Clinical judgment

The less potent vasopressors, such as metaraminol, also require close patient supervision during administration. The nurse follows the same procedure as that for norepinephrine and dopamine but may take blood pressure and pulse determinations at less frequent intervals, usually every 15 to 30 minutes. The nurse needs sound clinical judgment to detemrine the frequency because there is no absolute minimum or maximum time limit between detenninations. 

Critical Thinking Exercises—realistic patient care situations tiiat help die student apply the material contained in die chapter by exploring options and making clinical judgments related to die administration of dragp... 

Reassess therapy after 48-72 h and continue or streamline therapy based on microbiological data, clinical response, and clinical judgment... 

Stream-line antimicrobial therapy based on clinical judgment, patient response, and microbiological data... 

Consider short-course therapy (8 d) based on clinical judgment and patient response... 

The contents of this handbook should be utilized as a guide and in addition to sound clinical judgment. Consult full prescribing information and take into consideration each drug s pharmacokinetic profile, contraindications, warnings, precautions, adverse reactions, potential drug interactions, and monitoring parameters before use. 

Clinical judgment should be used to test for diabetes in high-risk patients who do not meet these criteria. 

Blood and other specimens should be cultured according to clinical judgment because meningitis frequently can arise via hematogenous dissemination or can be associated with infections at other sites. A minimum of 20 mL of blood in each of two to three separate cultures per each 24-hour period is necessary for the detection of most bacteremias. 

Equations are available to estimate resting energy expenditure (Table 57-6). The result should be multiplied by a factor to correct for stress or activity level based on clinical judgment. 

When the results of these studies and STAR are made available, the choice between the two alternatives will likely be very complex. Decisions will be influenced by the profile of the women, the importance of the different (bone and breast) risks, and additional risk factors. With quality evidences available, wise clinical judgment will be made on a case-by-case basis. 

Some of these measures are part of larger, semistructured interviews administered by the therapist. The most commonly used assessments in this category are a family of instruments developed mainly in the Veterans Administration (VA) hospital system. The first instrument in this family is known as the Addiction Severity Index (ASI McLellan et al., 1985). The ASI assesses for a wide variety of biographical data, so it has the advantage of potentially being used as part of an intake interview. The ASI asks about consequences in a wide variety of life domains, and determines recent and lifetime patterns of drug and alcohol use. The ASI also detects recent and lifetime occurrence of problems in these different life domains (e.g., work). Each domain can be scored for the severity of the problems based upon the responses of the client and the clinical judgment of the interviewer. The ASI can be administered by computer to provide for rapid interpretation of answers. 

Counselors and therapists have to determine when the client has made sufficient progress to move into this next phase of therapy. The decision whether the client is ready to be moved from formal treatment into aftercare is determined by client progress on the treatment plan. The counselor or therapist uses clinical judgment to ascertain whether the client has made sufficient progress on the plan to warrant movement from formal treatment into aftercare and whether the client is sufficiendy stable in his or her recovery to take this next step toward autonomous recovery. The next section covers factors that counselors and therapists should consider when making the decision to graduate clients from treatment into aftercare. In addition, this chapter provides an overview of what can be expected during this final phase of treatment and therapy for professionals, and for clients and their families. 

Tier 2 problems should be resolved before such referrals are made. The resolution of Tier 3 problems becomes more a matter of clinical judgment, but certainly a counselor or therapist will want to determine whether enough progress on Tier 3 problems has been made that the client can begin to direct his or her own treatment out in the real world. I would recommend that significant progress has been made on most, if not all, Tier 3 problem items on the treatment plan prior to discharge into aftercare. 

Dr. Harold Abramson, under a contract with the CIA in 1954, had reached a similar conclusion from a preliminary trial with four subjects. Based on his clinical judgment of response intensity, he estimated the inhalation dose to be only about one-third as effective as the same oral dose. In 1966, he gave me a hand-typed draft CIA report he had never published. The ingenuity of the technique he describes, using a rudimentary aerosol chamber, is evident in the report, which is provided on the following pages. 

Renal function impairment- In patients receiving pamidronate for bone metastases who show evidence of deterioration in renal function, withhold treatment until renal function returns to baseline. In a clinical study, renal deterioration was defined as follows for patients with normal baseline creatinine, an increase of 0.5 mg/dL for patients with abnormal baseline creatinine, an increase of 1 mg/dL. In this clinical study, pamidronate treatment was resumed only when the creatinine returned to within 10% of the baseline value. In other indications, clinical judgment should determine whether the potential benefit outweighs the potential risk in such patients. 

If this is not possible, exercise clinical judgment. When there is sufficient respiratory distress to warrant a small risk, then 2.5 mg/kg of theophylline administered in rapidly absorbed form is likely to increase serum concentration by approximately 5 mcg/mL. 

In treating pain, it is vital to assess the patient regularly and systematically. Regularly review therapy and adjust based upon the patient s own reports of pain and side effects and the health care professional s clinical judgment. 

Hypersensitivity to ethambutol known optic neuritis, unless clinical judgment determines that it may be used. 

Finally, it must be stressed again that the selected weighting factors W (and thus the biologically weighted doses) are based on available radiobiological data and clinical observation, but they always imply clinical judgment and experience. 

Thus, clinical judgment plays a major role in the decision to continue BZD anxiolytic treatment beyond 4 to 6 weeks. Although long-term administration may maintain... 

Dose and duration of treatment must be considered. Many treatment failures are due to inadequate dosage, which should be pushed to the limits of the patient s tolerance in refractory cases. The duration of treatment before giving up on a drug is a matter of clinical judgment. 

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