Chronic pain is at epidemic levels and has become the highest-cost condition in health care. This course uses evidence-based science with creative and experiential learning to better understand chronic pain conditions and how they can be prevented through self-management in our cognitive, behavioral, physical, emotional, spiritual, social, and environmental realms. The goal of this course is to blend creative, experiential, and evidence-based teaching strategies to help participants understand chronic pain conditions and how a human systems approach can be applied to self-management strategies to reduce risk factors, enhance protective factors, and prevent chronic pain. There are four major objectives to the course; 1. Describe the prevalence, personal impact, and health care dilemma associated with chronic pain. 2. Recognize the clinical characteristics and underlying etiology of several common pain conditions and the peripheral, central, and genetic mechanisms of chronic pain 3. Based on the literature associated with risk and protective factors in the seven realms of our lives, learn specific strategies in each realm that can be employed daily to prevent chronic pain and enhance wellness. 4. Appreciate the value of a human systems approach to health care and how it can provide a basis for integrative, interdisciplinary, and individualized care to preventing pain and enhancing wellness. CONTINUING EDUCATION CREDIT Health Care Professionals Health care professionals who participate in this CE activity may submit this certificate statement of participation to their appropriate accrediting organizations or state boards for consideration of credit. The participant is responsible for determining whether this activity meets the requirements for acceptable continuing education. Email your Coursera certificate statement of completion to your appropriate organization.
7 The Four Cs of Clinical Judgment
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Do curso por University of Minnesota
Preventing Chronic Pain: A Human Systems Approach
112 classificações
Na lição
Risk and Protective Factors in the Seven Realms (Week 9)
Conheça os instrutores
Dr. James Fricton, DDS, MSProfessor and Pain Specialist
University of Minnesota, HealthPartners Institute, and Minnesota Head and Neck Pain Clinic
These would be the five Cs of clinical judgment.
So the context, the client's story.
The contrast, between the present and the desired state.
The criteria are evidence used for making a judgment with the outcome.
Concurrent thinking.
Simultaneously thinking about how the assessment,
the problem and the outcome fit together.
The intervention, influences, the transition from
the present state to the outcome.
And then the outcome and its effects.
And then some conclusion.
And it's really simple conclusions.
Yes, you've achieved your outcome.
No, you haven't achieved your outcome.
Or perhaps maybe, you need to think again.
And reframe the situation, given the data, that you have to process.
So let's take a look and apply the OPT model now to Mr. Johnson's.
Mr. Johnson has just had a bilateral knee replacement surgery.
And so, if we put Mr. Johnson's total knee replacement in the middle of this web.
And we ask ourselves, what are the actual
or potential consequences of Mr. Johnson's surgical procedure here?
And this is predominately from a nursing framework, so these are nursing diagnoses.
Social workers might have a different set of diagnoses.
Physicians would have a different set.
Occupational therapists would begin to analyze and
look at this in a very different way.
But the process would be similar.
So Mr. Johnson would probably have acute pain.
He would have anxiety.
He would have risk for injury.
He would have risk for infection.
May have a knowledge deficit in relationship to his care.
He certainly has impaired physical mobility.
And he has activity intolerance.
There's probably other things associated with Mr. Johnson's condition.
He might have a self-care deficit.
He might have body image disturbance.
He might have fa-, fatigue.
And so you can see he's got multiple issues
and multiple problems that are sort of all identified.
In terms of his consequence and his response to
this particular procedure in terms of his total knee replacement.
And so we could approach this by taking each one of those
problems and identifying an intervention and a strategy to deal with that.
But critical reasoning invites us to think about
what's most important in this constellation of problems.
And what are the outcomes associated with these problems?
And more importantly, is there a center
of gravity associated with this constellation; that would
make our reasoning and our care process
more effective and efficient, in relationship to this?
And so here's how a clinical reasoning web works when you activate it.
You begin to ask yourself, how is one problem related to the other problem?
How does it influence it?
Is it bi-directional?
Does it increase it?
Does it decrease it?
Are there clusters of things together?
So you begin to ask yourself through self talk actually, thinking to yourself.
Sub-vocal speech, JB Watson said long ago, far away is what thinking was.
How is x related to y?
And if it's related, how so?
And you begin to connect the dots and put the elements
together in terms of the set of propositions in regards to this?
X is positively related to, because.
Since x is related to y, this means.
And these self talk learning prompts help you
reason about the complexity associated with Mr. Johnson's care.
Might be the greater, or the lesser.
The greater anxiety, the more the pain.
The greater the pain, the more anxiety.
The greater the pain, the, the more the sleep disturbance.
All of these things begin where, begin to become related.
And as you begin to spin and weave the clinical reasoning web,
you begin to understand that there's a system dynamic here that's operative.
And sooner or later, there is a phase shift that occurs.
So acute pain is related to activity intolerance.
The more pain he has, the less active he's going to be.
The more pain he has, the less mobility he's going to have.
The more pain he has, the more anxiety he's going to have.
The more pain he has, the less self care deficit he has.
And so you begin to, begin to think about this from the balcony view.
Zooming out, looking at the constellation
of problems surrounding Mr. Johnson's situation.
And you begin to realize and see that arrows converge on certain things.
And so it's important to draw lines of relationships.
And give voice to the relationships that you
believe are happening among and between these competing diagnoses.
So you begin to see a constellation of phase shift occur here, in regards
to acute pain being related to fatigue
and activity intolerance and impaired physical mobility.
And so you begin to understand that
pain fatigue and physical mobility are clustered together.
And that there's a center of gravity there.
And perhaps maybe, if you really ameliorate the pain as the keystone issue.
You begin to see, oh, we could change his fatigue.
We could change his activity and tolerance.
So we can increase his physical mobility.
So there's this constellation of things that happen
when you put together a clinical reasoning web.
And you activate your engagement with understanding
how all of these things fit together.
And you begin to develop perhaps maybe a
little theory about what's happening here or a proposition.
And you say, well, the greater the pain, the
greater the fatigue, activity tolerance and impaired physical mobility.
And so, that begins to make sense.
But notice that this is framed in regards to problems that Mr. Johnson has.
Another way to frame this, is to look at the opposite of those things.
And this is the complementary nature.
And so you could also argue, or reason the greater the comfort and pain control.
The greater the active joint movement, ambulation and energy endurance.
And so, you're looking at both sides of the coin and the clinical reasoning web.
And the way it's framed either in terms
of a problem orientation or an outcome orientation.
Enables you to reason forward in a different way.
And then you can put it together in an OPT
model worksheet or an electronic health record or a treatment plan.
Or any one of the other things that might be
available to you in your organization or in your practice.
Then you begin to see, in this particular issue.
The North American Nursing diagnosis knowledge classification
has a NANDA diagnosis keystone issue of pain.
The north, the nursing outcome classification come, knowledge
classification has the representation and knowledge of framing of pain control.
There are NOC outcome indicators.
Nursing outcome classification indicators, associated
with achievement of those outcomes.
And then ultimately there are targets
associated with the achievement of those outcomes.
So that things can be measured and rated.
So that you would be able to make, actually, a clinical judgement.
About the contrast, the criteria, the concurrent consideration
and the conclusion associated with effective pain control.
So there also some choices to be made.
And decisions to make about which of
the nursing intervention pain management strategies classified.
There are 43 activities and some of them include a comprehensive assessment.
Observing for non verbal cues.
Explore patients' knowledge and beliefs.
Teach principles of pain management.
Control the environment.
Provide optimal pain relief with prescribed analgesics.
And these are all framed from a nursing perspective.
But your discipline may in fact have a way of framing
interventions that would be useful, in
terms of understanding Mr. Johnson's situation.
And then, according to the NOC outcome classification, nursing
outcome classification, another representation
of knowledge and of framing.
Comfort is really identified as, as the extent
of positive perception of physical and psychological ease.
And this particular comfort level has been created that
has these clinical indicators associated with the informatics tags.
And as well as scales for making judgments of
radiance in regards to the achievement of the outcomes noted.
So you can do the same thing actually with the, with the interventions.
And begin to think about: where is the center of gravity here?
If I had a choice of interventions
based on my framing and my disciplinary perspective?
So, if comfort is the outcome.
And these are potential interventions associated with how you might
transition somebody from a present state to a desired state.
Education, psychological comfort, risk management, health
systems mediation, immobility management, self care.
You begin to see, as you ask yourself about
all of the different dimensions associated with these interventions.
There is a convergence on this issue of drug management.
And so most of the arrows associated with
analyzing and putting together a clinical reasoning web.
And giving voice to the relationships and monitoring your
thinking about your thinking in relationship to Mr. Johnson's case.
Suggests that drug management might be a
keystone issue in terms of intervention consideration.
So, the outcome present state test model and the activation of a clinical reasoning
web, helps clinicians to kind of figure
out the complexity involved in patient care.
And it requires you to have critical thinking in
terms of the knowledge work that you need on board.
Creative thinking, in terms of understanding the
tension that exists between problems and outcomes.
Complexity thinking, in terms of thinking about multiple things at the same time.
And then systems thinking, in terms of thinking of the patient as a system.
And, later on in the course, I think you're
going to get a case study from Dr. Fricton, Mona.
And she will be talking, he, you'll be able to think about all the
different dimensions and how the competing issues
in Mona's case, relate to one another.
And whether or not there's a keystone issue associated with that.
And what the center of gravity is.
And how you might zero in on that in terms of planning her care.
So, I'd like to conclude by asking you to think about these questions.
What idea, concept or I, was most useful to you in this particular module?
How might you use the information provided today?
Why do you think that information is important?
And then finally, why do you care about that
information, in terms of developing your own clinical reasoning skills?
And moving forward in the care that you provide people.
So, I hope the OPT model is useful to you.
I hope you consider using a clinical reasoning web when you have
complex patients and you're looking for what the center of gravity is.
And I hope you begin to learn
and read more about clinical reasoning, creative thinking.
Complexity thinking and systems thinking, as you develop your
clinical judgment and clinical reasoning skills over and through time.
Thanks very much.
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