Several aspects of daily life hamper the psychological, emotional, and social well-being of an individual. The effect may be mild to severe mental disorders such as obsessive-compulsive disorder, schizophrenia, anxiety, and depression that severely affect behaviour and thought. The paper deals with the case study of John Gray who is suffering from major depression. The paper presents the management of the patient using the Levett-Jone’s clinical reasoning cycle. This framework is effective to plan and evaluate the person-centred care appropriate for individual patient.
Mr. John Gray (Male, 28) lives in Brisbane. He is expected by his family to take over the family farm, as he is son of grazier. John is depressed due to longstanding drought that affected his farm. He had attempted suicide and is presented to hospital a week ago.
The data collected from the John’s handover informs of major depression and increased social isolation evident from disorientation and signs of withdrawal. He is not taking breakfast and skipped lunch as well. He slept with empty stomach. John’s vital signs as per the assessment data shows blood pressure 125/75, pulse rate 66, respiration rate 18. Physical examination reports of bruising and broken skin on his legs and arms. Around his neck a rope burned mark is prominent that indicates his suicide attempt. His current medications include Multivit I and Vitamin B Co I daily, Venlafaxine 75mg BD.
Collecting the patient cues is the next step of clinical reasoning cycle. In addition to the case details, I have collected more information by interacting with communicated with John and his family. To gain broad perspective on the Johm’s mental condition it is necessary to identify the risk factors for suicide and level of depression. Thus, collection of patient cues is necessary. Depression is the mental illness where a person loses interest to live. It is manifested as low self-confidence and self-esteem and ultimately an urge to commit suicide (Goesling et al., 2013). Depressions occur due to overwhelming crisis, where a person is unable to cope up. In this case is John is unable to cope up with drought and failure to fulfil farm’s responsibility. He is worried about future. Thus, he is withdrawing from social engagement may be due to feeling of guilt and shame. John is not involving in any communication and tends to be demonstrated. It can be interpreted as loss of interest and hope in life (Chu et al., 2015).
Identification of issues of nursing priority
After collecting the patient cues, I have identified the primary issues of the case. Firstly, John is worried about future. It is increasing his stress and anxiety. His thinking is of anxious pattern that may be due to longstanding drought and failure to fulfil family responsibility. He may be stressed thinking about the way to revive family’s farm. During depression people have tendency to engage in self-criticism and decrease communication an interaction with people (Cummins et al., 2015). Feeling of worthlessness is another risk factor for depression and suicide. This risk factor triggers impulsive thoughts and impairs concentration. It causes indecisiveness and self-harm behavior. According to Freud aggression, anger and negative feelings result from loss of objects. Loss of farm, lack of social support and deception are environmental triggers of depression and suicide in John (Cummins et al., 2015). Thus, it is important for mental health nurse to maintain the patient safety. It is necessary to minimizing self-harm and ensure positive outcomes by safe medication. It is necessary to eliminate the feeling of hopelessness in John so that he can resume his daily activities so that he can eat, read, and interact with people normally.
Thus, the three priority nursing areas are-
- Depression and low self esteem
- Suicide risk and self harm tendency
- Increased Social isolation, and disorientation
Other nursing issues considered are-
- Feeling of worthlessness
- Loss of hope in life
- Nutrition- Skipping breakfast and dinner
- Need of increasing adherence to medication
- Cure physical injury
The nursing goals as per the assessment of John and nursing issues identified are-
1.Depression and low self esteem
Improve the emotional and physical heath of the John to reduce anxiety and depression
2.Sucide risk and self harm
Assessment of the environment to prevent self-injury of patient. Assessment of the environment include identifying for objects such as ligature point, belt, knife and any other object that can help in self harm. The goal is to Monitor the mental status of the patient regularly to modify the risk factors (Smith et al., 2015)
3. Increased Social isolation
Increase communication and interaction with patient to help verbalise thoughts and reduce withdrawl and disorientation in-patient.
(Moorhead et al., 2014)
Nursing interventions and Rationale
The first nursing intervention classification is Anxiety reduction- The nursing interventions for anxiety reduction are establishing therapeutic relationship with client. John can be assisted to verbalise his feelings and voice out expression only by building strong rapport with him (Adams & Iseler, 2014). Further patient centred care will be provided to foster positive psychological balance in John. John will feel important and feel connected if he receives empathy (Forbes & Watt, 2015). Motivational sessions will be arranged for John to trigger positivity and increase courage to overcome fear and worthlessness (Robson et al., 2013).
The second intervention is suicide prevention- The intervention to prevent suicide involves modifying patient’s environment. Providing positive environment will prevent self-harm behaviour. Removal of sharp objects and anything that can assist John to self-harm is the part of the intervention (Happell & Gaskin 2013). Referral to mental health counselling in case is John is evident of suicidal intent. Counselling will help control distorted and impulsive thoughts in John. Further John will be provided health education. The health education is provided to increase adherence to medication and have proper diet as John is presently at risk of malnutrition. Health education create awareness on the consequences of depression and how it stimulates one to attempt suicide (Seo et al., 2015).
The third nursing intervention is crisis intervention and decrease social isolation- In order to enhance coping skills in John, his parents and family members will be involved. This will reinforce his self-esteem. Further, John will be involved in physical activity in-group where he can interact with other people of his age. Involving John in jogging, swimming, walking, whichever enhances mood will promote social connectedness. Depression, anxiety and social isolation can be minimised by physical activities like exercise (Storm & Edwards, 2013). John’s parents will be referred to crisis intervention agencies to receive help on current situation. Resolving crisis will prevent social withdrawl in client and promote willingness to eat, talk and live (France, 2015).
Evaluation of outcomes
The following outcomes indicate improvement in the John’s condition in regards to the priority nursing areas.
- Patient demonstrates increase in self-confidence and relaxed state of mind.
- John will show reduced anxiety in 2 weeks
- John will talk about feelings and express his anger or frustration
- Reduce the risk of suicide indicated by- reduced patient’s ability to accelerate risk, i.e, John does not harm self
- Increase in communication skills of patient, physical activity and engagement in daily activities indicate social engagement
I have realised from my experience with John’s case that patient centred care is fundamental aspect of the mental health care. Patients feel comfortable and respected when information is provided to them effectively. Using the clinical reasoning cycle was effective in developing care plan that is appropriate for John. I was able to design care plan appropriate to reduce depression and suicidal tendencies treatment plan for depression and anxiety. Demonstrating self-awareness is important while establishing the therapeutic relationship with patient. Establishment of interpersonal relations assisted in John’s assessment. The clinical reasoning framework helped me to think and analyse the cause of depression an current thinking pattern of John. It improved my critical thinking skills to collect information from patient with high level of psychological distress. I was able to assist John to believe in himself and foster a sense of control over his situation by giving support and empathy. It improved the overall care process and increased the verbal expression of the client. Involving his family, encouraged him to recover and helped in decision-making. I maintained the respect and dignity of the client as well as of his family members. I can conclude that up skilling is an essential part of nursing. I need to strengthen my professional skills even more to assist patients with mental health disorder.
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