Critical Thinking for the Nurse Practitioner

1. Critical Thinking for the Nurse Practitioner Debbie King Fall 2009 7735

2. Critical Thinking • Leads to; • Diagnoses • The setting of priorities • Institution of management/ plans

3. Critical thinking • Evidence based practice • Be a clinician • Not satisfied with superficial info or apparent patterns • Will look at each patient as a new challenge • Seek out pertinent information, even if the problem appears obvious • Think about what the patient feels • Wants a provider who is thorough and complete • Wants appropriate tests ordered to discover problem (based on differential diagnosis) • Wants a provider who listens and spends time with the patient

4. Steps • Information gathering • SOAP • Organize and integration of the information • Assess the organized info • Assignment of priorities • Do all problems have to be addressed today? • Need clinical judgment • Integration of preferences-both patients’ and providers’ • Consider feelings, attitudes, values • Consider probabilities and risks • Further assessment • Weigh advantages with risks while thinking of feelings, attitudes, and values • ID the problem • Form a hypothesis and determine next steps

5. Problem Identification • Problem • Anything that will need further evaluation or attention • Related to one or more; • Uncertain diagnosis • New findings related to a previous diagnosis • New findings of unknown cause • Unusual findings revealed by exam or tests • Personal or social difficulties

6. Problem Identification • Differential diagnosis formation • Based on training, experience, mentoring, continued education, training (or Uphold and Graham) • Listen to the patient closely for clues and descriptions of problems • A complete physical of the problem areas is needed • Examine one system above and one below the problem • Incorporating the patients CC, history of present illness, history as well as the family history in some situations • Use all the information gathered to develop hypotheses • Note absence of findings • There may not be a problem • There may be another unspoken reason for the visit

7. Problem Identification • Beware of ‘red herrings’ • Bits of information that are distracting and draw your thinking away • Examine unexpected or unusual findings carefully • Do not let them lead you astray, this may distort the information • Diagnosis is presumed from the differentials • Match subjective and objective • May need more test to confirm diagnosis

8. Decision making • Diagnosis • May be made based on all the information gathered • May need to order tests to seek out more information • There are at least three differential diagnoses for each one diagnosis • With experience and confidence you will learn to collect , analyze, evaluate, and synthesize information relating it to the CC • Be cautions • Don’t hurry • Do not let your thoughts narrow • More than one diagnosis may be present

9. Decision Making • Recognizing patterns • If it looks like a zebra it must be a zebra • Sampling the universe • Assuming everything is possible- precludes missing anything • Use algorithms • A rigidly defined thought process precludes error • http://www.righthealth.com/topic/Asthma_Treatment_Algorithm • Broad consideration of all findings • Resulting in the development of one or my hypotheses needing a disciplined, evidence-based approach

10. Decision Making • Guidelines to a sound decision-making process • Derive possibilities that are consistent with the CC • Common problems occur commonly, and rare one do not • Common problems can have unusual presentation and rare one may have seemingly common complaint • A rarity that has necessary treatment available should considered, less harm come to a patient • Do not rush to DX with no available treatment, and do no pursue a line of reasoning that will not alter your course of action • Do not order procedures that are not reasonably related to your hypotheses or DX • Realize you favorite hypotheses may not be valid. Stay open minded • Try to have a single process explain most or all data. But a patient may have more than one DX • Probability and utility should always be your guides • The best way to establish priorities

11. Valid Hypotheses • Critical thinking allows • Consideration of possible diagnoses • Discarding of irrelevant information • Positive outcomes rely on; • The quality of your decisions • Soundness of your hypotheses • Your sensitivity • To nuances, variations even in easy signs and symptoms • Sound clinical abilities comes with sensitivity to the meaning of findings and ability to intermingle the precise and the probable

12. Valid Hypotheses • Remember not all findings will always be labeled as one diagnosis • More than one disease process may go on at the same time • Acute illnesses happen to chronic patients • Document all information logically, explained by your ultimate conclusions • Tests and consultation may help validate and confirm

13. Barriers to Critical Thinking • Feelings, Attitudes, Values • Emotions intensify complexity • These may be strong opinions that may distort • Know what is really happening • Mechanism and Probabilism • Mechanistic or deterministic thinking is governed by a sense that knowledge must be certain • Knowledge is to be free of belief, attitudes, and values • No room for the probable, that which is likely but uncertain • Need a balance between mechanism and probabilism

14. Barriers to Critical Thinking • Introduce variables including what we bring • Our age • Our experience • Occasional fatigue • Our worry about malpractice • Accepting the inevitability of probability- simply recognizes the certainty of truth, what ever that may be, is hard to achieve. Why? • Causes may act or interact differently at different times • The same effect may not always have the same cause • The effect of a given cause cannot be isolated with certainty

15. Barriers to Critical Thinking • Our interpretations of causes, effects change probabilistically over time • Involves uncertainty, conjecture and chance • Depending on purely scientific and technical offers an unrealistic comfort • There is not a precise and discoverable cause for every event • Trying to find one every time would lead to great workups • Making judgments on the basis of well informed probabilities recognizes the complexity of the decision making process • Critical thinking does not require a compulsive list of all possible options in diagnosis and management • Critical thinking should be directed by hypothesis formation • Asking whether a particular DX is correct based on probability

16. Validity of the examination • With a competent clinical exam you can decrease the need for further workup saving money and time • The requires some assurance of the reliability of your observations • There is no way to quantify the information gathered on exam • There is some information needed that needs to be tested to obtain. • Keep the following in mind when assessing lab findings • Sensitivity • Specificity • True positive • True negative • False positive • False negative • Positive predictive value • Negative predictive vale

17. Bayes Formula • States; • The likelihood of your diagnosis being related to your findings depends on the probability of those findings being associated with that diagnosis, and the prevalence of both that particular diagnosis and that combination of findings in the community you are serving • Patterns prevail

18. In probability theory, Bayes' theorem (often called Bayes' law after Thomas Bayes) relates the conditional and marginal probabilities of two random events. It is often used to compute posterior probabilities given observations. For example, a patient may be observed to have certain symptoms. Bayes' theorem can be used to compute the probability that a proposed diagnosis is correct, given that observation. (See example 2) As a formal theorem, Bayes' theorem is valid in all common interpretations of probability. However, it plays a central role in the debate around the foundations of statistics: frequentist and Bayesian interpretations disagree about the ways in which probabilities should be assigned in applications. Frequentists assign probabilities to random events according to their frequencies of occurrence or to subsets of populations as proportions of the whole, while Bayesians describe probabilities in terms of beliefs and degrees of uncertainty. The articles on Bayesian probability and frequentist probability discuss these debates at greater length

19. Computers • Computers are a great resource • Recording • Providing info • Remind about unrecognized possibilities in diagnosis • Computers are a threat • Temptation to substitute for critical thinking • Has no sense of the subtleties of human dimension • Poses a serious threat to confidentiality • Computers bring great responsibility • Provide information appropriately • Guard what is the patients private information

20. Management Three or more possible situations • You know the diagnosis, and the plan is clear • You have a list of differentials, and need further workup to make the diagnosis, and plan the management • You know the diagnosis, but not the extent of the problem, and need further testing to determine management

21. Management • With critical thinking consider using one or more of the following • Labs • Consult • Medications • Appliances • Special care; PT • Surgery • Diet modification • Activity modification • Follow up visits • Patient education

22. Management • After planning which tools you will use, you must plan how soon, how urgent is the problem • Priorities must be set • What happens first, ECT…. • Patient’s physical condition • Patient’s social situation • Patient’s economic circumstance • The list is endless • There might be a sequence of steps that meets priority needs • By using critical thinking each patient may be handled differently

23. Management • The patient is also responsible for management • Subsequent behavior is a variable • In health prevention; stop smoking • Therapeutic; taking correct medication • Patients commitment • Subsequent behavior is a major variable • Are they ready to take the right steps and continue them • The depth of our understanding of the multiple factors in a patient’s life is measure of potential outcome

24. Critical Thinking • Develop a sequence for your own critical thinking • Facilitate this with careful attention to the problem oriented visit and documentation • Recording information well will suggest the discipline by which you can organize your thoughts and discipline your critical thinking, using the findings in the history and physical exam