Severe depression

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. His routine morning
observations were: 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
Multivit i daily
Vit B co i daily

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Case Study 370
Student Name
Institution
Date

CASE STUDY 370 3

Introduction

Clinical reasoning can also be termed as critical reasoning or clinical judgment (Kelton,
2014). It is the sourcing of clues about the patient’s symptoms in order to establish the cause of
epidemiology rather than simply how to treat it. By looking at patient history, determining
factors to the ailment and assessing response to previous medication, nursing staff can learn the
patient’s immune system and propose better ways to treat the patient (Rugen et al, 2014).
Clinical reasoning is a tactic in evident based practice. It comprises of; consideration for patient
situation, collection of cues and data about the patient, processing these cues/information,
identifying the problem or issue at hand, establishing treatment goals, taking action to administer
treatment, evaluating the outcome of the treatment and reflecting on the outcome (Tsingos,
Bosnic-Anticevich & Smith, 2014). This can be represented in the diagram below;

CASE STUDY 370 4
Figure 1. Clinical Reasoning Cycle: Source; Levett-Jones et al (2010).
Considering the patient situation
Consideration for the situation of the patient involves aspects such as; listening to what
the patient says, what their relatives say about the patient and assessing the condition. In some
cases such as emergency nursing treatment where the cause for treatment is injury, little
information is required to start the treatment (Jefford, 2012). There are indeed cases where the
entire clinical reasoning process will not apply. However, clinical reasoning is very effective for
chronic patient cases that include patients with cancer, arthritis, asthma, Leukemia and
challenges such as kidney failure, diabetes and ulcers (Staveski, Leong, Graham & Roth, 2012).
These patients often demonstrate a case of exposure to risk factors as well as possible dishonesty
in previous diagnostics and wrong use of medicine. This information needs to be captured if any
further diagnosis is to be done.
Gathering Health Information
Health information can be gathered in many ways. The most popular of these ways is to
check insurance records. The patient is to be made aware that such information is important for
their treatment thus should be retrieved with their consent (Forbes & Watt, 2015). All records
and files stored on chronic patients present a plethora of useful information that can really help
nurses in offering care to the patients (Cockerham et al, 2011). For instance, a patient who has
been catheterized needs to make it known before medical procedures are undertaken on them.
Such knowledge may however not be present beforehand if the patient is brought in by non-
relatives in a comatose /unconscious state of mind. Knowledge on past treatments helps avoid
allergic reactions in current treatments as well (Andrew & Robb, 2011). It is thus important for

CASE STUDY 370 5
nursing staff to be aware that they will require such information early hence begin looking for
ways to source it.
Processing Information
With the entire information ready, there is need to process the information as it is. For
instance, in the case of John, the patient in this case study, his history of causing self-harm
cannot be easily diagnosed without having prior information on what the motivation for the
harmful activities is. John’s friends and relatives can give the impression that he may have
bipolar disorder, hyperactivity disorder, depression or an anxiety disorder. However, it is
important to know if John has been using any drugs that may have either led to his disorders or
aggravated the situation in the past. Currently, he is on Venlafaxine (anti-depressant medication),
multivit (a dietary supplement) and vit B (Thiamine, Riboflavin and pantothenic acid). These
medications indicate treatment for an eating disorder as well as depression.
Identifying the problem
The next step is to find out why Mr. John is depressed. It could be as a result of family,
work or social issues. This information cannot be acquired from any other persons but the closest
family members. Interviewing these family members would indicate reasons Mr. John may have
been stressed to the point that he chose not to eat. In clinical reasoning, there is no assumption
made. Every little detail about the person has to go into the preparation of the diagnosis (Bratt,
2013). Finding out the main reason for Mr. John’s stress can lead to the proper therapeutically-
induced intervention for the patient. He may for instance need counseling more than he needs the
medication he is on. Additionally, Regardless, there could be other cases of infection or
epidemiology within his body. He may be on a different unhealthy diet that could be causing his

CASE STUDY 370 6
eating disorder. In order to arrest this; there may be need for urinalysis and blood testing.
tTesting the patient’s vitals is very important in any diagnosis (dit Dariel, Raby, Ravaut &
Rothan-Tondeur, 2013). From the vitals given; 125/75 mmHg, 36.3 0 C, Pulse 66 and Respirations
18, he seems to be out of danger at the moment. Therapy thus seems to be the imminent
treatment option.
Nursing Problems Based on Health Assessment
One of the key issues that I have identified from the provided case study is lack of patient
cooperation. It is reported that Gray He also avoids engaging in conversations with health
providers. T this can result in ineffective delivery of patient care as they clinicians cannot
properly tract the progress of Gray and provide quality care to him.
I am also concerned about Gray’s neck injuries and whether they could be linked to the
depression that he is currently suffering from. Research by Cockerham et al., (2011) reports that
severe neck or back pain can trigger can result in increased stress and depression. As a nurse, it is
crucial to conduct a diagnosis aimed at determining whether the depression is lined to the pain.
The other nursing issue that perturbed me is Gray’s behavior of not eating or participating
in recreational activities. Forbes & Watt (2015) enlighten that diet and activity play a central
roleare among the leading contributors towards of effective recovery from depression. Increasing
the number of activities aids depressed patients such as Gray to cope with depression. Therefore,
as a nurse I will encourage Gray to participate in events that he used to enjoy.

Goals for priority of Nursing care

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Goals for priority of nursing care are based on various principles assigned within the
clinical reasoning cycle. The most important goal is to ensure that all information acquired from
interviewing John’s contacts is captured and recorded for future use. The next goal is to ensure
that error omission is guaranteed by progressively seeking additional information to help in the
diagnosis and treatment of the patient. Whether the information provided seems significant or
not, it is vital to consider each new piece of information gained (Alfaro-LeFevre, 2012). It is also
vital to ensure that the incorporation of pathophysiological knowledge into the treatment is
balanced with the use of previous data and current information from significant sources. A nurse
has to make decisions based on what they know to be medically proven as true. This can be
knowledge based on study or knowledge based on practice (Barker, 2013). The ultimate goal
however is to ensure that the treatment option chosen is in the interest of the patient more than it
is in the interest of the hospital.
Nursing Care for John
John is on the right track to recovery based on the medication given to him. However, the
treatment of mental disorder and eating disorder is not sufficient. He needs to be under constant
surveillance without making it seem like he is being monitored. He also needs to seek
counseling. However, many patients often face denial and may not be willing to take this step.
As a result, the primary nursing solution would be to talk to John about his actions and over time,
get him to admit that he needs psychological help. By doing so, John can be fully assisted and on
the road to recovery. The medication he is taking needs to continue, as long as he is not cleared
of his psychological problem by a psychologist. In priority nursing care, it is important to
incorporate professional advice from colleagues and supervisors (LeMone et al., 2015; Barker,

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2013). This diagnosis thus needs to be discussed with other senior nursing officials to establish
the degree of accuracy in the diagnosis.
Evaluating outcomes
The outcomes anticipated by the proposed nursing care for John include; admission of
depression or mental problem, agreement to consult psychologist or the use of the hospital-
appointed psychologist, being more open about his issues and restoration of his former life. John
has to eventually continue being a father, husband and colleague to friends and family. He thus
ought to begin treatment that will make him open up about the problems he faces. The
importance of these strategies is that at the end of the day, John needs to be treated. The
medication he is using works on him but it is apparent that he does not take it willingly. He needs
to have an attitude change to accept medication before any medical intervention can work
(Staveski, Leong, Graham & Roth, 2012).
Reflection
John’s case is not an isolated one. He seems to be struggling with depression-related
problems. These problems are social in nature (Alfaro-LeFevre, 2012). There is need however to
incorporate evidence-based practice in the treatment of John’s depression that has led to eating
disorders, attempted suicide and self-inflicted injuries. Therapy seems to be the best option.
However, before he begins the therapy, John needs to take his medication and lower stress levels.
Once this has been done, he can then be treated and offered the necessary counseling to deal with
his depression.

CASE STUDY 370 9

References

Alfaro-LeFevre, R. (2012). Applying nursing process: the foundation for clinical reasoning.
Lippincott Williams & Wilkins.
Andrew, N., & Robb, Y. (2011). The duality of professional practice in nursing: Academics for
the 21st century. Nurse Education Today, 31(5), 429-433.
Barker, J. (2013). Evidence-Based Practice for Nurses: SAGE Publications. Sage.
Bratt, M. M. (2013). Nurse residency program: Best practices for optimizing organizational
success. Journal for nurses in professional development,29(3), 102-110.
Cockerham, J., Figueroa‐Altmann, A., Eyster, B., Ross, C., & Salamy, J. (2011, October).
Supporting newly hired nurses: A program to increase knowledge and confidence while
fostering relationships among the team. InNursing Forum (Vol. 46, No. 4, pp. 231-239).
Blackwell Publishing Inc.
dit Dariel, O. J. P., Raby, T., Ravaut, F., & Rothan-Tondeur, M. (2013). Developing the Serious
Games potential in nursing education. Nurse education today, 33(12), 1569-1575.

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Forbes, H., & Watt, E. (2015). Jarvis’s Physical Examination and Health Assessment. Elsevier
Health Sciences.
Jefford, E. (2012). Optimal midwifery decision-making during 2nd stage labour: the integration
of clinical reasoning into midwifery practice.
Kelton, M. F. (2014). Clinical Coaching–An innovative role to improve marginal nursing
students’ clinical practice. Nurse education in practice,14(6), 709-713.
LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015).
Medical-surgical nursing. Pearson Higher Education AU.
Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S. Y.-S., Noble, D., Norton, C. A., . . .
Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to
enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse
Education Today, 30(6), 517-519.
Rugen, K. W., Watts, S. A., Janson, S. L., Angelo, L. A., Nash, M., Zapatka, S. A., … & Saxe, J.
M. (2014). Veteran affairs centers of excellence in primary care education: transforming
nurse practitioner education. Nursing outlook, 62(2), 78-88.
Schmidt, N. A., & Brown, J. M. (2014). Evidence-based practice for nurses. Jones & Bartlett
Publishers.
Staveski, S., Leong, K., Graham, K., Pu, L., & Roth, S. (2012). Nursing mortality and morbidity
and journal club cycles: paving the way for nursing autonomy, patient safety, and
evidence-based practice. AACN advanced critical care, 23(2), 133-141.

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Tsingos, C., Bosnic-Anticevich, S., & Smith, L. (2014). Reflective practice and its implications
for pharmacy education. American journal of pharmaceutical education, 78(1).

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