIE

55. Physician Progress Note ID = Identification of patient ID = Identification of patient CC = Chief Complaint CC = Chief Complaint HPI = History of Present Illness HPI = History of Present Illness PMH = Past Medical History PMH = Past Medical History Personal History Personal History Health Habits Health Habits Health Maintenance Health Maintenance Family History Family History Review of Systems Review of Systems Physical Examination Physical Examination Diagnostic Studies Diagnostic Studies Plan of Care Plan of Care

56. PIE Charting P = Problem P = Problem I = Intervention I = Intervention E = Evaluation E = Evaluation

57. SOAP/SOAPIE S = Subjective information S = Subjective information O = Objective information O = Objective information A = Assessment A = Assessment P = Plan P = Plan I = Implementation I = Implementation E = Evaluation E = Evaluation

58. Principles of Test Selection and Use Reliability Reliability Validity Validity Sensitivity Sensitivity Specificity Specificity Predictive value Predictive value Positive predictive value Positive predictive value Negative predictive value Negative predictive value

59. Reliability Indicates how well repeated measurements of the same relatively stable phenomenon will give the same result Indicates how well repeated measurements of the same relatively stable phenomenon will give the same result Precision Precision May be measured for one observer or for more than one observer May be measured for one observer or for more than one observer

60. Validity Indicates how closely a given observation agrees with “the true state of affairs” Indicates how closely a given observation agrees with “the true state of affairs” Best possible measure of reality Best possible measure of reality

61. Sensitivity Identifies the proportion of people who test positive in a group of people known to have the disease condition, or the proportion of people who are true positives compared with the total number of people who actually have the disease Identifies the proportion of people who test positive in a group of people known to have the disease condition, or the proportion of people who are true positives compared with the total number of people who actually have the disease When the observation or test is negative in people with the disease, the result is termed false negative When the observation or test is negative in people with the disease, the result is termed false negative Good tests have a sensitivity of 90%, and help rule out disease because there are few false negatives Good tests have a sensitivity of 90%, and help rule out disease because there are few false negatives

62. Specificity Identifies the proportion of people who test negative in a group of people known to be without a given disease or condition or the proportion of people who are “true negatives” compared with the total number of people without the disease Identifies the proportion of people who test negative in a group of people known to be without a given disease or condition or the proportion of people who are “true negatives” compared with the total number of people without the disease When the test is positive in people without the disease, the result is termed, false positive When the test is positive in people without the disease, the result is termed, false positive Good test have a specificity of 90% and help determine disease because the test is rarely positive when disease/condition is absent, and there are few false positives Good test have a specificity of 90% and help determine disease because the test is rarely positive when disease/condition is absent, and there are few false positives

63. Predictive Value Indicates how well a given symptom, sign or test result – either positive or negative – predicts the presence or absence of disease Indicates how well a given symptom, sign or test result – either positive or negative – predicts the presence or absence of disease

64. Positive Predictive Value Probability of disease in a patient with a positive (abnormal) test, or the proportion of “true positives” out of the total population tested Probability of disease in a patient with a positive (abnormal) test, or the proportion of “true positives” out of the total population tested

65. Negative Predictive Value Probability of not having the condition or disease when the test is negative, or normal, or the proportion of “true negatives” out of the total population tested Probability of not having the condition or disease when the test is negative, or normal, or the proportion of “true negatives” out of the total population tested

66. Gold Standard The best or most successful diagnostic or therapeutic modality for a condition, against which new test or results and protocols are compared. The best or most successful diagnostic or therapeutic modality for a condition, against which new test or results and protocols are compared.

67. Gold Standard 95 True Positive 10 False - Positive 5 False - Negative 90 True Negative

68. Gold Standard Numbers related to presence or absence of disease are always displayed down the table in the left and right columns Numbers related to presence or absence of disease are always displayed down the table in the left and right columns Present = a + c Present = a + c Absent = b + d Absent = b + d

69. Gold Standard Numbers related to the test are always displayed across the table in the upper and lower rows Numbers related to the test are always displayed across the table in the upper and lower rows Test positive = a + b Test positive = a + b Test negative = c + d Test negative = c + d

70. Medical Terminology

71. Instructions Define the following terms in your interactive note book. Utilize KIM technique with the K = Key word/ key term; I = Information/ Definition; and M = Memory Cue – something that will help you to remember the term. Maybe a picture, word, or phrase.

72. Terms Scientific Method Scientific Method Hypothesis Hypothesis Nursing Diagnosis Nursing Diagnosis Actual Diagnosis Actual Diagnosis Risk Diagnosis Risk Diagnosis Possible Diagnosis Possible Diagnosis Syndrome Diagnosis Syndrome Diagnosis Wellness Diagnosis Wellness Diagnosis Etiology Etiology Medical Diagnosis Medical Diagnosis Rationale Rationale Universal Self Requisites Universal Self Requisites

73. Terms Self – Care Agency Self – Care Agency Self – Care Deficit Self – Care Deficit Reliability Reliability Validity Validity Specificity Specificity Sensitivity Sensitivity Predictive Value Predictive Value Positive Predictive Value Positive Predictive Value Negative Predictive Value Negative Predictive Value Gold Standard Gold Standard

74. Medical Abbreviations

75. Dx – Diagnosis Dx – Diagnosis Hx – History Hx – History H&P – History and Physical Examination H&P – History and Physical Examination amb – As manifested by amb – As manifested by 2° - Secondary to 2° - Secondary to aeb – As evidenced by aeb – As evidenced by USCR – Universal Self Care Requisites USCR – Universal Self Care Requisites

76. SCA – Self Care Agency SCA – Self Care Agency SCD – Self Care Deficit SCD – Self Care Deficit NANDA – North American Nursing Diagnosis Association NANDA – North American Nursing Diagnosis Association PIE – Problem, Intervention, Evaluation PIE – Problem, Intervention, Evaluation SOAPIE – Subjective, Objective, Assessment, Plan, Implementation, Evaluation SOAPIE – Subjective, Objective, Assessment, Plan, Implementation, Evaluation

77. VIP of the Week

78. Florence Nightingale Instructions: Research this person and write the following in your interactive notebook. Who is she? Describe her as a person. Who is she? Describe her as a person. What significance did she have to medicine, science, or health care? What significance did she have to medicine, science, or health care? How can you utilize her contribution in your profession? How can you utilize her contribution in your profession? How did her contribution affect the world? How did her contribution affect the world?