Steps to implementation.
- Gathering information (chart review, history and physical exam, family input).
- Organizing and integrating the information you have gathered.
- Assessing the organized information: what is the value and significance of the information.
- Prioritizing the information: which problems will you address first, which ones are related; this can be based on the seriousness and urgency of the diagnoses clinically, or on what the patient feels most strongly about, or even on what has effective treatments and what does not.
- Diagnoses/differential diagnoses.
- Integration of preferences: patient, family, professional.
a. Consideration of feelings, values, spirituality, priorities, goals and resources
b. Consideration of risks and benefits. - Formulation of plan.
- Initiation of first steps in plan.
- Re-evaluation after taking initial steps: assessing response to therapy, side effects, need for dosing adjustment or changes in medications, barriers to adherence and lifestyle changes.
- Adjustment of plan, etc.
At each step, EBP informs but does not dictate the decision-making process. In the end, regardless of what the health care provider may say or order, the patient and the family own the implementation of the plan. Studies have suggested that roughly 70% of younger to middle aged patients prefer a collaborative decision-making process with their provider. In older patients it is closer to 30-50%. More educated patients prefer the collaborative plan more often than less educated patients, but age is still a better predictor than education level of preference. Patients who do not want a collaborative plan will let you know. If you offer them several options, they may look at you and ask, “What would you do if it was you?” or “You’re the doctor, you tell me what to do”.
A collaborative plan can be as simple as, “There are two antibiotics that can treat this infection equally well. One costs more, but only has to be taken once a day. The other one is on the $4 list, but has to be taken twice a day. Many people have trouble remembering to take a pill twice a day. It is important that you take each dose until they are all gone. Would you prefer the $4 pill twice a day or the $25 pill once a day?” It can be as complex as discussing all the various levels of treatment that can be implemented or withheld from an elderly relative with Alzheimer’s who is being admitted to a nursing home.
Student’s Information for Assignment PMHN-622 WS3.4
Patient is a 26-year-old C, M, Female Referred by: Dr. John Doe, NP (PCP)
Chief Complaint and Interval HPI: JW reports having decreased energy, interest and motivation. She previously exercised daily and attended a women’s support group once a week but has done neither activity for the past month. She feels down and does not feel very hopeful about her future. She has not been taking care of her son without assistance and relies on her mother during the daytime and her husband at night. She is two weeks behind on completing assignments in her MSW program. Her appetite has been decreased. She sleeps 8 hours a night. She states “I just wish that I could go to sleep and not wake up”. She had periods of increased energy and did not have any trouble adjusting to having her sleep cycle disrupted with the newborn. She was very talkative and energetic. She would clean the house while the newborn slept. She would also shop online and make multiple purchases that the family did not need nor could they afford as her husband is the only one bringing income into the home at the current time. She denies OCD, eating disorder and/or PTSD.
Current Medications: None
Allergies: NKDA
ETOH/SA Use: She consumes 12 ounces of coffee each morning.
Review of Systems: Constitutional: neg Eyes: neg Ears/Nose/Mouth/Throat: neg
Cardiovascular: neg Respiratory: neg Gastrointestinal: neg Genitourinary: neg
Muscular: pos Integumentary: neg Neurological: neg Endocrine: neg Hematologic/Lymphatic: neg Allergies/Immune: neg Pregnant: No
Notes if Positive: right shoulder pain ongoing for 2 years
Psychiatric History: Her moods were stable while pregnant but have resurfaced over the past 6 months. Dr. Fair treated her for psychiatry from 18-23 years of age. She was stable on her current regimen so her PCP agreed to continue prescriptions and to monitor moods. PCP would refer back to psychiatry with any acute mood issues. She denies any hospitalizations, suicide attempts or SMB.
Social History: She was born in Houston, Texas and moved to NC at 4 years of age. She was born and raised in Guilford County with her mother and father and siblings. She is the second oldest of four girls and one boy. She attended NW Guilford High School and graduated with a 3.2 GPA. She played volleyball and ran track. She attended a local community college for 2 years and then transferred to a UNC-Greensboro to complete a Sociology Degree. She is currently in a graduate social work program at NC A&T University. She lives with her husband of 3 years and their and 8-month old son. Her mother lives within two miles of their home and visits often.
Abuse History: Denies.
Past Medical History: Dr. John Doe is her PCP. Last labs were more than one year ago. Past surgeries include: T&A and appendectomy.
Physical Examination: Weight: 135.6 lbs. Height: 5’5” Blood Pressure: 134/85 Pulse: 87
Gait/Station: Stable gait. Normal Muscle Tone.
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