Acute illness Acute illness is by definition a selflimiting disease which is mostly characterized by the symptoms having a rapid onset.

. These symptoms are fairly intense and resolve in a short period of time as either cure or death in the patient. We commonly know these acute diseases as colds, flu, bronchitis, childhood illnesses, tonsillitis, appendicitis, ear aches, most headaches, most infectious disease, etc. The same objective reporting is required for acute illness as for trauma, but here there is generally more information to report. Any Illness characterized by signs and symptoms of rapid onset and short duration. It may be severe and impair normal functioning. While acute illnesses may not last long, they can be very dangerous and in some cases are deadly. Management of acute illnesses requires determining what is making someone sick so that a treatment plan can be developed. Many people recover from acute illness with self care at home but in other cases treatment in a hospital are necessary. Signs of acute illness: onset rapidly, Someone may feel very healthy and abruptly experience symptoms like nausea, vomiting, diarrhea, headache, coughing, aches and pains, confusion, skin, and so forth. Clusters of symptoms appearing together can provide information about the nature of an acute illness. Causes can include allergies, drug reactions, infections with microorganisms, and autoimmune disorders. The term acute may often be confused by the general public to mean 'severe'. This however, is a different characteristic and something can be acute but not severe. The difference between a chronic illness and an acute illness A chronic illness is defined as any disease that develops slowly and lasts a long time. Examples of common chronic illnesses are diabetes, arthritis, congestive heart

failure, Alzheimer's disease, Parkinson's disease, and stroke. Chronic conditions are typically caused by multiple factors. Your family history may put you at greater risk. Your behavior and environment may increase your chances of developing a chronic condition. Some chronic diseases will never go away. However, you can live almost symptom free and have a good quality of life by making behavior changes and using the health care system wisely. An acute illness, on the other hand, typically starts suddenly and is short lived. Two common examples are colds and the flu. Some acute illnesses, those caused by viruses, will go away by themselves or with good home care; while others can be cured by antibiotics or other medical treatment.

Acute injury The term acute is often used to describe a type of injury (or illness) that is of rapid onset and progression but of a limited duration. These types of injuries are usually the result of a specific impact or traumatic event to the body. Acute injuries often require immediate medical attention, including first aid treatment with rest, ice, compression and elevation, or R.I.C.E. Chronic illness An illness that persists for a long period of time, the term "chronic" comes from the Greek chronos, time and means lasting a long time. A chronic illness is one lasting 3 months or more The term chronic describes the course of the disease, or its rate of onset and development. A chronic course is distinguished from a recurrent course; recurrent diseases relapse repeatedly, with periods of remission in between. As an adjective, chronic can refer to a persistent and lasting medical condition. Chronicity is usually applied to a condition that lasts more than three months.

The opposite of chronic is acute. A chronic illness isn't the name of just one illness. It's a word used to describe a group of health conditions that last a long time. In fact, the root word of chronic is "chronos," which refers to time. Serious chronic illnesses are a major health issue in modern society. Any illness is called "chronic" if it is longlasting or even lifelong. The opposite of chronic is "acute", referring to diseases that come on quickly and often do not last long (if they last, they are said to become "chronic")

What is Pathophysiology? Pathophysiology literally means disease process; it is the overview on what happens to the body when an individual has a disease or impairment. What is the importance of pathophysiology to the field of Nursing? We all know that all nurses should have the knowledge on basic anatomy and as well as disease processes, a nurse should know whether a particular disease is fatal or could lead to a serious complication. Nurses should know about basic disease processes to gain proper assessment on the patient and to give appropriate nursing intervention or management. The importance of proper assessment and appropriate management is crucial when dealing with critically ill patients or when in an emergency situation, every small intervention could mean a lot and could even save the patients life.

Chronic injury The term chronic refers to an injury, illness or disease that develops slowly and is persistent and long-lasting. Because many chronic injuries have mild symptoms, they are often ignored or simply overlooked for months or even years. Chronic injuries are sometimes referred to as cumulative trauma or overuse injuries. Overuse injuries tend to have subtle or vague symptoms that develop slowly. They begin as a small, nagging ache or pain, and can grow into a debilitating injury if they aren't treated early. Overuse injuries are the result of repetitive use, stress and trauma to the soft tissues of the body (muscles, tendons, bones and joints) without proper time for healing. They are sometimes called cumulative trauma, or repetitive stress injuries. Chronic conditions are those which are long term (lasting more than 6 months) and can have a significant impact on a person's life. Chronic conditions can affect people of all ages. Many chronic conditions can be managed to minimize the severity of the symptoms and the impact on a person's life. Management of chronic conditions may be through medication and/or significant lifestyle changes (for example: dietary changes, taking up exercise programs and/or stress management techniques). Report By: Bautista, Lady Cassandra Correlation of Pathophysiology to Nursing Assessment and Management.

Report By: Aguilar, Ludwig Erik Nursing Process Applied Acutely/ Critically Ill Patients to

Heatlh Assessment It has long been recognised that the physiological response of the patient to a stress or disease process will very largely determine the outcome. It is important, therefore, to monitor the physiological responses of patients since this not only allows the assessment of physiological reserve but will also give a baseline against which the effectiveness of any applied treatment can be judged. Assessment of Critically Ill Patient FANCAP F: Fluid: movement of fluid and electrolytes among body compartment. Electrolyte imbalance, Dehydration, hypervolemia, hemodynamic stability (V/S) A: Aeration: assess the patient clinically and laboratory. Type of respiration, breathing sounds, color of skin & mucous membrane, rate of respiration, ABGs determination is the best indicator for the patient condition. N: Nutrition: assess the patient through physical examination and lab. Inspect and ask the following question: Can we use the normal GI tract, what about the GI system condition, does the patient need biologic nutrition (TPN), what about vitamins and minerals supplementation? C: Communication: Assess neurological function (GCS), look at the patient eyes, is he cooperative, is he oriented. Activity: bed rest with mild activity (ADL), complete bed rest, up with help -need assistant. Up in chair -cannot walk. P: Pain: Physiological pain from the disease process, psychological pain from hopelessness, fear. P.Q.R.S.T. criteria for assessment of pain P: (Precipitating & palliating factors). Q: (Quality of pain) how would describe the pain burning, stabbing, squeezing description may indicate the cause. R: (Region & radiation) where is the pain, as; the patient to point the area of pain, does it travel any where. S: (Severity) does it make you stop what you are doing, double over. T: (Time factor) how often does the pain occur, how long does it lasts, when did you first experience the pain.

Primary Survey Airway with cervical spine control Look for: Evidence of airway obstruction Inadequate airway reflexes to protect an airway (decreased conscious level) Assessment: Can the patient talk normally? (If so, the airway is patent) Stridor / gurgling / snoring (partial airway obstruction) Look at the oxygen mask is it misting and demisting with respiration? Look in mouth for foreign bodies etc Feel for breath Actions: Apply Oxygen If evidence of actual or potential airway obstruction get help urgently Check for obvious foreign bodies in airway Consider gentle suctioning of mouth if secretions or vomit are present If airway obstruction associated decreased conscious level:

with

Airway manoeuvres (chin lift, jaw thrust) Recovery position (unless suspected spinal injury) A fall in O2 saturation is a late sign in airway obstruction In patients with a tracheostomy tube in place with the cuff inflated, breathing through the mouth/nose is not possible. A blocked tracheostomy tube should be treated with attempted suctioning or, if unsuccessful, deflation of the cuff allowing breathing through the mouth past the tracheostomy. Breathing

Look for: o Obvious distress o Cyanosis o Use of accessory muscles o Respiratory rate (This is the single most useful marker of critical illness) Feel for: o Tracheal tug/deviation o Chest wall movement + expansion

Listen for: o Air entry/breath sounds o Added sounds Check: o Oxygen Saturations (aim for >92% in most patients) O2 Saturation < 95% in a previously healthy patient is not normal Hypoxia kills more quickly that hypercarbia, so if hypoxic, give oxygen. Dont be fooled by apparently normal O2 saturations or PaO2 if high concentrations of oxygen are required Hypercapnia usually results from respiratory muscle fatigue due to increased work of breathing. The treatment is ventilatory support, not reduction of oxygen delivery Patients may become dangerously hypercapnic and acidotic before the SpO2 falls, so regular blood gases are essential in unwell patients. Not everyone with tachypnea has a primary respiratory problem, it can be secondary to a metabolic acidosis or a CNS problem Remember that adequate cardiac output and haemoglobin concentration are required for oxygen delivery to the tissues Circulation Look for: o Colour pale? Grey? Mottled? o JVP Listen for: o Heart sounds Feel for: o Peripheries warm or cool o Capillary refill time (central over bony prominence eg sternum) o Central pulse rate, volume, regular o Oedema o Peripheral pulses Check: o BP o ECG rhythm o Urine output (useful sign of poor perfusion in shock) *Normal capillary refill time is < 2 seconds Hypotension may be a late sign of shock in young patients

Check baseline blood pressure: 110/50 mmHg may be normal for some patients, but grossly hypotensive for others In cardiogenic shock, fluids may still be required but should be given cautiously, and the mainstay of management is to treat any immediate cause eg arrhythmia or ischemia, with inotropes as needed (in a critical care setting). If the patient is bleeding and hypotensive, use blood, ideally crossmatched, but type-specific or O Rhesus negative blood can be given in an emergency

Disability This should be a quick neurological screen the time to do a full assessment is later: Ask the questions: Is there a decreased conscious level such that the airway is at risk? Is there evidence of an immediately remediable cause (eg seizure, hypoglycaemia, opioid toxicity)? Assessment AVPU score Alert / Responsive to Voice / Responsive to Pain / Unresponsive o Alert - a fully awake (although not necessarily orientated) patient. This patient will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function.
o

Voice - the patient makes

some kind of response when you talk to them, which could be in any of the three component measures of Eyes, Voice or Motor .
o

Pain - the patient makes a

response on any of the three component measures when pain stimulus is used on them. Recognized methods for causing the pain stimulus include a Sternal rub (although in some areas, it is no longer deemed acceptable),

where the rescuers knuckles are firmly rubbed on the breastbone of the patient, pinching the patient's ear and pressing a pen (or similar instrument) in to the bed of the patient's fingernail.
o

Find out normal state ask nurses / check notes / call relative Report By: Castillo, Faye Gerarldine

Current Trends in the Management of Critically Ill Patients: Sedatives and Paralytics in the Critically Ill Use of Sedatives in the ICU In the ICU, sedatives and paralytics as a class are second in use only to antibiotics. Intravenous (IV) sedatives are commonly used to treat mechanically ventilated patients. Among the most frequently used drugs are opiates, benzodiazepines, anesthetic agents (eg, propofol), and, on occasion, neuroleptics (eg, haloperidol). In general, these drugs are administered via continuous infusion or intermittent IV bolus. Continuous infusion has the advantage of achieving a constant level of sedation, avoiding the peak-and-valley phenomenon associated with intermittent dosing and perhaps yielding better patient comfort. Continuous infusion may, however, result in increased drug use with higher expense than that of intermittent dosing, as well as the possibility of over sedation and a longer recovery from drug effect. While the preferred method of sedation is still a matter of debate, there are concerns that patients may be overmedicated with either route of administration. However, in some circumstances ICU patients, particularly those receiving MV, may require deep sedation. For example, hypoventilating a patient with acute hypoxemic respiratory failure or status asthmaticus can result in less damage to the patient's lungs caused by interaction with the ventilator. However, hypoventilating a patient often requires suppression of the innate drive to breathe. Patients with typeIV respiratory failure or ventilatory support for shock must also be sedated to rest the respiratory muscles in order to decrease lactic acid production. Finally, when treatment shifts from cure to comfort, deep sedation may be necessary to relieve severe dyspnea. If the patient is not naive to these drugs, very high doses may be necessary.

Unresponsive -

Sometimes

seen noted as 'Unconscious', this outcome is recorded if the patient does not give any Eye, Voice or Motor response to voice or pain GCS Pupils equal & reactive? Seizure activity Movement of all limbs? Check capillary blood glucose (DEFG dont ever forget glucose)

Deterioration in conscious level may have a primary neurological cause, or may be a response to other pathology eg shock and inadequate cerebral perfusion Airway protection may be indicated if conscious level is decreased (GCS <8 or P or U on the AVPU scale are typically regarded as indications for intubation) Confusion / agitation can be a manifestation of hypoxia / shock / hypoglycaemia / lots of other things for which sedation is not the treatment. Prevention of secondary brain injury due to hypoxia, hypercapnia, hyperglycaemia and hyperthermia is the most important thing you can do for many patients with brain injury.

Secondary Survey

History Abdominal, neurological or other examination as indicated Input / output chart consider urinary catheter Review medications CXR / ECG / ABG / Blood tests / Other investigations as required ABG analysis is not just for diagnosing respiratory failure it gives information on perfusion and lots of other useful things

Complications of Deep Sedation Because patients in the ICU may require deep sedation for extended periods of time, these agents pose added risks, including rare, potentially life-threatening complications as well as common side effects. Many of the uncommon complications of deep sedation arise from the accumulation of stabilizing agents with high dosing. High levels of propylene glycol, a stabilizer of many drugs, can lead to a hyperosmolar state, hemolysis, lactic acidosis, or renal failure. Sulfite, a stabilizing material in the generic preparation of propofol, can provoke an allergic reaction; hypertriglyceridemia has been associated with the Intralipid vehicle used to stabilize propofol. In the pediatric patient population, propofol has also been associated with lactic acidosis when used at extremely high doses (>/=75 micrograms [mcg]/kg per minute). More common expected complications of deep sedation result from the known actions of the drug. For example, sedatives reduce autonomic tone and therefore can cause hypotension and hypoperfusion, largely as a result of diminished venous return. In addition to the desired central nervous system (CNS) effects, opiate analgesics are known to act on peripheral receptors, resulting in complications such as ileus. Additional complications expected from the long-term use of sedatives include patient tolerance to the drug, as well as drug accumulation and protracted coma. Drug dependence and withdrawal symptoms become an issue for patients receiving opiates and benzodiazepines. The sedated, critically ill patient may also be unresponsive for extended periods of time, increasing the need for diagnostic tests to assess changes in mental status.

patients received either routine clinical care (control group) or a sedation regimen that was discontinued every day (STOP group). All patients received an opiate infusion of morphine sulfate; patients in the STOP and control groups were further randomized within each group to receive propofol or midazolam by continuous infusion. In the STOP group, sedatives were stopped once daily until the patient was awake and following commands; when the infusion was restarted, it was at one-half the prior dose and adjusted as necessary. In the control group, discontinuation was left to the discretion of the routine clinical care group. All patients underwent a daily assessment of their level of consciousness; the end points of the study were percentage of ICU days awake, incidence of diagnostic studies (brain CT, brain MRI, lumbar puncture), length of ICU stay, and duration of MV. As shown in the Table, the STOP group showed a significant decrease in the duration of MV and ICU length of stay, showed a significant increase in days awake, and required fewer diagnostic tests to assess mental status. Because there were no differences within each group between the 2 sedatives (propofol or midazolam) used, the important factor was clearly the strategy for administering the sedatives. Furthermore, the strategy of discontinuing sedative infusions on a daily basis produced no increase in adverse events, suggesting that this strategy is a safe alternative to continuous infusion. Patient Outcomes with Discontinuation of Sedatives Outcome MV days Hospital days Daily

STOP Control P Value (n=68) (n=60) duration, 4.9 6.4 7.3 9.9 16.9 9.0 16 (4) .004 .02 .19 <.001 .02

ICU LOS, days Impact of Daily Discontinuation Sedatives in ICU Patients of

LOS, 13.3

A randomized study was conducted to test the hypothesis that problems associated with continuous sedative infusion can be alleviated by once-daily discontinuation. In this study, critically ill

ICU days awake, 85.5 % Diagnostic tests 6 (3) evaluating cause of changes in mental status, No.

(No. positive)

Uncertainty regarding the illness, its consequences and effects on others add to the stress. Stress: a relationship between the person and the environment that is appraised by the person as exceeding his resources and endangering his well being. How a person reacts to stress depends on 2 processes: 1. Cognitive appraisal: process where a person evaluates the stressor and its potential effect on well being. 2. Coping: Refers to the peoples cognitive and behavioral efforts to manage, reduce, master, or tolerate the stressor and its effects. Coping has 2 functions: Dealing with the problem that is causing the distress (problem-focused coping). This is aimed at changing or managing the situation. An example of these behaviors is: painful problem solving, seeking information, and aggressive efforts to alter the situation. Dealing with emotions that arise from the problem (emotion-focused coping). This is aimed at changing or managing the persons reaction to the situation. Examples of these behaviors are: wishful thinking, escape or avoidance behaviors (drinking, using drugs, exercising), rationalization, accepting responsibility, using humor, and developing a positive outlook.

Organization Critical care medicine (CCM) provides a level of monitoring and treatment to patients with potentially reversible, lifethreatening conditions that are not available on general wards. Patients should be managed and moved between areas where staffing and technical support match their severity of illness and clinical needs. Five types of ward area are described: intensive care units (ICUs; level 3); intermediate or high dependency units (HDUs; level 2); admission wards (level 1); general wards; and minimal (or self-care) wards. The principles and practice of CCM encompass ward levels 13. Level 3 patients usually require mechanical ventilation or have multiorgan failure. Levels 2 (i.e. medical/surgical HDU, postoperative recovery areas, emergency rooms) and 1 (i.e. acute admission wards, coronary care units) overlap considerably. They provide a high degree of monitoring and support, with level 2 often able to provide non-invasive ventilation or renal replacement therapy. Critical care provision varies from ~2% of hospital beds in the UK to >510% in the USA. Nursing care The importance of skilled nursing in the management of critically ill patients cannot be overemphasized. Assessment, continuous monitoring, drug administration, comfort (e.g. analgesia, toilette), psychological support, assistance with communication, advocacy, skin care, positioning, feeding, and early detection of complications (e.g. line infection) are vital nursing roles which have a profound effect on outcome. Nurses also provide essential support for relatives, doctors, physiotherapists and other caregivers (e.g. technicians). Report By: Bautista, Lonneth Psychosocial Concerns in Acute Illness Stress & Coping Hospitalized patients experienced stress from certain sources such as physiological dysfunction, circadian rhythm disturbances, and limited access to family, familiar objects, and surroundings.

Flexibility in coping strategies is advantageous. It allows people a variety of responses and ability to come to terms with the experience and use it to further growth and adaptation. A number of coping strategies may be "tried out" to find the best approach to the situation especially after discharged to a more familiar environment where coping skills are not limited like they would be in a hospital. Social Support An exchange of resources between people that enhance the well being of the recipient, a factor that may affect the patients appraisal and response to stress. Types of support that may be provided are:

1. Instrumental support: direct support (financial support or assistance with household chores) 2. Informational support: giving of needed information (help with problem solving) 3. Emotional support: communication of love, caring, trust, or concern or facilitation of ties to a clergyman. Social support may serve as a buffering mechanism to decrease the negative effects. This is done by altering appraisal of the stressful event or by intervening between the experience of stress and onset of outcomes. Remember just because family members are present does not mean they are an adequate social support. Uncertainty This is a factor that may interfere with a person's coping efforts. Uncertainty is a cognitive state created when an event occurs that cannot be defined due to lack of information. The degree of uncertainty produced is influenced by: 1. Complexity of the event. 2. Amount of ambiguity surrounding the event. 3. Other factors such as previous experiences. A hospitalized patient with an acute illness or trauma has uncertainty due to unfamiliar sight and sounds, unfamiliar procedures and treatment can increase uncertainty. The positive side of uncertainty is it may facilitate hope. A person who is unsure about a diagnosis may focus on the possibility that things will work out. The negative side of uncertainty is there is no clear perception of what will happen next. Coping processes may not work because the person may not know how to help or change the situation and therefore may do nothing.

Hardiness has 3 dimensions: 1. Control: the perception of control motivates a person to seek explanations as to why something is happening and to be actively involved in making decisions. 2. Commitment: being involved in health related activities for the patients situation. (deep breathing exercises) 3. Challenge: the reappraisal of a stressor as an opportunity for personal growth, rather than as threat. These people are able to use available resources to cope with the stressors they experience. Sleep Deprivation It is the condition of not having enough sleep or it can be either chronic or acute. An overall lack of the necessary amount of sleep. In addition sleep deprivation can cause anxiety, restlessness, disorientation, depression, irritability confusion, combativeness, and hallucination. It can also cause further medical problems such as: Immunosuppression Decreased pain tolerance Decreased muscle strength

Sensory Overload It is a condition when one or more of the senses are strained and it becomes difficult to focus on the task at hand. A condition in which an individual receives an excessive or intolerable amount of sensory stimuli, receiving too much information or stimulation via visual or audio sources. It may results from an increase in the amount of unfamiliar sounds and sights in the environment. Powerlessness It is a lacking of strength or power, helpless or totally ineffectual. The quality of lacking strength and being weak. Altered Body Image A confusion or dissatisfaction in mental picture of ones physical self. Psychosocial Assessment of the Acutely Ill Includes determination of impact and meaning of the acute illness experience include the persons perceptions and characteristics such as new and on going stressors, the meaning of the stressors to the

Hardiness Helps a person explain the differences in coping with acute illness. It helps a person adapt to stressors by influencing their perception of the stressors, the coping strategies or social resources used.

patient and personal resources that affect the patients ability to cope with them. A nurse can develop an effective plan of action by knowing how the patient and family perceive the current situation, how stressors were approached in the past, what other stressor the patient has and how they deal with uncertainty. Find out how previous crisis has been handled. Each illness or traumatic event have individual and cultural meanings, therefore it is important that the family and patient understand the meaning of the illness event. Example: a gunshot wound carries different meanings depending on how the injury occurred. Planning The main focus is to conserve the patients energy and healing because crisis is exhausting. The goal is to return the patient to their highest level of functioning and healing of the psychological wound The goal of nursing interventions is to support effective coping strategies used by the patient and family. During a time of crisis, shortterm realistic goals are needed to help the patient and family reestablish equilibrium. Clinical Nurse Specialists (CNS) may assume the role of a contact person and interpreter of events for the patient and family therefore she is an invaluable asset to the family. The CNS can help establish the formation of support groups. In a support group, the family members can burden their concerns and fears to others in similar circumstances. The flexibility of families being allowed to see patients and stay longer has resulted in positive outcomes such as improved orientation, decreased anxiety and increase sleep. This balances the need for physical closeness and encourages communication and collaborative relationships between family and staff.

actions is as important as any other care provided. Information must be concrete and understandable Anxiety or distress is relieved by explaining expected sensory experiences associated with procedures (what will be felt, seen or smelled). Sensory information is also used for the patient to be able to predict or interpret symptoms associated with an illness. This provides the sense of mastery and self-confidence. Family information needs include such as -information booklets, videos, telephone contact and pagers can be used as concrete information and keep families updated on the patient condition. As time passes, the story of the event becomes more important, therefore the patient needs to tell and retell the story in order to define and come to terms with the illness. and

Report By: Alcanar, Merriam Bernardo, Yohannes Milcaanne

Critical Thinking Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgements and safe decision-making. Critical Thinking Skills and Abilities Critical thinkers in nursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing,

Intervention Sharing information such as the patients perceptions & feelings, decisions &

analyzing, generating, integrating and evaluating (Registered Nurse's Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse's understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.

Usually it is the patient who first recognizes that there is a problem and goes to the provider for help. Often, the patient's chief complaint leads to a more significant or underlying problem. In other cases, for example, during a routine reproductive health examination, the provider may encounter problems of which the patient is unaware. To identify the problem correctly, the provider needs to collect information from and about the patient that will assist in accurately diagnosing and treating the problem. 2. Diagnosis (Interpreting the Information) After gathering some information, the provider begins to formulate a differential diagnosis. Working from that list, the provider uses her/his experience, fund of knowledge and clinical inference to guide further collection of data to support or disprove certain diagnoses. If needed, additional information is gathered to help identify the problem and move toward a working diagnosis from the list of all possible differential diagnoses. Ultimately, through the process of hypothesis testing, the provider chooses a working diagnosis as a basis for planning treatment. 3. Planning (Developing the Care Plan) After deciding on a working diagnosis, the provider chooses a treatment plan, if several options are available, using the data collected in the previous steps. For example, for the woman experiencing postpartum bleeding, a decision will be made whether the best course of treatment is to administer oxytocic agents, perform external uterine massage or immediately use bimanual uterine compression. The decision will be based on the amount of bleeding, available medications, success of previous treatment and other information. The provider will weigh the costs and risks of negative consequences, as well as positive consequences, that could result from each treatment alternative. The provider will then make detailed provisions for implementing the chosen course of action, with special attention to contingency, or backup, plans if known risks should occur. 4. Intervention (Implementing the Care Plan) The next step in clinical decisionmaking is implementing the solution or treatment option chosen. Implementation

Self-directed Decision Making Skills One of the challenges to developing clinical decision-making skills is that until recently the process involved was not clearly understood. It is now known, however, that clinical decision-making follows a process that can be clearly described, taught and practiced. The ability to make decisions does not depend entirely on the gathering of information but on the ability to organize, interpret and act upon this information. That ability is highly dependent on experience, knowledge and practice. These are, in fact, the most influential factors in decisionmaking. CLINICAL DECISION-

STEPS IN MAKING

1. Assessment (Gathering Information) This first step in clinical decisionmaking is completed by both the patient, through self-assessment, and the provider.

requires certain clinical skills and an attention to detail during the performance of these skills. Some actions will have to be carried out simultaneously and others in a specific order, one immediately after the other. Sometimes the treatment will be carried out by the patient (such as taking a medication and observing for the results) and other times it will be carried out by the clinical team (such as performing procedures to treat postpartum hemorrhage). Advance preparation of equipment, supplies and personnel will make the implementation of the planned treatment easier. 5. Evaluation (Evaluating the Care Plan) In the evaluation step of clinical decision-making the treatment plan chosen for the diagnosis is evaluated for its effectiveness. If it has not been effective, other treatment options must be considered and another intervention must be chosen. Thus, planning, intervention and evaluation follow a circular pattern in much the same way that assessment and diagnosis do. Indeed, sometimes the evaluation of the treatment, especially if it has not been effective, will also require additional data collection or revision of the diagnosis, thus effectively restarting the entire clinical decision-making process. Evaluation of the treatment can also lead the provider to a final diagnosis - a working diagnosis that has been confirmed by more objective information. When the final diagnosis agrees with the working or provisional diagnosis, the provider will use the details of this case in her/his body of clinical experience. Report By: Aceron, Angelica group 1