Clinical Decision Making Flashcards
Clinical decision making
The use of logic, intuition, and critical
thinking based on history-taking and physical
examination skills in order to distinguish an
accurate diagnosis and plan of care for a
presenting health problem.
To determine and implement the most appropriate evidence-based drug treatment
for the individual patient/symptoms with the
fewest adverse effects
Clinical decision making considerations
◦ Patient factors
◦ Disease factors
◦ Drug factors
◦ Available evidence
One of the first steps in pharmacotherapy
medication reconciliation. What medications are they taking
two approaches to get an initial red rec
ask pt to bring in medications. contact the pharmacy
A MN meaningful measure
you have done a med rec everytime you see the patient.
examples of questions around prescription medication
taking, not taking dose frequency time taken duration
Verify that allergies are
up to date
Do not forget about
social drugs
example of social drugs
coffee, tea, cola, choclate, etoh, tobacco, pot, opioids
examples of PMH factors
Comorbidities
Baseline laboratory status
Allergies
examples of drug factor history
◦ Mechanism of action ◦ Efficacy ◦ Cost ◦ Naming ◦ Adverse effects ◦ Administration Frequency Ease Storage
Insurance considerations
look at formulary. Some drugs are covered differently. Tier 1, 2, 3 etc.
Evidence Based Medicine
Is an approach to practicing medicine in which the
clinician is aware of the evidence in support of
clinical practice, and the strength of that evidence
example of a tool to use to make a decision about prescribing
JNC 8
EBM are
guidelines. It is up to the provider to make decisions
Nursing Skills and Expertise (what will you use)
◦ Subjective data
◦ Objective data
◦ Intuition
◦ Previous clinical experience
Elements of conceptual model
nursing skills and expertise
scientific knowledge
patient factors
Scientific knowledge
Pharmacotherapeutic knowledge
Evidence based medicine
patient factors
Age, belief system, physical abilities,
socioeconomic
Strategic vs. Tactical Decisions (strategic)
Focus on questions of whether and what (drug)
Involve planning and forecasting
tactical decisions
Focus on questions of how
Involve the implementation of the strategic decision
Strategic questions and considerations
what is wrong? What is the underlying patho? What are the objectives of treatment? Which treatment should be used first? If medication treatment fails, what is the next best treatment?
What is wrong examples
◦ CC, HPI, PMH, PE, Labs
What are objectives of treatment examples
◦ Patient’s normal state. S.E., costs
what is important with objectives
the pt’s goals
Which treatment should be used first? considerations
Available meds, risks/benefits, prognostic
indicators, prescriptive predictors
Tactical questions and considerations
how is the medication treatment optimally applied?
How long should the medication treatment be applied before declaring the trial unsuccessful?
How long should an effective medication
treatment be continued?
How should a successful medication
treatment be discontinued?
How is the medication treatment optimally
applied?
Dosing, frequency, lab test monitoring,
pharmacokinetics, pharmacodynamics, S.E.,
race/culture, age/gender, comorbid conditions
How long should the medication treatment
be applied before declaring the trial
unsuccessful?
Patient/family report of S.E., practice guidelines,
managed care guidelines, evaluation tools
Pharmacokinetics
what does the body do to the drug
pharmacodynamics
what does the drug do to the body
How long should an effective medication
treatment be continued?
◦ Patient/family report of S.E., practice guidelines,
costs
How should a successful medication
treatment be discontinued?
Practice guidelines, patient report, drug factors
half-life, potential for rebound symptoms
phases of pharmacologic managment
Initiation
Stabilization
Maintenance
Medicine Free
Initiation
Primary and secondary considerations
Stbilization
Assessment of target sx, S.E., drug monitoring,
expected timing of medication effects
Maintenance
Patient ed, monitoring efficacy, S.E., labs, when to
dc
Medicine Free
Duration of treatment, tapering, symptom
recognition, relapse prevention
One of the big thing to look at in regard to efficacy of a medication
adherence
Evaluation of efficacy first four
Adherence
Target symptom outcomes
QOL
Laboratory tests
Evaluation of efficacy last three
Rating scales
Side effects
Stress
Tools for clinical decision making (7 items)
Problem Identification Underlying patho of disease Desired Outcomes Therapeutic Alternatives Optimal Plan Assessment parameters Patient Counseling
three factors that influence clinical decision making process
nursing skills and expertise
pharmacotheraputic knowledge
client factors
