Diagnostic Reasoning in the

Context of Patient Safety

Use of the
Developing Nurses’ Thinking (DNT)
Model
Dr. Mary Tesoro
 Developing Nurses’ Thinking (DNT)
Model
• Patient safety

• Critical thinking process

• Domain knowledge (includes nursing

process)

• Repeated practice
M Tesoro January 2012
 Critical Thinking Skills
Analyzing
Break up the presentation/question into
parts (cues) to determine meaning (i.e.
normal vs. abnormal). Identify cues.
Cluster cues to determine meaning..
Generates hypotheses.
Applying standards
Use research based standards/rules to rule
in or rule out hypothesis.
NDX defining characteristics, related
factors and risk states; patho
Making a judgment as to “fit”
Discriminating
Look for differences and similarities
Does this help confirm or disconfirm
hypothesis
Information seeking
Do you need more information to solve
this problem? Information from patient/SO?
Lab data? Further physical assessment?
Logical reasoning
Draw conclusions
If this then probably that
Confirm or disconfirm DX
Predicting
Predict potential patient problems and
envision a plan & desired outcomes .
How will this prob/plan affect patient
safety? If I do this then….
Transforming knowledge
How will you recognize this same
concept/problem in other situations?
Critical Thinking Skills and Habits of the
Mind
(Scheffer and Rubenfeld, 2000)
Patient’s presentation and assessment findings Habits of the Mind
Mr. Redford is a 55 year old male admitted to the hospital Confidence
Are you confident in your reasoning
yesterday with a diagnosis of unresolved pneumonia. Prior to abilities?
admission he was treated with two courses of antibiotics Contextual perspective
without resolution of the infection. Mr. Redford states that he Have you considered the entire context of
this problem? Age, co-morbidities,
did “miss a few doses” of the prescribed antibiotics. medication, etc.
  Creativity
PMH: denies any medical problems or surgical interventions. Were you creative when you generated or
restructured ideas? Did you think of
  alternatives?
PSH: states that he drinks alcohol “occasionally” and works Flexibility
approximately 70 hours per week. Did you consider multiple possibilities? Did
  you get stuck on one train of thought?
Inquisitiveness
The student nurse who is assigned to this patient collected the Were you eager to correctly interpret the
following patient data. situation/problem and did you use
 Focused assessment: observation and thoughtful questioning to
explore possibilities?
  Intellectual integrity
The patient stated: “I feel a bit short of breath and I have a Did you use research-based process and
headache especially in the morning” research-based criteria to interpret the
situation/problem?
  Guessing without a basis for deriving
Vital signs: BP 145/88, pulse 110, respirations 25, temperature meaning does not count
98.0 F, SAO2 90% on room air (RA). Intuition-pattern recognition
Did you recognize anything that seemed
  familiar from past experiences?
Neuro: alert and oriented to person, place and time. Patient was
noted to be restless during assessment. Open-mindedness
Were you open to other possible
  interpretations of the situation/data?
Respiratory: respiratory rate 25 with nasal flaring, chest rises
symmetrically, inspiratory course crackles in the right lower
lobe.
Perseverance
  Were you determined to accurately
Identify patient problems and strengths to consider: interpret the situation/problem?
Reflection
Did you constantly reflect on your
thinking, assumptions, and decisions to
assure accurate interpretation of data?
Patient Safety
Problem sheet: these can be NANDA (decreased cardiac output), possible medical problem (infection, MI), or description of the problem (change in mental status)

Problem Confirming Disconfirming Does this Expected Interventions/

Defining characteristics characteristics problems affect Outcomes Evaluation
Assessment findings that Assessment patient safety? If
support the findings that do yes how?
identification of the NOT support
problem. (this includes choice of this
related factors & those problem
that put patients at risk
for problems)
1.

2.
 Critical Thinking Skills
Analyzing**********
Break up the presentation/question into
parts (cues) to determine meaning (i.e.
normal vs. abnormal). Identify cues.
Cluster cues to determine meaning..
Generates hypotheses.
Applying standards****
Use research based standards/rules to rule PSH: states that he drinks alcohol “occasionally” and works approximately
in or rule out hypothesis.
NDX defining characteristics, related
factors and risk states; patho
Making a judgment as to “fit”
Discriminating*******
Look for differences and similarities
Does this help confirm or disconfirm
hypothesis
Information seeking***
Do you need more information to solve
this problem? Information from patient/SO? restless during assessment.
Lab data? Further physical assessment?
Logical reasoning
Draw conclusions
If this then probably that
Confirm or disconfirm DX
Predicting**
Predict potential patient problems and
envision a plan & desired outcomes .
How will this prob/plan affect patient
safety? If I do this then….
Transforming knowledge
How will you recognize this same
concept/problem in other situations?
Critical Thinking Skills and Habits of the
Mind
(Scheffer and Rubenfeld, 2000)
M Tesoro January 2012
Patient’s presentation and assessment findings Habits of the Mind
Mr. Redford is a 55 year old male admitted to the hospital yesterday with a Confidence
diagnosis of unresolved pneumonia. Prior to admission he was treated with Are you confident in your reasoning
two courses of antibiotics without resolution of the infection. Mr. Redford abilities?
Contextual perspective*********
states that he did “miss a few doses” of the prescribed antibiotics.
Have you considered the entire context of
this problem? Age, co-morbidities,
PMH: denies any medical problems or surgical interventions.
medication, etc.
  Creativity
Were you creative when you generated or
70 hours per week. restructured ideas? Did you think of
  alternatives?
The student nurse who is assigned to this patient collected the following Flexibility*******
patient data. Did you consider multiple possibilities? Did
 Focused assessment: you get stuck on one train of thought?
  Inquisitiveness
The patient stated: “I feel a bit short of breath and I have a headache Were you eager to correctly interpret the
especially in the morning” situation/problem and did you use
observation and thoughtful questioning to
 Vital signs: BP 145/88, pulse 110, respirations 25, temperature 98.0 F,
explore possibilities?
SAO2 90% on room air (RA).
Intellectual integrity***
 Neuro: alert and oriented to person, place and time. Patient was noted to be Did you use research-based process and
research-based criteria to interpret the
 Respiratory: respiratory rate 25 with nasal flaring, chest rises situation/problem?
symmetrically, inspiratory course crackles in the right lower lobe. Guessing without a basis for deriving
  meaning does not count
Identify patient problems and strengths to consider: Intuition-pattern recognition*
Possible Problems Possible Strengths Did you recognize anything that seemed
Respiratory compromise: young age familiar from past experiences?
hypoxia, atelectasis, pneumonia, airway probably healthy
Open-mindedness
clearance: increased RR, flaring, 90%, has a job Were you open to other possible
restless, crackles interpretations of the situation/data?
Acute illness
Antibiotic resistant bacteria
Ineffective self health management
Stress overload (may impact health management) Perseverance
Possible alcohol withdrawal Were you determined to accurately
Slightly elevated BP interpret the situation/problem?
Reflection
Need more information seeking to confirm or disconfirm prob/strenghts.
Did you constantly reflect on your
Priority problem: RESPIRATORY at present: next page thinking, assumptions, and decisions to
assure accurate interpretation of data?
Patient Safety
Problem sheet: these can be NANDA (decreased cardiac output), possible medical problem (infection, MI), or description of the problem (change in mental status)
Problem Confirming
Defining characteristics
Assessment findings that
support the identification
of the problem. (this
includes related factors
& those that put patients
at risk for problems)
1. Etiology or related to that
meet this pt: ventilation-
perfusion imbalance
Impaired Gas (pneumonia RLL w
Exchange (IGE) secretions)
Defining Characteristics
(S&S): RR 25(abnormal
Excess or deficit breathing), c/o “I feel a bit
co2 or o2 SOB” (dyspnea), headache
upon awakening, SAO2
90%* RA (hypoxemia),
Priority problem
restlessness, HR 110
Confirmed (tachycardia)
Possible IBP also
but more info
seeking needed
2. Etiology or r/t
Ineffective Breathing Maybe this patient has
fatigue or chest pain that
Pattern (IBP)
prevents him from taking
deep breaths, we don’t know
Inspiration or if he is obese or has any h/o
expiration that does sleep apnea
not provide adequate (hypoventilation syndrome-
ventilation sleep apnea or any prob that
prevents pt from breathing
Disconfirming Does this Expected Interventions/
characteristics problems affect Outcomes Evaluation
Assessment patient safety? If
findings that do yes how?
NOT support
choice of this
problem
Patient is A&O x 3 Profound hypoxemia SAO2 >=94% Independent: position to
so not confused can lead to HR: < 100 improve ventilation:
respiratory arrest, BP: approaching pt elevate HOB, frequent
cardiac arrhythmias normal resp and assessment sao2
and decreasxed RR: <= 20 w/o nasal (q15-30 minutes to start),
cardiac output flaring or use of include patient in the plan
accessory muscles of care: discuss all
N/C of headache therapies and S&S to
N/C of dyspnea report, monitor VS q2h to
Patient will start, note WBC to note
participate in the plan response to therapy
of care Collaborative: administer
O2, antibiotics, assess
sputum and blood
cultures, chest PT and use
of Incentive Spirometer
(IS) to improve
ventilation
Don’t know. Need Already considered us of
more information chest PT and IS that
would cover this problem
so would not need to
discuss in our plan of care
and nursing notes