Medical surgical nursing clinical reasoning in patient care pdf


A diagnosis, in the sense of diagnostic procedure, can be regarded as an attempt at classification of an individual’s condition into separate and distinct categories that allow medical decisions about treatment and prognosis to be made. Subsequently, a diagnostic opinion is often described in terms of a disease or other medical surgical nursing clinical reasoning in patient care pdf, but in the case of a wrong diagnosis, the individual’s actual disease or condition is not the same as the individual’s diagnosis.

Such elucidation can be useful to optimize treatment, further specify the prognosis or prevent recurrence of the disease or condition in the future. Knowledge of what is normal and measuring of the patient’s current condition against those norms can assist in determining the patient’s particular departure from homeostasis and the degree of departure, which in turn can assist in quantifying the indication for further diagnostic processing. A complaint expressed by a patient. The fact that a patient has sought a diagnostician can itself be an indication to perform a diagnostic procedure.

Even during an already ongoing diagnostic procedure, there can be an indication to perform another, separate, diagnostic procedure for another, potentially concomitant, disease or condition. Diagnostic tests can also be used to provide prognostic information on people with established disease. Processing of the answers, findings or other results. Consultations with other providers and specialists in the field may be sought. In reality, a diagnostic procedure may involve components of multiple methods. The final result may also remain a list of possible conditions, ranked in order of probability or severity.

Even if it doesn’t result in a single probable disease or condition, it can at least rule out any imminently life-threatening conditions. Unless the provider is certain of the condition present, further medical tests, such as medical imaging, are performed or scheduled in part to confirm or disprove the diagnosis but also to document the patient’s status and keep the patient’s medical history up to date. This may be the primary method used in cases where diseases are “obvious”, or the provider’s experience may enable him or her to recognize the condition quickly. Theoretically, a certain pattern of signs or symptoms can be directly associated with a certain therapy, even without a definite decision regarding what is the actual disease, but such a compromise carries a substantial risk of missing a diagnosis which actually has a different therapy so it may be limited to cases where no diagnosis can be made. The clinician interacts with the software utilizing both the clinician’s knowledge and the software to make a better analysis of the patients data than either human or software could make on their own. Typically the system makes suggestions for the clinician to look through and the clinician picks useful information and removes erroneous suggestions. An “exhaustive method”, in which every possible question is asked and all possible data is collected.

This is often referred to as a “diagnostic workup”. 25 years of data and 350,000 claims. Overdiagnosis is the diagnosis of “disease” that will never cause symptoms or death during a patient’s lifetime. Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant.

A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Medical diagnosis or the actual process of making a diagnosis is a cognitive process. A clinician uses several sources of data and puts the pieces of the puzzle together to make a diagnostic impression. The initial diagnostic impression can be a broad term describing a category of diseases instead of a specific disease or condition. After the initial diagnostic impression, the clinician obtains follow up tests and procedures to get more data to support or reject the original diagnosis and will attempt to narrow it down to a more specific level. Diagnostic procedures are the specific tools that the clinicians use to narrow the diagnostic possibilities.

Diagnosis can take many forms. It might be a matter of naming the disease, lesion, dysfunction or disability. It might be a management-naming or prognosis-naming exercise. It may indicate either degree of abnormality on a continuum or kind of abnormality in a classification. It’s influenced by non-medical factors such as power, ethics and financial incentives for patient or doctor.

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