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Nursing Case Study

Person-centered care is a very active but not commonly used strategy for a patient’s well-being and safety. Some people say that person- centered care is a sort of holistic approach which only means, treating the whole person rather than just mere symptoms. According to Levett-Jones (2013), patients should no longer be viewed as passive people but rather active participants in a healthcare setting. Health professionals are supposed to be empathetic, morally upright, open-minded, ethical, respectful and self-conscious (Romans & EduMed Corporation, 2007).

The Clinical Reasoning Process is a process whereby clinicians and nurses collect, process and analyzes information that aids them in understanding the patient’s situation/problem (Levett-Jones, 2013; Robertson, 2012). After that, the clinicians implement an intervention, evaluation of outcomes and learn from the experiences. In the Clinical Reasoning Cycle, there are eight steps to follow. They include: considering the patient’s current situation, collection of information, process the information, identify the problem, establish goals, take action, evaluate the outcome and finally, reflect on the progress and new learnt content (Reid-Searl, Dwyer, Moxham & Levett-Jones, 2009).

1. Consider the patient’s current situation

In this stage, we list facts, people, contexts or objects (Holland et al., 2012). We come across a 28-year-old man, Mr. John Grey who appears to have tried to harm himself. Rope burn mark on his neck that looked from the struggle of strangling himself explains the attempted suicide. Bruises and broken skin are also noticed on his arms and legs from the fall during the incidence. These injuries seem to be covered in non-adherent dressing and tape.

2. Collect information

Here, we review on his current information and also try to gather new ones. Mr. John is a single man and expected to be in-charge of the family farm. From his handover reports, he did not get up for breakfast again, this behavior since to be recurrent and sluggishly went for lunch which he ate very little and immediately went back to bed. According to the medical history reports, it is evident that he has visited a therapist. His therapist claims that John is still reluctant to involve himself in any activities including games or even one-on-one discussions. His medical tests are as follows; blood pressure 125/75, temperature 36.3ºc, pulse rate 66 and respirations 18. He is also under medication. These include Venlafaxine 75 mg, Multivitamin once daily and vitamin B once in a day.

3. Process information

Under this objective, relate new information that has been discovered, predict an outcome, comparison of normal vs. abnormal and so on (Levett et al., 2013). Mr. Grey has seen an occupational therapist. It means that the fact that he is supposed to take over the family business depresses him to the point of almost taking his own life. We also see that he is not willing to participate in any activities which mean he is not ready for any responsibility. Mr. Grey seems to be resisting to therapy and treatment. Blood pressure is related to bodily fluids (Pesut & Herman, 1999; Williams, 1999). Since his blood pressure is normal, then the body fluids status is sufficient. His temperature is normal. Pulse rate readings are also average as well as respiration rates.

Moving on to his medication; the importance of taking vitamin B once in a day is because it aids in digestion and also one gets a healthy appetite, has neurological benefits, helps in the growth and formation of red blood cells. Secondly, Multivitamin contributes by providing vitamins that might not have been ingested through the diet. It as well treats vitamins deficiencies. Lastly, Mr. Grey is given Venlafaxine because it’s an anti-depressant. According to LeMone (2017) this drug reduces depression rates. Venlafaxine affects some chemicals in the brain that seem to be unbalanced in patients with depression (Holland & Watson, 2012; Hayes, 2014).

4. Identify the problem(s)

Under this objective, you synthesize facts that will give a concrete diagnosis to the patient’s behavior. As in this case, the patient does not seem to be ready to co-operate. Lack of cooperation is observed when going to introduce myself to Mr. Grey but he was under his covers and showed no interests. He also grunts and turns to face the wall while trying to address him. John is not ready to strike a conversation with anyone and is not willing to be involved in any activities.

5. Establish goals.

Here, I will focus on the desired outcome or a time frame on what I want to happen. Ensure John takes his meals as and medications effectively. It helps in not only his recovery but also health.

6. Take action.

While ensuring he takes his meals and medications properly, creating a rapport is essential. Creating a rapport helps to build confidence in the patient and gives him a sense of belonging. With time he will open up on what is bothering him (Gillies, Levett-Jones & Sullivan, 2013). When writing a report to the doctor, the doctor will know what medications to give how to advise the patient and so on.

7. Evaluate the outcome.

Establishing outcomes will help one understand what the patient has been going through and understand him better. Be calm enough to ask the patient whether he feels much better, whether there is something that has not been clarified and so on. Such type of questions helps the nurse to leave no stone unturned.

8. Reflect on the process made and new learning.

As a nurse, we learn new things on the way as we encounter the different type of patients. It is essential for one to learn from their mistakes and practice more. According to Eby & Brown (2009) this step helps the nurse to contemplate what he/she has learned through the process and also know what ought to have been done differently.

Nurses’ experience a number challenges/issues when dealing with patients. Based on the health assessment of Mr. Grey, I faced certain problems. They are lack of cooperation from the patient, fear, workplace hazards among others.

  1. Lack of cooperation

John refuses to cooperate in anything. Even when I get colder to him and try to introduce myself, he looks away and does not bother. He is also not ready to participate in any activities or socialize with anyone. This makes the treatment process rather tricky at first because it is hard to tell where the problem is. Patience is a virtue that is required in all nurses.

John is a depressed patient who tried to harm himself. The bruises on his arms and legs and also the rope mark on the neck are proof enough. Being left with such a patient who has the audacity to do all this to himself create tension as he might unleash his anger on the closest person around who unfortunately is his nurse (Drouin & Geisler, 2011).

  1. Work place hazards

Nurses work for long hours and deal with many patients which might lead being predisposed to certain illnesses while doing their jobs. For example a cold, flu, injuries etc. According to the statistics in the Bureau of Labor, nurses experience severe injuries/pains that involve, their shoulders, back, feet and hands.

As a nurse, I must be able to provide patient care that is compassionate and effective to the patient. It is essential to establish goals and objectives to ensure the nursing care is up to standard and competence is noticed. These goals include; proper use of pharmacological regimens which includes therapy and medication, providing proper care and treatment for the chronic mentally ill patient by use of rehabilitation inventions, being a participant is psychiatric administration which results to improvement in performance and lastly proper psychiatric treatment should be provided while coordinating and working together with noon-medical therapist (Coppard & Lohman, 2008).

In regard to the nursing problems above, nurses are supposed to be protected to avoid the hazardous accidents. This will ensure proper running of the hospital. Security should also be offered to nurses dealing with mentally ill or rather depressed patients as violence is likely to occur anytime. Nurses should learn to be patient. It takes time for a depressed person to open up to someone (Carpenito-Moyet & Carpenito, 2012). For a patient to open up to a nurse, the nurse has to be friendly and communicate effectively with the patient. There are 5 steps to follow in nursing care. They are:

  • Step 1: Assessment Phase- Here the nurse gathers all information regarding the patient. This includes the sociological, physiological and psychological data. The patient’s history will be taken as well as some physical examinations

  • Step 2: Diagnosing phase- In this phase, the nurse will make certain judgments or conclusions about the actual health problem of the patient.

  • Step 3: Planning phase- Here, a plan of action is developed.

  • Step 4: Implementing phase- The nurse then follows through the plan.

  • Step 5: Evaluation phase- This step ensures whether the goals have been met.

After all these steps are followed, Mr. Grey should be able to overcome his problems. Should be able to participate in various activities including taking over the family farm and cultivate it and save it from the drought. He should also know the dangers of self-harm.

We notice that clinical reasoning exhibit positive outcomes in all patients. Teaching approaches, as well as contemporary findings, do not always bring about development when it comes to clinical reasoning skills. It is the readiness of the nurses who are adequately prepared to work in the challenging and complex health care center (Berman, Snyder, Levett-Jones, Burton, & Harvey, 2016). Knowledge might be sufficient to some nurses, but they lack clinical reasoning skills which are very vital. A nurse, who is well experienced, might get into a patient’s room and immediately observe the patient’s behaviors, conclude and recommend treatment appropriately. It is due to their skills, knowledge and most of all experience (Levett, 2009; Levett-Jones, 2013). Clinical reasoning is challenging and requires determination from the students and very active engagement. It also requires reflection on previous assessments, and any newly learned information is put into practice.


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