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. [SOUND]. [BLANK_AUDIO]
