Collecting Information from Patients

Due to the varied nature of various diseases in a hospital, hospital professionals such as nurses need to adopt a method of personalized care approach which helps to ensure that the right information about patients is collected and the information is processed and used to provide a patient specific care. According to Dalton, Gee, & Levett-Jones, (2015) the clinical reasoning cycle is one of the best models of care where nurses collect information from patients, conducts implementation and evaluations of the outcomes. The clinical reasoning cycle then benefits the nurses because it provides a platform for learning.

The question at hand focuses on a mentally ill patient by the name john gray. John has attempted self-harm for several times and he is under hospital care where he is receiving psychiatric treatment. This paper uses the clinical reasoning cycle to show how the information about the patient is collected, processed and evaluated in order to assist nurses in handling similar scenarios. This begins with a brief introduction outlining the structure, consideration of facts from the patient, collection of information, processing, identification of the problem, the goals, action taken and finally the evaluation and reflection.

Factual information from the patient is important in order to rule out all speculations that may arise regarding the patient. The nurse needs to consider that the patient being in a psychiatric ward would fail to give up the information or alter the information regarding their health needs. The kind of the disease that a patient has is therefore an important factor to consider when determining how to collect the information from a patient. This is because the patient depending on the illness may be unable to give information regarding their health (Hunter, & Arthur, 2016).

According to the case scenario, the information collected about john regards his health and his mental psychosocial condition. The patient is suffering from severe depression from a failed suicidal attempt. From his vital signs, he has a normal blood pressure, purse and respiration. However, he is reluctant to perform normal physical and physiological activities such as getting up for meals and even when compelled to do so, he still doesn’t eat. The information also includes the physical injuries inflicted by the rope with which he tried to strangle himself with and also his social behavior where he is currently anti-social and resigned to life.

According to Daly, (2018) previous health and social history should also be collected from the patient and his relatives in order to examine the success and failures of previous interventions, the past treatments and results of medical investigations. In this case, the nurse is also expected to gather information on the comorbidities and risk factors that predispose the patient to the suicidal attempts.

Analyzing and Interpreting Information

From the information collected, an analysis to interpret the information and identify the care needs of the patient. From the case scenario, from the information regarding his social status, it is clear that john does not refuse to talk due to inability to do so but due to the fact that he is feeling depressed. From his social background it is possible to relate his stress and depression from the disappointment at the farm. This has helped the nurses to diagnose medicine such as venlafaxine (Pennaforte, Moussa, Loye, Charlin, & Audétat, 2016). From the physical and medical examination, it is also possible to determine individual ways of dealing with various stress and depression. For john, the main identifiable way is retrogression whereby the person retreats to an earlier stage. John’s disregard for human interactions shows a retrogressive way of dealing with depression.

From the analysis, it is also possible to depict john’s antisocial tendencies. He results to suicide and self-harm as a result of stress and depression. This is observable in his attempted suicide and dodging meals and medication. It is also clear that the patient has no regard to life whereby one can say that he is resigned to life.  

According to the identified case scenario, the main problems affecting the patient is psychosocial problems being stress and depression. Due to the defense mechanisms, the patient is likely to develop various complications based on whatever defense mechanisms the patient is likely to adopt. Defense mechanisms such as projection may also influence the relationships the patient has with other people. The patient is also likely to develop certain dietary complications due to bad eating habits argues Levett-Jones, et al (2010). This may include deficiency diseases or very severe nutritional deficiencies. Malnutrition may therefore cause the worsening of already existing conditions.

The patient is also likely to develop complications due to the fact that the patient is dodging medicine. This may also cause deterioration of the health condition. The unsteady gait may also cause falls which may also result to fractures. Poor dietary habits also cause loss of weight to the patient. As part of the problem, the patient also develops hyperglycemia due to poor management of blood glucose (Koivisto, Multisilta, Niemi, Katajisto, & Eriksson, 2016).

According to the clinical reasoning cycle LeMone, et al (2015), a nurse is required to prioritize health interventions in the order of their importance. It is therefore essential for a nurse during diagnosis and treatment to arrange the interventions in the order of their importance. In the case scenario, the most important intervention is to relieve the patient from all pain. After relieving the pain, the nurse is then supposed to also ensure that someone curbs all bleeding, both internal and external. The nurse is also supposed to dress any open and exposed wounds and other physical deformities.

Identifying Problems and Goals

After taking care of all the bleeding, pain and wounds, there are long term goals that the nurse needs to address which include curing any diseases and giving personalized advice to help heal the person. From the medical examination, the nurse may also decide on whether to administer glucose or any other supplements that the patient may be lacking due to poor feeding habits. Forsberg, Ziegert, Hult, & Fors, (2016) argues that Psychotherapy is also a necessary goal as part of the goals of curing the patient. This is aimed at curing the patient’s stress and depression. This helps to develop a mentally stable patient. This helps to reduce the effects of stress and depression on the patient that may put his health at risk.

After close examination of the underlying problems and goals, what remains for the nurse is to take the necessary patient centered course of action. The measures taken should reflect an all-round perspective where the nurse should focus on the ethical, legal, holistic and person centered approach. The nurse is also expected to make evidence based conclusions in determining the course of action (Kriewaldt, & Turnidge, 2013). This has to go in line the patient’s societal culture and the demands. It is important for a nurse to identify with the patient’s attitudes and beliefs. For instance, according to the case scenario, maybe the patient fails to open up to the doctors just because the doctors don’t understand him. The nurse also needs to consider the legal ethical considerations such as allowing a patient access to their health information, giving alternatives and advice on the laws surrounding suicide. For instance, the nurse may advise the patient that taking their life would make someone to be convicted in court for attempted suicide.  

The nurse is also expected to act as a link between the patient and their families (Huang, Huang, Lee-Hsieh, & Cheng, 2018). He or she informs the patient’s family on the progress of the patient and also gives them psychosocial support to be able to handle the patient. The nurse also assumes an advisory role towards the patient. In this case, it may help them to understand the reason for the suicidal attempt. This may help in preventing re admission or subsequent suicide attempts.

The final step in the clinical reasoning cycle is to evaluate the effectiveness of all the other interventions in achieving the person centered care for the patient and a learning platform for the other nurses. At this point, it possible to examine the advantage of the nursing interventions and the shortcomings that have resulted from the whole cycle. The evaluation and reflection stage also highlights areas that need improvement in the future and with regard to other patients. It is at the evaluation and reflection stage that a nurse can understand what worked and what did not work for the patient (Licón, et al. 2015).

Taking Patient-Centered Action

Mather, McKay, & Allen, (2015) the evaluation and reflection stage also gives the potential areas for improvement and what nurses can do better after following the example of the case scenario. Finally, at this stage, a nurse can be able to assess whether the interventions really helped the patient and the nurse can also recommend further action in case he or she feels that the goals for treatment have not been met to the latter. The nurse at this stage can act upon what they did not do right by assessing the impact it had on the patient. According to the case scenario, nurses should look whether the patient is being friendly to health workers, taking their prescription and resolving their internal conflicts. The patient is also expected to show a positive attitude towards life.

Conclusion

In conclusion, it is important to consider that the clinical reasoning cycle is an important tool that helps nurses to come up with a method of handling patients and providing a patient-centered holistic approach. The clinical reasoning cycle helps to seal all gaps that may be omitted by health officials in addressing patient needs and most importantly, it ensures the best for the patients.

References

Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement: Clinical educators’ perceptions. Nurse education in practice, 18, 73-79.

Koivisto, J. M., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E. (2016). Learning by playing: A cross-sectional descriptive study of nursing students’ experiences of learning clinical reasoning. Nurse education today, 45, 22-28.

Forsberg, E., Ziegert, K., Hult, H., & Fors, U. (2016). Assessing progression of clinical reasoning through virtual patients: An exploratory study. Nurse education in practice, 16(1), 97-103.

Licón, M. T. C., Uribe, H. E. R., Ruiz, O. C., López, E. D., & Rodríguez, J. M. (2015). The clinical reasoning through the basic cycle, an option for the integration of the medical sciences. Revista Educación Médica del Centro, 7(1), 18-30.

Daly, P. (2018). A concise guide to clinical reasoning. Journal of evaluation in clinical practice.

Pennaforte, T., Moussa, A., Loye, N., Charlin, B., & Audétat, M. C. (2016). Exploring a new simulation approach to improve clinical reasoning teaching and assessment: randomized trial protocol. JMIR research protocols, 5(1).

Huang, H. M., Huang, C. Y., Lee-Hsieh, J., & Cheng, S. F. (2018). Establishing the competences of clinical reasoning for nursing students in Taiwan: From the nurse educators’ perspectives. Nurse Education Today, 66, 110-116.

LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU.

Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based education to’flip’the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing, The, 33(2), 29.

Levett-Jones, T., Sundin, D., Bagnall, M., Hague, K., Schumann, W., Taylor, C., & Wink, J. (2010). Learning to think like a nurse. HNE, 15.

Kriewaldt, J., & Turnidge, D. (2013). Conceptualising an approach to clinical reasoning in the education profession. Australian Journal of Teacher Education, 38(6), 7.

Mather, C. A., McKay, A., & Allen, P. (2015). Clinical supervisors’ perspectives on delivering work integrated learning: A survey study. Nurse education today, 35(4), 625-631.