Importance of critical thinking and clinical reasoning in nursing practice
In contemporary nursing, the issue of critical thinking is of paramount importance to adopt suitable strategies in line with the patient condition with the purpose of improving the clinical outcomes. Nurses resort to such practices in their professional pursuit to render quality and safe healthcare service to the patient for improving the situation through prudent identification of the patients at risk and employing pragmatic approaches to account for harboring optimal results pertinent to the patient condition (Hunter & Arthur 2016, p. 74-76). Apart from the professional skills and competencies, critical reflection skill is vital to enhance the treatment delivery scheme as offered by the nurses through proper application of the clinical reasoning cycle. Clinical reasoning is referred to as the process, through which nurses perform the essential functions of collecting cues, processing information, identifying problems, planning or implementing interventions, evaluating the outcomes and finally reflecting on and learning from the process (Kuiper, Pesut & Arms 2016, p. 100-106). The following assignment will highlight on how I incorporate and implement clinical reasoning cycle in professional practice to obtain desirable outcomes.
Mr. John is a 76 year old man admitted to the medium secure rehabilitation unit of the psychiatric ward in the hospital following diagnosis of depression. He was admitted to mainly provide psychiatric intervention associated to his depression condition. He lost his wife, a year ago and has been reported to stay at home all by himself since then. He has one daughter who has been married off and lives out of state. She pays visit to her old father twice a month because of her tight schedule at work. He was consumed with thoughts of suicide due to his loneliness and leads a life of seclusion without much socialization. Upon consultation with a psychiatric physician, he was diagnosed with depression and symptoms of apathy, restlessness and irritability. He did not suffer from any other notable chronic ailment apart from hypertension and was under lisinopril medication to keep it under control for the past 14 years. Citalopram was advised as antidepressant for him. Further, his medical history revealed that he was a non-smoker and took alcohol only occasionally. The concerned physician for holistic address of his situation referred him to the mental rehab. Upon admission, it was found that he remained sad, seldom communicated and got easily irritated if approached by anyone. No significant changes in his vital parameters were noted.
Use of clinical reasoning cycle to assess patient’s condition
I was the attending nurse in charge to look after John after admission. As part of my assigned duty I paid visit to him during the night shift at about 23:30 hours when he complained of not being able to sleep and felt restless. He was visibly sweating profusely. The handover report from the previous shift showed that all his vital signs were within normal limits when blood pressure, heart rate, temperature, breathing rate, oxygen saturation were recorded to be 130/80 mm of Hg, 74 beats per min, 36.8 ° C, 14 per min and 96% respectively. Irritable behavior, poor appetite and anxious mood of the patient were also documented in the report.
It was around 23:30 hours and I was attending John when I noticed he was sweating profusely and expressed a sense of discomfort on not being able to sleep. John added saying that he was feeling anxious than usual recently, that refrained him from sound sleeping. On knowing about his condition, I quickly reviewed his medical record from evening shift and then immediately performed a nursing assessment to detect any change in his vital parameters that might have lead to his current observation. On assessment, his vital signs for the present situation were found to be as follows:
Blood Pressure: 138/82 mm of Hg
Heart rate: 96 beats per min
Temperature: 37 ° C
Breathing rate: 26 per min
Oxygen saturation: 90% in ambient room temperature
Data retrieved pertaining to present situation and on comparing it with the previous documentation from the evening shift showed that there were stark differences in the vital signs. Blood pressure was found to increase from 130/88 mm of Hg to 138/82 mm of Hg with a mild increase in body temperature from 36.8 ° C to 37 ° C. On the other hand, oxygen saturation diminished from 96% to 90% in room air. Major detectable changes were observed to change from 74 beats per min to 96 beats per min and respiratory rate soared high from 14 per min to 26 per min. Therefore, analyzing from the data available it is evident that John has developed conditions related to tachycardia and tachypnoea. Moreover his complaint of restlessness and difficulty to sleep is also suggestive of the fact that all his symptoms for insomnia, profuse sweating and anxiety may be corroborated with his medication side effects. Side effects to medications often have been found to be related to adverse side effects that affects the patient significantly.
Identification of medication side effects
John was reportedly under the medication of citalopram drug that is commonly used as an antidepressant for medical benefits (Ulbricht et al. 2016, p. 1123). However, similar to any drug it has been suspected that it also possess certain side effects that might account for negative results in the patient. The symptoms of restlessness, increased sweating in conjunction with sleeping difficulties as occurred in case of John is indicative of deviations from normality as far as vital signs of the patient is concerned (Amitai et al. 2016, p. 1348). Vital signs are necessary to detect the ongoing physiological mechanisms within the human body that may not always be externally manifested but may be identified through proper procedural efforts. In case of John, the vital signs may underlie potential mechanisms that may be related to the altered physiological status. Side effects due to medication are of particular concern for the medical fraternity as it may threaten the lives of the victim (Hodgson et al. 2015, p. 2612). John has been found to be under medications including lisinopril and citalopram as prescribed by physician to treat his chronic condition of hypertension and depression respectively. Out of these medications, he has been consuming the antihypertensive medication for last 14 years without any adverse implication. Hence, the symptoms that have aroused in John may be due to his recently prescribed medication of antidepressant. Citalopram has been reported to cause side effects of sleeping problems and sweating, both of which matched with John’s case. Moreover, depression in geriatric patients has been found to be intimately with the risk for developing cardiovascular abnormalities (Lavretsky et al. 2015, p. 564-567). John was already afflicted by hypertension and side effects due to medication that indirectly affected his vital parameters may thus further accentuate this risk putting him in an unfavorable and dangerous zone for being affected by a cardiovascular disease. The heightened heart rate and breathing rate is indicative of his abnormal physiological condition that calls for prompt attention and intervention (Elderon & Whooley 2013, p. 512-520). Therefore, in this case Mr. John was under the threat of developing a cardiovascular anomaly that might risk his life as well.
The medical management of Mr. John includes taking measures that will prevent further deterioration of his condition. On inspecting his current situation a short term goal was set for the patient that resorted to management of heart rate and symptoms related to tachypnoea. Moreover, his level of oxygen saturation was also required to be kept under control to avert any negative outcomes. Empirical evidences support that ideally heart rate should remain around 60-100 beats per minute while breathing rate should be within 12-24 per min. Further, oxygen saturation is required to be maintained at 95%-100% to maintain the homeostasis (Melmed 2016, p.165). Maintenance of these vital parameters is likely to benefit the patient through ensuring his normal functioning (Sharma 2016, p.273). Additionally, a long-term goal of addressing the depressive symptoms of the patient was also established so that John may be offered the necessary opportunities to thrive a healthy life. Ensuring health and wellbeing is the key to a meaningful life here a person may enjoy things on his own terms. Conditions like those of geriatric depression have been found to raise the risk for co-morbidities such as cardiovascular disorders, obesity, diabetes and others (Fan et al. 2014, p. 38-40). Under such circumstances, catering to the mental health needs and depressive symptoms as exhibited by the patient will ensure fruitful results to mitigate the condition.
Setting short-term and long-term goals
On reviewing the patient condition, I immediately brought it to the attention of the doctor on call mentioning his vital parameters and other associate condition. In the meantime, I applied 2L/min of oxygen supply through nasal prong for the sake of improving his oxygen saturation level and respiratory rate (Pilar & Fernandez 2016, p. 423-432). Considering that his certain vital parameters were not within normal limits I tried to calm him down by asking him not to panic and relentlessly supporting him with positive talks so that his mental state do not aggravate and he regains his own self to cope up with the situation. Therapy in the form of counseling was the preferred method to empower the patient with better coping skills to deal with the stress condition. On administration of oxygen supply, I kept on checking his oxygen saturation level simultaneously with his heart rate through pulse oximeter, to check for any adverse symptom that might lead to medical emergency (Millar, Lutton & O’Connor 2014, p. 63). The doctor on arrival checked his medical record and took a note of his present medical parameters and advised to continue with the oxygen supply until the vital parameters are brought to normal. On deeper probe, he further instructed to discontinue with the citalopram antidepressant for the time being. In order to give him relief from sleeping trouble and improve his overall mood, he prescribed ativan. Ativan has been recognized as a sedative that is capable of depressing the functioning of the central nervous system (Fletcher et al. 2014, p. 798-801). Mirtazapine was prescribed as the antidepressant as a substitute for citalopram (Rehman et al. 2016, p. 2914). Thus, administration of sedative will ensure proper management of John’s condition. Moreover, on consultation with the attending psychiatrist at later hours it was decided that his daughter will be called upon and advised to give him company in the next few days to harbor better clinical outcomes and treat his depressive symptoms. Support from family has been identified as a crucial determinant that holds the potential to manage the depressive symptoms in elderly patients (Levens, Elrahal & Sagui 2016, p. 343-350). Thus, company and assurance from daughter is likely to exert positive influence in John thereby ameliorating his depressive condition by filling in the void due to loneliness particularly after his spouse’s death.
Measurements of John’s vital parameters were noted down 1 hour post intervention and signs of improvement were clearly evident. Oxygen saturation went up to 95% in room air, heart rate and breathing rate were respectively noted as 78 beats per min and 18 per min. His behavioral symptoms were also found to be quite settled and restlessness was also under control. Further, upon inspection in the next morning it was found that he slept well and appeared fresh and responsive. Overall it seemed that John showed significant improvement, however he was to be kept in close surveillance to check for any adverse symptoms.
Implementation of appropriate interventions
The close association with this case study enhanced my experience as a nurse as I got to know a lot of new things related to mental health nursing. I got accustomed to work in real life setting where compliance to codes of practice is considered crucial to ensure safety and quality healthcare option for the patient (Townsend 2014, p.357). The issue of side effect to certain medications and adherence to prescribed drugs at other times were also made clear to me. I am keen to apply the knowledge gained from this scenario to better handle the patient and account for harboring optimal outcomes thereby minimizing the risks for adverse clinical results.
References
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