Nursing Studies: Therapeutics and Diagnostic Reasoning - Essay Example

of Derby Bachelor of Science (Honours) in Nursing Studies THERAPEUTICS AND DIAGNOSTIC REASONING Module 6NU511 Module Leader: Martin Collins Student Name: Nice Mathew Student Number: 100351442 Word Count: 3500 Introduction Therapeutic and diagnostic reasoning is a constituent of clinical decision-making, which entails the identification of cues and the psychoanalysis of data in a clinical situation. The practice of reasoning will lead in diagnostic labels that can differ as the function of task complexity. There are numerous steps in a process of diagnostic reasoning. According to Wilkinson, there are four steps of diagnostic reasoning, these steps consists of Interpreting these entails Identifying significant cues, clustering cues and identifying data, drawing conclusion regarding the current health status and determining etiologies and categorizing the problems. The other steps include verifying, labeling and recording (Afful-Broni, 2014). This paper aims at identifying and critically analyzing the ethical, legal, practical, and administrative issues concerning to drug administration. The paper then explored and critically discussed facets of diagnostic reasoning and pharmacokinetics pertinent to a variety of medications mostly used in patient’s care. Practical, Ethical, legal, and administrative issues There is a growing necessity for nursing practitioners in both primary and secondary care settings to enlighten themselves on various issues surrounding drug administration. Drug administration is an essential part of nursing role that is underpinned by professional and legal requirements. In order to maintain patient’s safety, it is of the essence that nurses’ post registration and pre-registration knowledge and skills be developed in order that they can be able to competently administer medications and perform drug calculations (American Academy of Pediatrics, 2013, p. 67). There are various principles that govern drug administration in nursing. These principles aim to provide patients safety. In order to provide secure drug administration, the nurse ought to perform the rights of drug administration. These rights are the right client, the right drug, the right dose, the right time and the right route. With familiarity in drug administration, there are five additional rights, which are essential to nursing professional. These additional rights include the right assessment, the client’s right to education, the right documentation, the client’s right to refuse, and the right evaluation (Andersen, 2012, p. 56). The principle of the right client or right patient entails administering medication to the right patient. The right client or patients needs to be confirmed by looking at the wristband, and by read-through a second bit of identification. This might be a depiction on the chart, or a case number, which is both on his wristband and chart. Therefore, identification of the right client should be performed before any form of medication is administrated. In the case where a nurse administer a drug to a wrong patient leading to adverse effect, a nurse will be legally held accountable of the action (Suggs, 2014, p. 78). The right drug means that the patient gets the drug that has been prescribed by a medical doctor (MD), podiatrist (DPM), an advanced practice registered nurse (APRN), dentist (DDS) medications (Armitage, & Knapman, 2013, p. 78). Nursing implication in the principle of right drug includes the nurse to check that medication order and ensure it is legible and complete, the nurse to know why the patient is being administered a particular drug. The nurse should be able to know indications of medications prescribed so that to determine if the patient is legible to be administered the drug. In some instances where the drugs may have more adverse effects compared to therapeutic benefit, a nurse do away with the drug and administer different drugs that has more therapeutic benefits that side effect (Baker, 2013, p. 23). After not administering a drug that is more harmful to the patient, a nurse should inform a physician. The nurse should counter check the drug label at least three times prior to the administration. It is essential for a nurse to know the start time that the medication was ordered and the finishing time (Baker, 2013, p. 23). The right dose entails the right amount of drug that the patient is given. The nurse is accountable for questioning and inquiring any dose, which appears to be too high or too low for a particular. A nurse should consult a pharmacist or peer if the amount appears inaccurate. When a nurse finds the dose to be too high to the patient, the nurse must exercise the ethical value of beneficence. The nurse should adjust the dosage to suit the patient (Baker, 2014, p. 54). It is indispensable to beware of pediatric dosages, which are based clients body weight. Often the weights may change day by day, therefore, regular assessment and evaluation of dosages is decisive. The nursing implications on the right dosage are to calculate the drug dosage properly. For a number of drugs, two nurses are required to sign off on a fresh order such insulin and heparin. The nurse should counter check the PDR, drug package insert, and other form of drug references for suggested array of precise drug dosage (Nagelkerk, 2013, p. 55). The right time is the time at that the set dosage must be given. Nursing implications include administering medication at the precise times. Medications may be administered 0.5 hour prior to or after the time prescribed depending with the company or hospital policy. In some scenario when the there is need for the drug to be administered before the prescribed time or there is urgent indication for drug administration, it is argued that the patient should be administered the drug. For instance, the patient is in great pain and the due time for analgesics is in hour’s time, a nurse is obliged to administer the drug before time to promote patients comfort. The nurse to give drugs which are adversely affected with foods, prior to meals for example tetracycline to be given before meals (Sage, 2013, p. 67). The nurse should administer medication, which can irritate the gastric mucosa with meals for instance aspirin or potassium to be administered with food. The drug administration plan may from time to time be flexible to accommodate the patient’s daily activities or preferences. It is nurse duty to be sentient of procedures or tests, which are being done and may influence drug administration, for instance endoscopy and fasting blood tests. The nurse to confirm the expiring date on drug and return to pharmacy they are expired. The right route is essential for satisfactory or suitable absorption. Nurse to assess patient’s ability to swallow prior administering per oral medication. In the case where the patient has been prescribed oral medication and the patient is unable to swallow drugs or there is other contraindication, a nurse should not administer and opt for another route. Nurse not squash or combine drug into other stuff prior consulting the pharmacy. Always use aseptic technique when giving medication and Stay with the patient until per oral drugs have been swallowed (Berntsen, 2014, p 24). Various medical ethical values govern drug administration in nursing. Do no harm also termed as non-maleficence, implies that the nurse should not administer treatment that will have harmful impact to patients health, therefore a nurse should way the side effect of the drug and therapeutic benefit of medication. Similarly, a nurse must balance between beneficence and non-maleficence, the balance is the one amid the risks and benefits of treatment. There are several issues surrounding the critical concept of drug administration. Many of these issues arise in a bid to address the numerous mistakes that can be made during the prescription, dispensing, transcription and administrative phases of preparing and distributing drugs (American Academy of Pediatrics, 2013, p. 67). Many of the errors that result during drug administration are either acts of omission or commission. Moreover, they may entail the following: wrong dosage, improper routine, and drug mix-up. In addition, the omission may be as a result of improper timing of drug administration and contraindications that may result during drug administration. Others include incorrect drug procedure, erroneous infusion rate, and terminated prescription date or several prescription errors. It is important to note that some of these errors can occur either intentionally or unintentionally. Several factors that may cause drug administration errors can be divided into system errors and errors attributable to individual health care practitioners. Another key issue that can contribute to errors in drug administration is that of incident reporting (Anderson &Webster, 2012, p. 67). Diagnostic reasoning Diagnostic reasoning is a constituent of medical or clinical decision-making, which entails the identification of cues and the psychoanalysis of data in a clinical situation. Through diagnostic reasoning, a nurse should exhibit Critical thinking. Critical thinking in nursing is a fundamental constituent of proficient accountability and excellence nursing care (Cohen, 2012, p. 78). A critical thinkers nurse exhibits these behaviors in their mind: contextual perspective, confidence, creativity, inquisitiveness, flexibility, intuition, intellectual integrity, perseverance, open-mindedness, and reflection. A critical thinker in nursing performs the cognitive skills to analyze, apply required standards, logical reasoning, information seeking, transforming knowledge, and predicting (King, 2014, p. 67). Clinical diagnostic reasoning and pharmacokinetic monitoring are integral components of nursing care and should be based on the particular pharmacotherapy, treatment goals, and disease states of the patients (Hurley, 2014, p. 78). It is important to note that pharmacokinetic monitoring is important in achieving positive results for patients across the continuum of care. Examples of these results include decreased treatment durations, decreased mortality, decreased morbidity, and decreased admission to the hospital (Avorn, Monette & Lacour, 2012, p. 89). Furthermore, proper diagnostic reasoning results in decreased adverse effects resulting from incorrect drug therapy. Within the nursing care setting, physicians’ clinical duties should entail suitable and cost-effective therapeutic drug checking, as well as the establishment of experimental pharmacokinetic appraisals. Clinical diagnostic reasoning is essential when the range between minimal efficacy and toxicity is narrow, and the outcomes of the drug assay offer significant information for clinical decision-making. For instance, the absence of drug concentration measurements and patient-specific characteristics, physiological markers can be used to make clinical pharmacokinetic evaluations and make the necessary dosage-regimen recommendations (DiMatteo, 2014, p. 78). Diagnostic or Clinical reasoning stands out as a sited, it’s a practice-based type of reasoning which requires a background of technological and scientific research based facts concerning broad cases, compared to any particular case (Helsm & Quan, 2013, p. 12). It also needs practical aptitude to distinguish the significance of the proof behind universal technical and scientific knowledge and the way it applies to a certain client. The nurse considers the client’s particular medical trajectory, their preferences and concerns, and their vulnerabilities (for example, having numerous comorbidities) and sensitivities to care involvement (for example, a well-known drug allergies, other contradictory comorbid cases, incompatible or irreconcilable therapies, and previous responses to the therapies) when formulating diagnostic or clinical decisions and conclusions (Lunney, 2013, p.23). Measures that can improve or enhance diagnostic reasoning accuracy can be generally categorized into two groups. First, it can be enhanced through improving individual nurses’ diagnostic reasoning skills second, it can be improved through improving the health care systems in order to support nurses through the diagnostic reasoning process. Improving individual diagnostic reasoning can be achieved through personal Continuous Improvement (DiMatteo, 2014, p. 54). The individual nurse may practice at least three diverse measures to enhance their diagnostic reasoning. These measures include feedback, metacognition, and deliberate practice. In feedback, the solitary way decision makers may enhance their judgment is by feedback. When the diagnostic decisions are accurate, reinforcement happens (Horne, & Weinman, 2012, p. 18). On the other hand, when diagnostic decisions are inaccurate, recalibration happens. In improving and enhancing Health Care Systems in order Improve Diagnostic reasoning, presently, the modification of diagnostic ability is a personal quest, powered by a nurses’ own force for fineness. Conversely, as organization recognize the pecuniary, safety, quality, and legal implications of diagnostic errors; they will turn out to be more and more motivated to assist nurses improve their diagnostic accuracy by technology, by processes derived from information systems, and by cultural approaches (Benner, Tanner & Chesla, 2013, p. 78). There are various ways and steps of diagnostic reasoning. Mostly known are the four steps of diagnostic reasoning and the 6 steps of clinical or diagnostic reasoning. According to Wilkinson, there are four steps of diagnostic reasoning, these steps consists of Interpreting these entails Identifying significant cues, clustering cues and identifying data, drawing conclusion regarding the current health status and determining etiologies and categorizing the problems. The other steps include verifying, labeling, and recording (Wilkinson, 2013, p. 22). The other method of diagnostic reasoning consists of six steps. These steps are; categorize data and utilize the ISDA (Intan’s Screening Diagnoses Assessment) to identify recognize probable nursing diagnoses and problems. The second step is to activate probable collaborative problems and nursing diagnoses. the third step is to learn or read from suitable references regarding those potential collaborative problems and nursing diagnoses and establish whether the diagnosis are definite or whether the diagnosis are ruled out and if further evaluation is required linked to the collaborative problems and the nursing diagnoses (Rew & Barrow, 2012, p. 45) . The fourth step is to employ the poster for nursing diagnosis that have an ‘A’ group. The fifth step is continuing focused evaluation if essential to recognize etiology and other defining factors. Step 6 involves labeling the diagnosis. ISDA is a main tool in the six steps of diagnostic reasoning, which assist nurses when evaluating their patients by scrutinizing all possible collaborative problems and nursing diagnoses. Intan’s Screening Diagnoses Assessment is based on the consideration that data gathered can belong to collaborative problems or nursing diagnosis or both (Kink & Clark, 2012, p. 67). In comparison of four step and six step technique of diagnostic reasoning, the six step is identified as more promising reasonable diagnoses and DDx (differential diagnoses) in comparison to the 4 step method. The six step method of diagnostic reasoning similarly lessen the likelihood to identify incorrect diagnoses. It is also measured as easier, more proficient, helpful, and expected to be applied in a clinical setting than the 4 steps diagnostic reasoning method (Bucknall, 2013, p. 78). Pharmacokinetics Pharmacokinetics usually entails drug distribution, drug absorption, metabolism, and excretion. The basic concept in pharmacokinetics is the drug clearance, which is the removal of drugs from the body system, similar to the conception of the creatinine clearance (McQueen, 2014, p. 78). The core competencies of therapeutic interventions include the role of the nursing practitioner in stabilizing the patient, reducing physical complications, and increasing the patient’s general health potential. The final objective of any medical psychotherapy is to fulfill sought after goals within the apprehensive patient (Whitney, 2013, p. 72). These anticipated results are part of the purpose of the management of various health conditions and diseases. However, despite the many efforts of health care professionals, these results may not be achieved in cases where the patient becomes non-compliant. Therapeutic drug monitoring is crucial in management of patients on medication. Therapeutic drug monitoring remains to be a core responsibility of a nurse. The fundamental suppositions underlying drug monitoring are that drug clearance or metabolisms vary from one patient to another and the plasma level of a drug is closely linked to the drugs therapeutic toxicity and effect compared to the dosage (Fowler, 2012, p. 67). In cases where a patient is prescribed a drug that they are unlikely to clear or metabolize, a nurse should do the right thing by not administering the drug and opt for an alternative drug. There are various indications for drug monitoring which include; medications with the narrow therapeutic index must be monitored. This is where the therapeutic drug level does not vary much from levels linked with a serious toxicity for example, phenytoin, Lithium, digoxin (O’ Neill & Dulhy, 2011, p. 67). As in the case where the drug linked with toxicity and is can be helpful to a patient, it is argued that a nurse should monitor the patient closely after drug administration. Monitoring of the patient involves regular check up of patient’s vital signs and note any deviation from the baseline. Drug monitoring should also be done on patients that have impaired drug clearance with a narrow therapeutic index. It is essential for a nurse to know and understand clearance mechanism of the medication involved. For example, clients with renal failure or kidney problems have reduced clearance of digoxin, therefore, these patient are at a greater risk of drug toxicity (Edmunds & Mayhew, 2014, p. 29). Drug monitoring should also be done on medications that toxicity is hard to differentiate from a clients underlying condition or disease. For instance, Theophylline in clients with COPD (chronic obstructive pulmonary disease) must be monitored. Similarly, medications whose effectiveness or efficacy is hard to determine clinically, it may need monitoring of its plasma levels for instance, Phenytoin (Gorman, 2013, p. 67). Principles of pharmacokinetics, such as bioavailability, distribution, and metabolism should be accurately understood before the nurse can make the choice for the most appropriate treatment for each patient (Fowler, 2012, p. 56). These Pharmacokinetic principles are also know as pharmacokinetic parameters and are imperative in drug monitoring. It argued that a nurse should be able to understand and appreciate pharmacokinetic principle or parameters in order to manage patients on medications. Bioavailability is one of the pharmacokinetic parameters. The bioavailability of a medication relies in part on its formulation. The medication, which is greatly metabolized as it passes via the liver shows a discernible first pass effect, decreasing the efficient oral absorption of a drug (Suggs, 2014, p. 43). A decrease in this first-pass effect might lead a clinically considerable enhancement in efficient oral drug absorption. Volume of distribution and distribution phases is the other parameter or principle of pharmacokinetic. The volume of distribution of a medication greatly establishes the plasma level reached following the loading dose. The distribution phase on the other hand is the time used for the medication to distribute from the plasma to the fringe or periphery. Blood taken prior to the completion of an extensive distribution phase cannot reproduce the concentration of pharmacologically active remedy at place of action for instance, in Digoxin and lithium (Basford, 2013, p. 62). Drug clearance is an essential parameter in drug monitoring. Drug clearance can be at the renal or non-renal, which is generally hepatic. When there is alterations in renal the clearance, it can be predicted on the basis of creatinine levels, there is no custom liver function test for evaluation of hepatic drug metabolism (Leach, 2012, p. 78). The half-life of a drug usually relies on its clearance and volume of distribution and establishes the time used to attain a steady state level. Following a period of about 4 half-lives, the serum levels of the drug will be about 93.5% of the steady state. Clients with reduced drug clearance and thus raised drug half-life may take long duration to reach an elevated steady state level. Generally, as non-steady state drug concentration are hard to interpret, drug monitoring typically entails measurement of the drug levels at steady state (Doenges & Morrhouse, 2012, p.123). It is vital for a nurse to understand Drug Interactions before drug administration to avoid adverse effect. For clients getting more than one medications, the likelihood of drug interactions influencing drug breakdown should be highly considered. In the case where the patient is on quinidine and digoxin, the Quinidine will decrease clearance of digoxin (Zenk, 2014, p. 56). Drug monitoring can be done in three different ways, first, impact of a drug can be monitored by its clinical impact or impact for example the prophylaxis of migraines, reduction of blood-pressure, or the decrease of inflammation with steroids. Therefore, a nurse should the expected outcome of a drug, prior administration. In case a drug is not achieving its therapeutic effect, the nurse should opt for another medication. The second way of monitoring is by the biological impact of the medicine can be trailed by its biochemical impacts or effect for instance, increasing prothrombin time with use of warfarin, lessening in plasma viscosity by anti-inflammatory drugs, the reducing of uric acid with allopurinol or glucose control with insulin (Taxis & Barber, 2013, p. 45). Therapeutics impact on patient care With drug administration, healthcare provider expects positive outcome. For diabetes type 2 patients, therapeutic information is necessary for informing the patients about the best management practices for the disease. In the case on when the patient is hyperglycemia, with drug therapy plays role in normalizing sugars. The patient is give insulin on a regular basis to control sugars. Patients should be advised on the best way to follow the prescribed treatment regimen and adhere to the prescribed drug dosage. Moreover, they should be guided on taking medicines in a regular schedule, and the recognition of any form of insufficiency in their treatment procedure (Doenges & Morrhouse, 2012, p. 67). They should also be advised to take regular exercise and ensure they eat a balanced diet, with emphasis on taking sufficient carbohydrates in every meal and eating regularly. Diagnostic reasoning, which entails critically thinking clinical reflection and appropriate judgment a nurse, can manage any patient effectively. Nurses caring for asthmatic patients should be able to apply their diagnostic reasoning skills to recognize the symptoms at the onset and select the necessary objectives for the management of the health condition (Bell, Caspi, Schwartz, Grant, Gaudet & Rychener, 2012, p. 78). Furthermore, the practitioner is expected to utilise their pharmacokinetic skills in managing the condition with the necessary prescription regimens. When it comes to treatment regimens, the physician must be able to select a range of medications according to their pharmacological properties (Vincent, 2013, p. 45). For the management of depression, effective collaboration across specialist and primary care is of fundamental importance for effective diagnosis and pharmacokinetic care. Diagnostic reasoning enhances the detection, recognition, and treatment of the condition. Furthermore, the adherence to evidence-based guidelines enhances diagnosis and treatment outcomes (O’ Neill & Dulhy, 2011, p. 67). Alternative approaches and perspectives to care. A number of recent trends indicate that conventional medicine that puts great emphasis on diagnostic reasoning and pharmacokinetic parameters may yield a pluralistic health care system. This would be where various models of care may have to co-exist. However, it is notable that the co-existence of various health care modalities does not necessarily produce an integrative system of health care (Barnes, Abbot, Harkness, & Ernst, 2012, p. 78). Within the present health care system, providers and patients encounter problems when multiple, yet uncoordinated, approaches are followed during diagnostic reasoning and pharmacokinetic considerations. Some of the succinct alternative approaches to nursing care include the introduction of integrative care that not only enhances the strengths of conventional health care approaches, but also helps in balancing its deficiencies, such as the possible undesirable side effects of poly-pharmacy and discrete pharmacological proxies (Faass, 2012). Other issues include high costs and the depersonalizing nature of the current technological interventions. Integrative care is also effective in addressing the suppression of symptoms that does not necessarily result in the promotion of overall healing (Marcum, 2012, p. 67). An extensive experience base with a particular patient population can enable the physician to form comparisons, distinctions and nuanced differences within a given population of patients with certain injuries, conditions, or diseases. The comparison between several specific patients can facilitate the creation of a matrix comparison for clinicians. Such a matrix can enable the clinicians to perform effective patient-specific detective procedure. This should be done in cases where patients fail to achieve the desired and predictable outcomes following therapeutic intervention (Keepnews & Mitchell, & 2013, p. 76). It is important to note that background and foreground information, in regards to a clinician’s attention, often shifts as predictable changes in the patient’s condition emerge. This can be seen as patients recover from operations such as heart surgery, or during the expected times of labor and subsequent delivery. With time, the physicians develop a better understanding that enables the application of expert intervention skills and precise diagnostic reasoning skills (Mello & Brennan, 2012, p. 67). References Adjei, P. (2012). International journal of infectious diseases, vol 10, issue 6,. chicago : word press. Adcock, K, 2012. Prescribing principles for children. Foundations of rational approach. 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