8-19 Clinical decision making and Med admin

what are the 7 steps of the clinical decision making process

Recognize cues

analyze cues

define hypothesis

generate solutions

take action

evaluate the results

Start over

What is the most important factor in developing clincial decision making skills

the number and type of supervised pt contacts

Confirmation/anchoring bias

involves selectively gathering and interpretating evidence to conform with ones belief as well as rejecting evidence that contradicts it

Outcome bias and improvement bias

believing that clinical results good or bad are soley attributable to care decisions

availability bias

what comes to mind most readily

diagnosis made based on previous patients with similar symptoms

affect heuristic

clinicians actions are swayed by emotional reactions

inherent bias

a clinicians unconscious and automatic judgements about their patient or the patients condition. Often based on stereotypes or oversimplifying.

personality traits that effect patient care

risk aversion- error on side of conservative medicine

ambiguity tolerance- ability to work in gray area

dunning kruger effect

people overestimate their knowledge or ability in a particular area

believe they posses superior skills and knowledge compared to others even though actual skills level is far below.

ways to minimize cognitive bias

cognitive forcing strategy- conscious consideration of alternative diagnosis/not calling off the search

cast a wide net

narrow DD based on evidence

4 methods used to develop clinical decision making in EMS

Case studies

scenarios

hospital clinical rotations

field internships

requirements for effective clinical reasoning

knowledge/skill base

abilitiy to handle large amounts of data

identify and deal with medical ambiguity

analyze and compare situations

explain and support decisions

courage to lead

etiology

the cause or origin of a disorder

pattern recognition

a patterns of assessment findings helping to get to field impression

medical ambiguity

pt presents without typical pattern for a specific condition

field impression

AKA field diagnosis

care for a pt where we are unable to form field impression

manage ABCs

treat s/s

consult medical direction

transport

advantages and disadvantages of protocol use

advantages:

• help minimize risk

• standardized approach to patient care

• detail general and specific procedures

• define and outline performance parameters

disadvantages

• cant cover every variation

• promotes a linear cookbook approach to card

• difficult to apply to patients

  • when a field impression cant be reached

  • with multiple underlying causes or presenting conditions

divergent vs convergent data analysis

divergent- considers many possible solutions

convergent- one cause and one answer

intuitive and analytical thinker

intuitive- quick automatic more efficient global processing. Relies on pattern recognition, becomes primary with experience. can lead to incorrect decision

analytical- utilized by less experienced clinicians- longer and less susceptable to error

define good clinical judgement

to consistently provide the best treatment to maximize benefit to the patient and minimize risk ensuring no harm is done.

sterile vs asepsis

sterile is no germs

asepsis- less germs- wiping with alcohol wipe

contact vs exposure

exposed to potentially infectious body fluids with intact skin- contact

• wash with soap and water, notify preceptor and let faculty know (can be in writing)

exposure-intro of foreign body fluids into mucous membranes (eyes, nose, mouth) or non intact skin

• soap and water

• notify preceptor and follow their guidelines

• verbally contact faculty

list action to take with medication error

contact physician treating the pt and contact supervisor (faculty in my case)

SQ needle gauge and length

24-26 gauge

3/8” to 1”

IM needle gauge and length

19-21 gauge

1-1.5”

IV needle gauge and length

standard- 18-20 gauge, 1.5”

Trauma (large amounts of fluid)- 14-16 gauge, 2”

geriatric/peds: 22-24 gauge, 3/4-1”

IO needle gauge and size

ALL IO needles are 15 gauge

peds- 15 mm

adult 25mm

bariatric/humeral- 45mm

ampule

break neck of glass with gauze

carpuject/tubex

place med vial in holder, screw plunger into bottom of vial, rotate clamp to puncture vial, connect to luer lock and admin

admixiture

med added to bag of fluid

sites for SQ injection and what angle

lateral + posterior side of upper arm

and the abdomen

45 degrees. Max fluid is 1cc

3 IM injection sites and max amount of fluid in each

vastus lateralis- anterior lateral surface of thigh, 5 ccs

deltoid- two finger widths below acromion process, midline of arm- max 2ccs

Dorsogluteal- divide cheek int0 4 quadrants- upper outer for inection- 5 ccs

what places should be avoided for IVs

avoid places with pulsation, above joints, dialysis fistulas or shunts, same side of body as mastectomy, and signif trauma to extremity

3 indications for IV acces

when you need or suspect you may need to

• give IV med

• give fluids, electrolytes, or blood products

• obtain blood for lab specimen

how are IV admin sets defined

number of drops/gtts needed to form one CC of fluid

microdrip

60gtts/cc

used for med infusion admin

fluid admin for very young

used for TKO

macrodrip

10gtts/cc or 15gtts/cc

fluid admin

list equipment needed to start IV

BSI

IV catheter

admin set

extension set

TQ

gauze

securing device

5 indicators of a patent IV

flashback

catheter threads into vein easily all the way to hub

IV flushes easily with NS from flush or from bag

blood flash during aspiration with syringe (or when lowering IV bag)

no signs of local complications

infiltration

fluid or med leaking into surrounding tissue. caused by improper placement or dislodgement

thrombosis

formation of blood clot on distal end of catheter preventing line from flowing.

connected IVs should be running TKO (to keep open) to avoid this

thrombophlebitis

local

commonly found in patients with long term IV access

irritation of blood vessel due to formation of clot and manifests as redness and irritation to site

cellulitis

a bacterial infection of the outer layers of the skin. This creates a large surface area of redness/irritation that can be warm to touch and painful

what is the first step of giving a bolus?

are you allergic?

pyrogenic reaction

systemic

antigens found in tubing or fluid from manufaturing process

abrupt onset of very high fever, chills, headache, N/V and bachache, can lead to shock

catheter shear

tip of catheter is sheared due to poor technique

PE symptoms

CVA s/s

circulatory overload

systemic

too much fluid admin to someone as risk of overload

pulmonary edema and dyspnea

thromboembolism

blood clot forms due to trauma to vessel wall- can break off

PE or stroke

air embolism

usually in arterial lines

shock symptoms and cyanosis

hemolytic reaction

shock

significant fever and back pain

flushing of skin

bolus vs infusion

bolus- syringe

infusion- bag

what angle for venipuncture

20