Chapter 14 Critical Thinking and Critical Decision 批判性思维和批判性决定

1、Chapter 14Critical Thinking and Clinical Decision MakingNational EMS Education Standard CompetenciesAssessmentIntegrate scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. This includes developing a list of differential diagnoses throu

2、gh clinical reasoning to modify the assessment and formulate a treatment plan.IntroductionParamedics must be able to:Identify problems.Set patient care priorities.Develop a care plan.Execute the plan.IntroductionCookbook medicine can lead to ineffective care.Patients may present atypically.The scene

3、 may be unstable.You are expected to provide quality patient care. Mark C. IdeGathering, Evaluating, and SynthesizingYou must be able to communicate and obtain information from many types of patients, including:Different age groupsDifferent educational backgroundsDifferent abilities to communicatePa

4、tients who have consumed drugs or alcoholGathering, Evaluating, and SynthesizingAssess and evaluate gathered information to develop a treatment plan.Check the validity of information using your judgment and communication skills.Be as objective as possible in the decision-making process.Gathering, Ev

5、aluating, and SynthesizingEvaluate the information you obtain from:The sceneThe patientA bystanderDetermine what is valid and invalid.Synthesize the information.Gathering, Evaluating, and SynthesizingExample: 64-year-old man reporting chest pains; history includes type 1 diabetes since childhood; lo

6、ng-time smoker; COPDDeveloping and Implementing a Patient Care PlanTreatment plan guided by:Patient care protocolsStanding ordersProtocols or standing orders define the essential standard of care.Developing and Implementing a Patient Care PlanProtocols and standing orders specify:Performance paramet

7、ersWhen medical control should be contactedProtocols promote a standard approach and quality of care.They do not cover atypical presentations.Using Judgment and Independent Decision MakingYou must immediately recognize and treat life threats.Circumstances determine the treatment plan.Use critical-th

8、inking and decision-making skills. Jones & Bartlett Learning. Courtesy of MIEMSS.Thinking and Working Under PressureTo avert disaster, you must have:KnowledgeExcellent psychomotor clinical skillsYou must be able to:Work under extreme pressureThink and perform quickly and effectivelyRange of Patient

9、ConditionsYou must be able to determine if the patient is sick or not sick.If a patient is sick, quantify how sick.Clear thinking in an emergency starts with triage. Peter Willott, The St. Augustine Record/AP PhotosRange of Patient ConditionsCritical patientsSerious patientsMortally wounded or dead“

10、Walking wounded or minimally injuredCritical life threats include:Major multisystem traumaDevastating single-system traumaEnd-stage disease presentationsAcute presentations of chronic conditionsRange of Patient ConditionsSerious conditions include:Serious multisystem traumaAcute presentations of “fi

11、rst-time medical eventsMultiple disease etiologiesNon-life-threatening injuries include:Simple abrasionsPartial-thickness burns of an extremity, with less than 5% body surface areaSmall lacerations with only capillary bleedingConcept FormationFirst stage in prehospital care Gather information from y

12、our senses and diagnostic tools.Begins as the paramedic arrives at the scene Craig Jackson/InTheDarkPhotography Concept FormationPrimary assessment identifies medical condition and threats.Secondary assessment determines: Pertinent medical historyAny medications the patient is takingThe patients aff

13、ect Vital signs are then taken.Data InterpretationSecond stage of the critical-thinking processEvaluate all gathered information.Understand how the body works.Have a background in anatomy, physiology, and pathophysiology.Have a good attitudeApplication of PrincipleThird stage of critical-thinking pr

14、ocessInitial field impression becomes a working diagnosisThe treatment plan is determined by patient care protocols, or standing orders.Reflection in ActionFourth step Treat patients while monitoring intervention effects.Avoid tunnel vision. Craig Jackson/InTheDarkPhotography Reflection on ActionLas

15、t stage Occurs after the call is overReflect on and learn from the decisions and actions taken on each call.Reflection on ActionElements that contribute to critical thinking:Knowledge in medical sciencesAbility to gather and organize data Ability to focus on specific and multiple dataAbility to iden

16、tify medical ambiguityAbility to understand relevant/irrelevant dataAbility to analyze and compare situationsAbility to explain reasoningFrom Theory to Practical ApplicationEach call has unique circumstances.Checklist to support thinking under pressure:Scan situation.Stop and think.Move forward, mak

17、e decisions.Stay calm.Continue reevaluation.The Six RsRead the scene.Overall safety Environmental conditionsImmediate surroundingsAccess and egress Mechanism of injury Jones & Bartlett Learning. Courtesy of MIEMSS.The Six RsRead the patient.Observe the patient.Talk to the patient.Touch the patient.A

18、uscultate lung sounds.Identify life threats.Obtain vital signs. Mark C. IdeThe Six RsReact.Treat any life-threatening problems.Develop a working diagnosis or provide care based on presenting signs and symptoms.Reevaluate.Follow up on interventions.The Six RsRevise the plan.Be open to changing workin

19、g diagnosis.Review the performance.Continuous quality improvement (CQI) meetingInformal discussions with partnersSummaryThe first cornerstone of the paramedics practice is the ability to gather, evaluate, and synthesize information.A paramedic needs to assess and evaluate the validity of information

20、 and its impact on the patient care plan.After evaluation, the information must be processed (synthesized).SummaryThe second cornerstone of paramedic practice is the development and implementation of a patient care plan.The patient care plan is defined by protocols and standing orders of the paramed

21、ics EMS system.The third cornerstone is judgment and making independent decisions.SummaryThe fourth cornerstone of practices is the ability to think and work under pressure.The first stage in prehospital care critical thinking is gathering initial information through the five senses and diagnostic t

22、ools, using the process of concept formation.SummaryData interpretation is the second stage of the critical-thinking process and occurs when the paramedic evaluates the gathered information.The third stage of the critical-thinking process is the review after the call is completed.SummaryThe six Rs will help the p