Unfolding Clinical Reasoning

UNFOLDING Clinical Reasoning Case Study

History of Present Problem:

Jeremy Brown is a 30-year-old Caucasian male who was brought to the emergency department (ED) by the police after being involved in an altercation at work. Jeremy was at work today, and he threw a large piece of metal at a coworker and began yelling, “Stop following me, I know what you have been up to!” Because Jeremy was very agitated and upset, and the police were called.

Since arriving in the ED, he has been agitated, displaying rapid pressured speech and repeating the phrases he hears the police and others in the ED say. Jeremy reported that he recently stopped taking his risperidone and citalopram because he believed his coworkers have been breaking into his house and poisoning his medications. Jeremy’s manager reports that he was diagnosed with schizophrenia five years ago.

Personal/Social History:

Jeremy graduated from college with a 4.0 GPA and was in his first year at law school when he experienced the first episode of acute mental illness and was diagnosed with schizophrenia. He had to drop out of law school at age 24 and never finished. Jeremy lives at home with his mother and father and recently broke up with his girlfriend.

Jeremy likes his job at the foundry but feels he is a disappointment because both of his sisters are lawyers, as is his father. Jeremy has no close friends and only a few acquaintances. Jeremy’s mental health had been stable up until the last three months. He has been feeling more paranoid the past three months and experienced a dramatic increase in symptoms when he stopped taking all of his medications one month ago.

What data from the histories are RELEVANT and have clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment:

T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain

P: 100 (regular) Quality:

R: 22 (regular) Region/Radiation:

BP: 130/84 Severity:

O2 sat: 98% room air Timing:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT VS Data: Clinical Significance:

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:

Current Assessment:

GENERAL

APPEARANCE:

Calm, body relaxed, no grimacing, appears to be resting comfortably

RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort

CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill

NEURO: Alert & oriented to person, place, time, and situation (x4)

GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU: Voiding without difficulty, urine clear/yellow

SKIN: Skin integrity intact, skin turgor elastic, no tenting present

Mental Status Examination:

APPEARANCE: Diaphoretic, uncombed shoulder-length, somewhat greasy hair; cloths are stained and torn.

Cooperative with the admission process.

MOTOR BEHAVIOR: No abnormal muscle movements

SPEECH: Rapid and pressured. Client often repeats words and phrases he hears others in the emergency room say. The client says, “He was brought to the emergency room” over and over again when he is not distracted or engaged in conversation.

MOOD: Reports feeling very upset

AFFECT: Becomes agitated/anxious when talking about his co-workers and his meds; guarded and suspicious, mood and affect are congruent.

THOUGHT PROCESS: Linear but irrational

THOUGHT CONTENT: Displays paranoid delusions that coworkers are following him to hurt him and are poisoning his medication.

PERCEPTION: Denies auditory or visual hallucinations, or feelings of depersonalization (feeling detached from self or environment)

INSIGHT: Poor-believes he was brought in to the emergency room for protection from his coworkers

JUDGMENT: Poor-stopped meds and is acting aggressively towards co-workers

COGNITION: Alert and oriented times 4 (person, place, time and purpose), is easily distracted

INTERACTIONS: Is in good control when talking with nursing staff, his boss, and police.

SUICIDAL/HOMICIDAL: Denies any suicidal thoughts or thoughts of self-harm. Stated he wants to “punish” his coworkers.

RELEVANT Mental Status Exam Data: Clinical Significance:

Lab Results:

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

Clinical Reasoning Begins

What is the primary problem that your patient is most likely presenting?
What is the underlying cause/pathophysiology of this primary problem?

Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Most Recent:

Sodium (135–145 mEq/L) 130 135

Potassium (3.5–5.0 mEq/L) 3.5 3.8

Glucose (70–110 mg/dL) 160 128

Creatinine (0.6–1.2 mg/dL) 1.1 1.0

Complete Blood Count (CBC:) Current: High/Low/WNL? Most Recent:

WBC (4.5–11.0 mm 3) 6.5 8.2

Neutrophil % (42–72) 60 68

Hgb (12–16 g/dL) 12.5 12.8

Platelets (150-450 x103/µl) 250 289

Collaborative Care: Medical Management

Care Provider Orders: Rationale: Expected Outcome:

Admit to the inpatient mental health unit on a voluntary status

Risperidone 2mg PO BID

Citalopram 20mg PO at HS

Lorazepam 1mg PO every 6 hours PRN for anxiety or agitation

Haloperidol 5mg IM every 4 hours PRN for severe agitation

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:

 Lorazepam 1mg

 Citalopram 20mg

 Haloperidol 5mg

 Risperidone 2mg

 Admit to inpatient

mental health unit

Collaborative Care: Nursing

What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

What body system(s) will you assess most thoroughly based on the primary/priority concern?
What is the worst possible/most likely complication to anticipate?
What nursing assessments will identify this complication EARLY if it develops?
What nursing interventions will you initiate if this complication develops?
What psychosocial needs will this patient and family likely have that will need to be addressed?
How can the nurse address these psychosocial needs?

Evaluation: Six Hours Later

The client has been admitted to the adult inpatient mental health unit, and you are now the nurse caring for the client.

Current VS: Most Recent: Current PQRST:

T: 97.4 F/36.3 C (oral) T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain

P: 78 (regular) P: 100 (regular) Quality:

R: 16 (regular) R: 22 (regular) Region/Radiation:

BP: 118/70 BP: 130/84 Severity:

O2 sat: 99% room air O2 sat: 98% room air Timing:

Mental Status Examination:

APPEARANCE: Recently showered, dressed in hospital gown and clothing

MOTOR BEHAVIOR: No abnormal muscle movements

SPEECH: Normal rate and rhythm

MOOD/AFFECT: Flat, watchful

THOUGHT PROCESS: Linear

THOUGHT CONTENT: Continues to believe meds at home are poison; willing to take meds in the hospital because they are sealed. Continues to state people at work were out to harm him

PERCEPTION: Denies auditory or visual hallucinations

INSIGHT/JUDGMENT: Fair- Client acknowledges his diagnosis of schizophrenia and understands this is why he is in the hospital

COGNITION: Alert and oriented times 4

INTERACTIONS: Sitting at table with other clients but not engaging in conversation

SUICIDAL/HOMICIDAL: Denies any thoughts of suicide or self-harm or thoughts to harm others.

What clinical data are RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Clinical Significance:

RELEVANT Assessment Data: Clinical Significance:

Has the status improved or not as expected to this point?
Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Current Assessment:

GENERAL

APPEARANCE:

Resting comfortably appears in no acute distress

RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks

GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU: Voiding without difficulty, urine clear/yellow

SKIN: Skin integrity intact

Situation:

Name/age:

BRIEF summary of the primary problem:

Background:

Primary problem/diagnosis:

RELEVANT past medical history:

RELEVANT background data:

Education Priorities/Discharge Planning

What educational/discharge priorities will be needed to develop a teaching plan for this patient and family?
How can the nurse assess the effectiveness of patient and family teaching and discharge instructions?

Caring and the “Art” of Nursing

What is the patient likely experiencing/feeling right now in this situation?
What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a

person?

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention at the moment as the events are unfolding to make a correct clinical judgment.

What did I learn from this scenario?
How can I use what has been learned from this scenario to improve patient care in the future?

Assessment:

Most recent vital signs:

RELEVANT body system nursing assessment data:

RELEVANT lab values:

TREND of any abnormal clinical data (stable-increasing/decreasing):

How have you advanced the plan of care?

Patient response:

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation:

Suggestions to advance the plan of care:

SOLUTION

Unfolding Clinical Reasoning

The case study is about Jeremy brown, a thirty-year-old Caucasian male. Today he is brought to the emergency department. His present problem and personal social history are presented to help in clinical diagnosis. These two data are relevant since each has a clinical significance.

Important Data From Present Problem

Clinical Significance

Jeremy Brown is a 30 –year old Caucasian male.

He is involved in an altercation at work.

He threw a large piece of metal at a coworker and began yelling.

He is agitated, displaying pressured speech, and repeating phrases he hears from police and others in the ED.

He reports having stopped taking risperidone and citalopram because he believes his medication is poisoned (Forneris, Neal, Tiffany, Kuehn, Meyer, Blazovich & Smerillo, 2015).

The significance of this data is to enable the physician to undertake the right diagnosis.

It allows the patient to be sent to the right doctor for an accurate diagnosis.

Relevant Data From Social History

Clinical Significance

The patient was a bright student of law and with sound mental reasoning.

He experienced the first episode of mental illness and diagnosed with schizophrenia.

He recently broke with his girlfriend

Both of his sisters are lawyers and his father as well, and he feels disappointed

He has no close friends.

His mental health has been good until the last three months

He has been paranoid in the past three months

The patient experienced a dramatic increase in symptoms when he dropped medication (Shellenbarger & Robb, 2015).

Patient history data is essential information for effective clinical decision making.

It helps understand the medication the patient had been taking.

The history data based on the medication history help the clinician undertake the correct diagnosis.

It also helps in making a change in medication decisions or adopts a new treatment strategy to the patient (Forneris, Neal, Tiffany, Kuehn, Meyer, Blazovich & Smerillo, 2015).

Patient Care Begins

What vital sign data important to be interpreted by nurse for clinical significance?

Relevant vital sign data

Clinical significance

BP: 130/84

P-Q-R-S-T pain assessment:

P: regular

O2 sat:98% room air

These vital signs offer critical information on the patient’s states of health.

They are essential to the diagnosis of other related diseases like heart disease, cardiac arrest, among others (Shellenbarger & Robb, 2015).

It helps to narrow down the diagnostic process.

What assessment data important to be interpreted by nurse for clinical significance?

Important Assessment Data

Clinical Significance

Overall appearance ,

Respiration,

Cardiac,

Neurology assessment

The general appearance informs the nurse on whether the patient is relaxed, violent, and which help undertake mental assessment.

Respiration, cardiac, and neuron assessment is relevant to nurse. Patients with mental illness and hot-tempered can develop related health problems in the mentioned areas of evaluation (Forneris, Neal, Tiffany, Kuehn, Meyer, Blazovich & Smerillo, 2015). A nurse must interpret the information with a lot of care.

Relevant Mental Exam Data

Clinical Significance

Appearance

Thought process

Thought content

Insight

Judgment

Cognition

Interaction

Mood

Suicidal/Homicidal

The clinical significance of various mental assessment area is to provide the nurses with critical information that help in making the right diagnosis and determining the most appropriate treatment (Shellenbarger & Robb, 2015).

Clinical Reasoning Starts

Primary problem that that the patient is likely representing

Based on the physical examination conducted on the patient, the primary problem is schizophrenia’s, a mental disorder caused by a combination of different factors. Some of these factors are the environment and brain chemistry. The identified factors cause hallucinations and disorganized thinking. They also cause delusions and other negative symptoms (Forneris, Neal, Tiffany, Kuehn, Meyer, Blazovich & Smerillo, 2015).

Principle Causes of the Primary Problem.

The patient condition is caused by a group of heterogeneous disorders that are not well known. The alteration of dopamine neurotransmission causes imbalances. The environmental factors of work subject the patient to conditions that eventually bring out schizophrenia (Forneris, Neal, Tiffany, Kuehn, Meyer, Blazovich & Smerillo, 2015). The patient is always disappointed that her two sisters are lawyers and his father as well. He became easily agitated, and trigger work relationship problem with others

Collaborative Care Nursing

Nursing Priorities That Will Guide the Treatment Care Plan

(1)Lorazepam 1mg, (2) Citalopram 20mg, (3) Haloperidol 5mg, (4) Risperidone 2mg, (5) Admit to inpatient mental health unit

What Interventions to Induct Centered on the Significance?

Treatment Interventions	*Justification*	Anticipated result
Administering Lorazepam 1mg for every 6 hours	Lorazepam will help in reducing anxiety or agitation.	The patient expected to react positively, become relaxed and comforted.
Citalopram 20mg	It will help to treat depression, and it’s the right antidepressant. It works to restore the balance of a natural chemical in the brain	Patients improve energy levels and feelings of their well-being.
Haloperidol 5mg in every four hours	It is useful in severe agitation. It is effective in the treatment of schizophrenia disorders to help control motor movement.	It decreases the excitement in the patient brain.
Risperidone 2mg PO BID	Help to treat bipolar disorder, control agitation.	Help the patient to think clearly and take part in everyday activity.
Admit to inpatient mental health unit	Inpatient admission will help monitor patient behavior. Have close observation of patient actions.	Resuming reasonable condition after the admission period.

Body System to Assess Thoroughly based on the Primary Concerns

The primary diagnosed problem was detected as schizophrenia; this condition affects the nervous system, the endocrine system, as well as the neurological system. Schizophrenia is a mental disorder; therefore, conducting a thorough assessment of the mentioned system is very important (Shellenbarger & Robb, 2015).

Worst Possible/most likely Complication to Anticipate

The most likely complication to anticipate include social isolation, health and medical problems, inability to work or attend school, and madness. Other complications include aggressive behavior, legal and financial problems.

Nursing Assessment that will recognize the Problem first if it develops rapidly

Some of the nursing valuation to help identify complications is behavior monitoring. Also, a study of the patient’s cognitive action will allow a nurse to identify this complication early enough. Close monitoring will help learn as soon enough when difficulty begins.

Nursing Interventions to Initiate when Complication Begins

As mentioned above, the worst complexity is the patient to become mad. In such a case, admitting him for inpatient in a mental hospital would be the most appropriate nursing intervention. At the mental hospital, the patient will be under the care of a psychiatrist to help him in managing the conditions (Shellenbarger & Robb, 2015).

Psychosocial Needs that Patients and Families will Likely Need to be addressed

Having diagnosed patients with schizophrenia, it is essential to address his psychosocial needs that of the family as well. Most of them are stress management and stigmatization. Communicating and showing a lot of empathy will help significantly (Shellenbarger & Robb, 2015). Nursing can help address these needs by offering professional counseling to patients and family members.

Evaluation: Six Hours Later

What clinical data are essential and should be considered clinically relevant?

Significant vital sign	Clinical importance
Temperature:97.4 Pressure: 78 (regular) Respiration: 16 regular Blood pressure: 118/70 O2 sat: 99% room air	The information becomes critical to nurses as it helps if the treatment plan is useful to the patient
Relevant assessment data	Clinical importance
Appearance Motor behavior Thought process Perception Judgment Cognition Interactions	These are fundamental areas to asses so as to evaluate the patient’s response to the treatment plan.

Has Condition better or not as anticipated to this Point

The patient condition has been enhanced to the expectation. It is only after six hours, and assessment indicates a positive response.

Whether Nursing Care Needs Modification in any Way after Six Hours of Evaluation

I don’t think at this point, and there is a need for modifying the care plan. However, after 24 hours, evaluation, it can be adjusted accordingly.

SBAR report

Situation

Name/age: Jeromy Brown aged 24 years

A summary of the primary problem: according to the physical examination conducted on the patient, the fundamental problem is schizophrenia’s mental disorder caused by a combination of different factors. Some of these factors are environment and brain chemistry which causes hallucinations, disorganized thinking, delusions, and other negative symptoms

Background:

Primary difficult/finding: schizophrenia

significant historical health account: His mental health has been good until the last three months

He has been paranoid in the past three months

The experienced a dramatic increase in symptoms when he dropped medication.

RELEVANT background data: Jeremy Brown, a 30 –year old Caucasian male.

He is involved in an altercation at work.

He threw a large piece of metal at a coworker and began yelling.

He is agitated, displaying pressured speech, and repeating phrases he hears from police and others in the ED (Forneris, Neal, Tiffany, Kuehn, Meyer, Blazovich & Smerillo, 2015).

He reports having stopped taking risperidone and citalopram because he believes his medication is poisoned.

ASSESSMENT

Most recent vital signs: T: 97.8 F/36.6 C (oral) P: 100 (regular) R: 16 (regular) R: 22 (regular) 130/84 Severity: O2 sat: 98% room air

RELEVANT body system nursing assessment data: Appearance

Motor behavior

Thought process

Perception

Judgment

Cognition

Interactions.

Relative lab values:

TREND of any abnormal clinical data (stable-increasing/decreasing): there is an increase in temperature, respiratory rate, pressure

How have you advanced the plan of care? The care plan has not been advanced.

Patient response; patient responding well

INTERPRETATION of current clinical status (stable/unstable/worsening): the current situation of the patient is adjusting well.

Recommendation:

The patient should be evaluated after another six hours. The cognitive process should be assessed. If no further positive change recorded, counseling interventions will be advisable.

Education Priorities/ Discharge Planning

There is a need to develop a teaching plan for the patient and family. Offering professional guidance will be most appropriate. The family needs to be taught how to relate to the patient.

How can the Nurse Assess the Effectiveness of Patient and Family Teaching and Discharge Instructions?

A nurse can assess the effectiveness of teaching to patient and family by first setting the goal to be achieved and reviewing if they are met after some period.

Caring and the “Art” of Nursing

What is the Patient Likely Experiencing/Feeling Right now in this Situation?

In this situation, the patient is feeling under reasonable care, and he is thankful for hospital efforts of helping him recover (Shellenbarger & Robb, 2015).

What can you do to Engage Yourself with this Patient’s Experience, and show that he/she Matters to you as a Person?

As a nurse, I would establish a good and effective communication plan for the patient. I would also engage him in conversation, and show him all the possibilities of him resuming his average life.

References

Forneris, S. G., Neal, D. O., Tiffany, J., Kuehn, M. B., Meyer, H. M., Blazovich, L. M., & Smerillo, M. (2015). Enhancing clinical reasoning through simulation debriefing: A multisite study. Nursing Education Perspectives, 36(5), 304-310.

Shellenbarger, T., & Robb, M. (2015). Technology-based strategies for promoting clinical reasoning skills in nursing education. Nurse Educator, 40(2), 79-82.

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