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The Role of Clinical Reasoning in Nursing

Question:

Discuss about the Case Study of John Gray.

Nursing is a profession that is based on practice and experience (Levett-Jones, 2013). Therefore, the application of clinical reasoning methods in nursing is considered an essential aspect of the profession. A nurse who possesses a well-defined skill for clinical reasoning has a greater level of effectiveness in terms of providing a positive impact on individuals (Levett-Jones, 2013). These individuals provide a considerable amount of positivity in the clinical outcomes for the patients and their families (Alatri et al., 2012).  Patients and their families often obtain a positive and satisfactory clinical experience upon interacting with nurses who display clinical reasoning skills. On the contrary, the lack of clinical reasoning in a nurse often leads to the failure of identification of signs of deterioration in the health of the patient. Nurses who lack sufficient skills of clinical reasoning often are unable to identify patient concerns and signs of ill-health (Parth, Hrusto-Lemes, & Löffler-Stastka, 2014).

The outcomes of patient experience generally depend upon the level of satisfaction of each individual towards the nurse and the experience that they gain from the health care experience (Huh et al., 2012).

Particularly in mental health nursing or psychiatric nursing, the practice of developing critical thinking and clinical reasoning in order to determine the outcomes for the patient at every stage of healthcare is one of the most essential aspects of healthcare (Puntil et al., 2013). Patients of mental health concerns, depression in particular, have several levels of challenges and these problems translate to nursing care concerns (Smith et al., 2014).  Depression has a high aetiology rate and is becoming increasingly common in the recent years and is considered a common occurrence. Mental health issues and depression demand the existence of clinical reasoning amongst psychiatric nurses (Osafo, Knizek, Akotia, & Jhelmeland, 2012). Depression is an enfeebling disorder and often weakens the individual in body and spirit. In mental health nursing, it is of critical importance to analyse the various stages of patient care. The clinical reasoning model that is followed in the current essay is the Levett-Jones model of clinical reasoning. This model follows a series of steps for the evaluation of patient condition, information, and clinical signs and symptoms (Levett-Jones, 2013).


Clinical reasoning comprises of the assessment of patient concerns and considerations. This is followed by the collection of the patient information and listing the observations from the patient history and previous and/or ongoing medical treatments (Linkins et al., 2012). This is followed by the analysis of the patient information and history, recognition of the specific concerns for that patient, setting of nursing goals, identification of the nursing goal that has highest priority, and a final evaluation of the fulfilment of the nursing priorities identified.

Importance of Clinical Reasoning in Mental Health Nursing

The current essay evaluates the patient outcomes for John Gray, a 28-year-old male patient diagnosed with severe depression followed by a failed suicide attempt. The present article follows the individual steps for patient nursing priorities for John.

John is a 28-year-old male patient admitted to the hospital following an episode of self-harm. John has a farming background in Brisbane and his father was a grazier. John is expected to supervise the family farm, which has been greatly affected by a long-term drought condition, and relieve his father of his duties by taking over.  The primary considerations of the patient include depression, self-harm and suicidal tendencies, lack of interaction, unstable intake routine of medication, mood-swings, and behavioural inconsistencies.

John’s behaviour has been stand-offish and relatively repulsive. He does not display any interest in conversation and was rude upon introduction. He has very little or no appetite. His medical records indicate normal-slightly low blood pressure (125/75), normal body temperature (36.3 degree Celsius), normal (borderline low) pulse rate (66 beats per minute), and a normal rate of respiration (18 per minute).


John has a mark on his neck caused by the rope that he used whilst attempting suicide. He additionally has broken skin patches and few bruises caused from the fall upon failure of his attempt. He is not found with any serious injuries and his bruises have been bandaged. He does not show any interest in group activities or one-on-one conversation. John’s ongoing treatment protocol includes anti-depressant drug venlafalxine with a daily dosage of 75 mg bd and doses of vitamin B and multivitamin tablets.

The patient information indicates that there is an absence of physical or physiological illness or injury. The history of the patient suggests that the primary cause for his depression is likely to be the lack of a stable future and the drought that has severely impacted the everyday life of his family and thus, his own. Since John is expected to take over the farm activities, it is most likely the cause for severe worry and resultant depression.

John has no vital abnormalities in his physical health parameters, which indicate a near-optimal physical health status. However, John seems to have a relatively low pulse, respiratory rate, and body temperature. John has attempted suicide recently and is still suicidal and uninterested in group activities or conversation. Since depression is a debilitating mental health condition, it can drain the energy and strength in a person (Kelton et al., 2013). Therefore, multivitamin tablets and Vitamin B has been included into the medical treatment regimen for the individual (Puntil et al., 2013).

The Case of John Gray: Evaluation of Patient Outcomes

John presents with a severe case of depression and is suicidal. He has attempted suicide in the past and does not seem to have recovered completely from the shock and the trauma of the failure of his attempt. The primary concerns for this specific patient is the pharmacological and medical treatment for bruises and mild injuries and more importantly, his depression symptoms. The use of anti-depressant drug Venlaflaxine can lead to mood swings, which can prove dangerous in John, since he is suicidal and has many mood swings (Coutre, Leung, & Tirnauer, 2015). Venlaflaxine causes mood swings, behavioural changes, hyperactive or restless behaviour, hostility and aggression, impulsivity, irritation, lack of interest, and agitation. John displays most of these symptoms and shows severe disinterest in activities or conversation, along with being moody or hostile. The primary concern in this patient is therefore to focus on monitoring his reactions to Venlaflaxine and closely monitoring and ensuring the regular intake of his Vitamin tablets and medication. The patient has to be closely monitored to prevent suicidal or aggressive behaviour. An attempt to build a trusting and pleasant nurse-client relationship and rapport is crucial (Cuker, Gimotty, Crowther & Warkentin, 2012).

The goals and priorities identified for John include:

  1. Monitoring and ensuring the regular intake of Venlaflaxine, Vitamin B, and multivitamin tablets.
  2. Closely monitoring and recording changes in behaviours, moods, and attitudes
  3. Prevention of self-harm and hostile behaviour with the help of a trusting and pleasant nurse-client relationship.

The present case of John presents several challenges for the fulfilment of the goals identified in nursing. The effects of Venlaflaxine can be adverse in certain conditions and can catalyse hostile or suicidal tendencies in young adults. The nursing priorities must therefore focus on interventions that can help prevent self-harm, suicide, or behavioural and mood changes. Therefore, of the three nursing goals established, the most critical goal is to the prevention of self-harm and suicide. These goals can be achieved by monitoring the patient’s mood and behaviour changes.

The realisation of the goals and priorities set for the nursing intervention for John are complex and difficult to achieve, due to the inconsistencies of moods and behaviour in the patient. Therefore, my action plan is to:

  1. Prevention of self-harm and suicidal tendencies by watching the patient closely and controlling the availability of objects that can be used for self-harm. The patient has to be observed continuously; however, care has to be taken that the patient does not learn that he is being watched or monitored, in order to avoid suspicion or irritation in the patient.
  2. Monitor the intake of drugs periodically by closely watching the drug intake behaviour in the patient.
  3. Building a patient and trusting rapport with the patient by constantly engaging him in conversations, despite his aloof or cold reaction. However, at times if he is reluctant or shows severe disinterest, I have chosen to give him additional time.
  4. Outcomes of the action and evaluation:

The current case of John Gray has been particularly challenging in terms of building a rapport and monitoring his mood swings or behavioural adversities without his knowledge. The primary nursing priority was to prevent self-harm. I ensured this by restricting availability of objects that can be used for self-harm. I monitored his progress gradually and the outcomes of my nursing intervention are the following:

  1. His comfort-level and rapport with have greatly improved. He has started to greater interest and participation in one-on-one and group activities and conversations
  2. His self-harm tendencies seem reduced.
  3. He has learned to cope with mood swings resulting from Venlaflaxine intake by limiting conversation at times of disinterest or irritability. He has developed insight on his mood swings and has improved sustenance to these side-effects of his anti-depressant, Venlaflaxine medication.
  4. He has improved relations with his peers and physicians. He reports absence of suicidal thoughts.
  5. Reflections of the nursing experience:

The case of John Gray was both devastating and emotionally disturbing for me, especially because he is a young individual. His attempt at suicide and the subsequent depression was severe and has annihilated his interest in life. Gradually, with the nursing intervention and the progress of my interactions with him, I discovered that persons with depression respond to nurses or simply individuals who pay keen attention to their well-being as compared to their response to medication. I have found that John’s improvement resulted from a variety of factors, including his interactions with me, his nurse. I learned from this episode, that the psychiatric nurse plays a crucial role in the prevention of suicide and in cases of depression, it is the critical reasoning that a nurse displays, that can eliminate the likelihood of suicidal tendencies.

References

American Psychiatric Nurses Association (2015).  Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals at Risk for Suicide. Retrieved fromhttps://www.apna.org/files/public/Resources/Suicide%20Competencies%20for%20Psychiatric-Mental%20Health%20Nurses(1).pdf.

Levett-Jones, T. (Ed.) (2013). Clinical reasoning: learning to think like a nurse. Frenchs Forest, New South Wales, Australia: Pearson Education.

Levett-Jones, T., Sundin, D., Bagnall, M., et al. (2013). Learning to think like a nurse.  HNE Handover:  For Nurses and Midwives, 3(1), 15-19

Miller, C.A. & Hunter, S. (Ed.) (2012). Nursing for wellness in older adults. Sydney, NSW: Lippincott Williams & Wilkins

Huh, J. T., Weaver, C. M., Martin, J. L., Caskey, N. H., O'Riley, A., & Kramer, B. J. (2012). Effects of a late-life suicide risk-assessment training on multidisciplinary healthcare providers. The American Geriatrics Society, 60(4), 775-780. doi:10.111/j.1532-5415.2011.03843.x

Osafo, J., Knizek, B. L., Akotia, C. S., & Jhelmeland, H. (2012). Attitudes of psychologists and nurses toward suicide and suicide prevention in Ghana: A qualitative study. International Journal of Nursing Studies, 49(6), 691-700. doi:10.1016/j.ijnurstu.2011.11.010

Puntil, C., York, J., Limandri, B., Greene, P., Arauz, E., & Hobbs, D. (2013). Competency-based training for PMH nurse generalists: Inpatient intervention and prevention of suicide. Journal of the American Psychiatric Nurses Association, 19(4), 205-210. doi:10.1177/107839031349275

Smith, A. R., Silva, C., Covington, D. W., & Joiner, Jr., T. E. (2014). An assessment of suicide-related knowledge and skills among health professionals. Health Psychology, 33(2), 110-119. doi:10.1037/a0031062

Alatri, A., Armstrong, A. E., Greinacher, A., Koster, A., Kozek-Langenecker, S. A., Lance, M. D., et al. (2012). Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy–a European Perspective. Thromb. Res., 129, 426–433. doi: 10.1016/j.thromres.2011.11.041

Coutre, S., Leung, L. L. K., and Tirnauer, J. S. (2015). Management of Heparin-Induced Thrombocytopenia. Retrieved from https://www.uptodate.com/contents/management-of-heparin-induced-thrombocytopenia - H37.

Cuker, A., Gimotty, P. A., Crowther, M. A., and Warkentin, T. E. (2012). Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood, 120, 4160–4167.

Kelton, J. G., Arnold, D. M., and Bates, S. M. (2013). Nonheparin anticoagulants for heparin-induced thrombocytopenia. N. Engl. J. Med., 368, 737–744.

Linkins, L. A., Dans, A. L., Moores, L. K., Bona, R., Davidson, B. L., Schulman, S., et al. (2012). Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest, 141, (Suppl. 2), e495S–e530S.

Parth, K., Hrusto-Lemes, A., and Löffler-Stastka, H. (2014). Clinical reasoning processes and authentic clinical care for traumatised patients. J. Trauma. Stress Disord. Treat. Sci.
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