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NURS13135 The Professional Nurse

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NURS13135 The Professional Nurse

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Course Code: NURS13135
University: Central Queensland University

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Country: Australia

Question

Case Study – Mental Health
John Gray, 28 years old, severe depression following suicide attempt
Mr. John Gray is a 28 year old single male admitted to the unit a week ago after an episode of intentional self-harm.  John is the son of a grazier from a farming community north of Brisbane who is expected to take over the family farm. The farm has been severely affected by the longstanding drought conditions in the district.
You are the nurse assigned to John’s care for the afternoon shift. On handover you were informed John did not get up for breakfast again, went to lunch reluctantly only because he was compelled to but ate almost nothing, and returned to his bed immediately afterwards.
Vital Signs:

Blood pressure 125/75
Temperature 36.3
Pulse 66
Respirations 18.

John has a rope burn mark on his neck caused by the breaking of the rope with which he attempted to hang himself and some bruising and broken skin on his arms and legs from the subsequent fall but no serious physical injuries. The areas of broken skin were covered with a non-adherent dressing and tape. The occupational therapist reported John was still choosing not to take part in any activities, including small group games or one-on-one activity.
When you go to introduce yourself to John, you find him lying on his bed with the covers pulled up high. He appears reluctant to engage in conversation with you. When you address him to introduce yourself, he grunts and turns over to face the wall away from you.
Medications:

Venlafaxine 75 mg bd
Multivitaminonce daily
Vitamin B once dailydaily

Answer

Clinical Reasoning Cycle
Introduction
According to the professional code of conduct of the Shahriari et al. (2013), it is the duty of the nurse to practice in a reflective manner. The following essay is based on the case study of Mr. John Gray, a 28-year-old man with severe depression and a tendency of self-harm. In order to analyze the case study of Mr. Gray, the essay will use Levett Jones Clinical Reasoning cycle for the perspective of a professional nurse who has come to procure care for Mr. Gray in the afternoon shift. The clinical reasoning cycle will mostly highlight the current patient situation and will analyze the area where specific care plan is mandate based on collection of cues and processing of information (Levett-Jones, 2018). At the end, the essay will highlight three main nursing interventions that will be best suited for Mr. John Gray.
Patient situation
John Gray is a patient of severe depression who has attempted suicide, which is evident from his rope burn mark on his neck. He has broken skin over his arms and legs due to subsequent falls with no serious injuries. The broken area of the skin is covered with non-adherent dressing. While I went to introduce myself, John was reluctant to engage in conversation and mainly responded with grunts and no eye contact. He had confined himself in his rooms with covers pulled up high.
His vital signs include

Blood pressure 125/75
Temperature 36.3 degree C
Pulse rate: 66
Respiration rate: 18

Patient is unwilling to consume food and had reluctantly gone for nurse only because he was compelled but almost ate nothing. His current medication include

Venlafaxine 75 mg bd
Multivitamin once daily
Vitamin B once daily

Collection of cues
Mr. John Gray, 28-year-old male encountered an episode of self-harm. John’s father is a grazier from a farming community of north Brisbane and John is supposed to take over his family farm. The farm has been severely affected by longstanding drought conditions in the district. I think his peer family pressure of taking the entire responsibility of the entire family and financial unrest due to prolong drought in their district might have been the main source behind John’s severe depression. According to Radfar, Ahmadi and Fallahi Khoshknab (2014) turbulent life and peer family pressure increases stress and thereby influencing young adults to pass onto depression. His vital signs, blood pressure, temperature, pulse and respiratory rate was found to be normal. This is the reason for which I feel that her state of mind of current condition is mostly mental and do not have any significant underlying pathological influence. His prescribed medication mainly contains anti-depressive pill (Venlafaxine) and vitamin supplements. Thus, further highlights that there is no potential pathological influence behind his current condition. Butcher, Mineka and Hooley (2013) highlighted that development of depression is mainly from the unstable mental condition and do not have any significant physiological pathology.
Processing of information
His vital signs are all within the normal range and which is something expected at his age (28 years). I would rather conduct a mental state examination (MSE) of Mr. John Gray in order to ascertain his current mental health condition. According to Gluhm et al. (2015), MSE is a crucial part of the clinical assessment in mental health practice. It is an ordered way of observing and describing the psychological condition of the patient at any given point of time. The factors, which are taken into consideration, include appearance, behavior, attitude, mood, though process, affect, speech, perception, cognition, insight and judgment (Mitchell, 2013). His refusal to make eye contact, reluctance in having food, confinement under close door and his frequent attempts of self harm further emphasize the importance of MSE.
Identification of Problems
The main observation which I would like to highlight while assessing Mr. John Gray’s condition include, increase tendency of self harm, reluctance in having food, refusal to interact with other person, refusal to make eye contact and confinement in a enclosed room with negligible connection with the external world. According to Yoshimura et al. (2013), depression causes loss of appetite and this in turn give rise to malnutrition. This is case in case of John and the condition is further evident from his vitamin supplements. Thus, his lack of appetite and lack of proper intake of food is a problem because lack of adequate ingestion of food might call in severe malnutrition which in turn will pose further pathological complications (Costello, 2016). Lack conversation and confinement inside a room can be regarded as another problem because lack of exposure to the external world might further increase his tendency of self-harm (Hawton et al., 2013).
I also observed that his areas of broken skin are covered with non-absorbent dressing. This can be a problem area because according to McDaniel and Browning (2014) as per the evidence-based practice, removal and reapply of dressing is preliminary steps for fast healing of wound. Another problem will be his rope burn mark on his neck this is frequently termed as ligature mark. According to Ambade et al. (2015), ligature mark can cause serious internal injury if not examined and treated on time.  
Establishment of goals
Goal 1: Initiating for the mental state examination in order to check his actual mental health condition and actual reason underlying his frequent suicidal attempts
Goal 2: Increasing his food intake in order to increase the nutritional content of the body and thereby side passing the chances of malnutrition
Goal 2: Checking the wound status of John present over his arms or legs, which have resulted from his subsequent falls
Actions required to be taken
Action for Goal 1:
I will use specific questions and methods in order to access the mental state of Mr. John Gray. According to Fernando and Carter (2016) the mental state examination must be undertaken under a comfortable atmosphere where the patient is willing to interact and the set of questions for the assessment of the mental state must be framed in such a way that it might not harm the cultural and spiritual thoughts of the patients. I will undertake the mental state examination under the detailed supervision of the mental health nurse. Assistance to mental health nurse will help me o execute the process in a proper direction.
Action for Goal 2:
I will encourage John to increase his food intake. This can be done via making nutritional dishes, which score high both in terms of taste and in terms of nutritional value. Observance of the cyclic menu under the detailed supervision of a professional dietician will help to promote proper feeding habits for John.
Action for Goal 3: I would first take permission from Mr. John Gray in order to remove his dressing and if he refuses to remove it, I will explain the reason behind it. After that, I will remove the dressing in order to check the current wound status. Then I will reapply the dressing with proper wound anticoagulant ointment. According to professional code of conduct by the nursing professionals as highlighted by Shahriari et al. (2013), it is the duty of the nurse to indulge the patient in informed decision-making process via providing accurate information underlying the care plan. This comes under the principle of autonomy as mentioned by the ethical standards of nursing code of conduct (Shahriari et al., 2013).
Evaluation
In order to evaluate the outcome in terms care procured to John, I will take into consideration of his weight in respect to his height and age after one week of observance of diet plan specific for John and this will help to ascertain John’s nutritional content of the body. Moreover, further evolution of the outcome will be ascertained on the domain of regular monitoring of the wound in his arms and legs. I will also ask the assisting mental health nurse whom I will take for MSE to assess the mental health outcome. Based on the results of the MSE, person-centered care plan can be devised for John
Reflection on the nursing process and new learning
This clinical reasoning process based on the case study of John helped me to understand professional duty of care for the registered nurse. I understood that it is the duty of the nurse to help the patient participate in the informed decision making process as highlighted by the nursing standard of Ethiopia (2013) ethical guidelines of autonomy. Olsson et al. (2013) of the opinion that this helps to promote person centered care plan. I will also facilitate the care provision under multidisciplinary team and this will help to improve the overall health outcome as highlighted by the Ethiopian Nursing Standard (2018). I will also follow evidenced based practice. Townsend and Morgan (2017) stated that evidence-based practice is an important provision of nursing care for getting the desired outcome.
However, I come across same situation once again; I will first interact with the parents or the direct caregivers of the concerned patients. If the patient is not willing to interact, interaction with the direct caregivers or the guardian will help to get an overview of the underlying cause behind the current mental health condition of the patient (Cook, et al., 2017).
Conclusion
Clinical reasoning cycle is an important framework that helps the nursing professionals to practice with proper reflectivity and ethically. The analysis of the case study based on the framework of the clinical reasoning cycle, I want to conclude that MSE is a vital tool that must be used while devising care plan for severely depressed patients like John who have undergone suicidal attempts and have a tendency of self-harm. The framework of the clinical reasoning cycle also highlighted the importance of multidisciplinary care approach and informed decision-making process towards person-centered care plan. The case study further highlighted that how peer pressure from family and lack of financial support can engulf young adults under severe depression and how this depression leads to lack of appetite leading to increase in the requirement of the vitamin supplements.
References
Ambade, V. N., Tumram, N., Meshram, S., & Borkar, J. (2015). Ligature material in hanging deaths: The neglected area in forensic examination. Egyptian Journal of Forensic Sciences, 5(3), 109-113.
Butcher, J. N., Mineka, S., & Hooley, J. M. (2013). Abnormal psychology. ^ eNew York New York: Pearson.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., … & Mallah, K. (2017). Complex trauma in children and adolescents. Psychiatric annals, 35(5), 390-398.
Costello, C. G. (2016). Depression: Loss of Reinforcers or Loss of Reinforcer Effectiveness?–Republished Article. Behavior Therapy, 47(5), 595-599.
Ethiopian Nursing Standard (2018). Nursing Standard. Access date: 16th August, 2018. Retrieved from: https://forsslund.org/StandardHealthFaclitiy/Nursing%20Home.pdf
Fernando, I., & Carter, G. (2016). A case report using the mental state examination scale (MSES): a tool for measuring change in mental state. Australasian Psychiatry, 24(1), 76-80.
Gluhm, S., Goldstein, J., Loc, K., Colt, A., Van Liew, C., & Corey-Bloom, J. (2013). Cognitive performance on the mini-mental state examination and the montreal cognitive assessment across the healthy adult lifespan. Cognitive and behavioral neurology: official journal of the Society for Behavioral and Cognitive Neurology, 26(1), 1.
Hawton, K., i Comabella, C. C., Haw, C., & Saunders, K. (2013). Risk factors for suicide in individuals with depression: a systematic review. Journal of affective disorders, 147(1-3), 17-28.
Levett-Jones, T. (2018). CLinical Reasoning: Learning to think like a nurse (2nd Ed). Frenchs Forest, N.S.W: Pearson. Access date: 15th August 2018. Retrieved from: https://www.utas.edu.au/__data/assets/pdf_file/0003/263487/Clinical-Reasoning-Instructor-Resources.pdf
McDaniel, J. C., & Browning, K. K. (2014). Smoking, chronic wound healing, and implications for evidence-based practice. Journal of wound, ostomy, and continence nursing: official publication of The Wound, Ostomy and Continence Nurses Society/WOCN, 41(5), 415.
Mitchell, A. J. (2013). The Mini-Mental State Examination (MMSE): an update on its diagnostic validity for cognitive disorders. In Cognitive screening instruments (pp. 15-46). Springer, London.
Olsson, L. E., Jakobsson Ung, E., Swedberg, K., & Ekman, I. (2013). Efficacy of person?centred care as an intervention in controlled trials–a systematic review. Journal of clinical nursing, 22(3-4), 456-465.
Radfar, M., Ahmadi, F., & Fallahi Khoshknab, M. (2014). Turbulent life: the experiences of the family members of patients suffering from depression. Journal of psychiatric and mental health nursing, 21(3), 249-256.
Shahriari, M., Mohammadi, E., Abbaszadeh, A., & Bahrami, M. (2013). Nursing ethical values and definitions: A literature review. Iranian journal of nursing and midwifery research, 18(1), 1.
Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing: Concepts of care in evidence-based practice. FA Davis.
Yoshimura, K., Yamada, M., Kajiwara, Y., Nishiguchi, S. and Aoyama, T., 2013. Relationship between depression and risk of malnutrition among community-dwelling young-old and old-old elderly people. Aging & mental health, 17(4), pp.456-460.

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