MSc Nursing with NMC Registration

MODULE NAME: Nursing in Practice Mental Health

WORD COUNT: 1983            

Clinical Reasoning and Care Prioritization

Nursing practitioners are critical in the provision of healthcare. Thus, they must be equipped with the knowledge and skillset – competence, to help in disease prevention and control. Among the competencies, a nurse should think, reason, and act ingeniously through clinical situations and trajectories. That is what Carvalho, Oliveira-Kumakura, and Morais call clinical reasoning (2017, p.662). Besides, nurses must attend clinical issues in order of priorities (Standing, 2014, p.126). These competencies are illustrated in this essay by reflecting on the nursing decision-making process and prioritization of care in a clinical case

Clinical Case

A 22 years old female named Devi is rushed into the Accident and Emergency Unit of a local hospital. She and her sister live with their parents, who are Indian Mauritiana natives. Her sister may not be living longer with them, as she and the entire family are preparing for her wedding. Two years ago, Devi was diagnosed with psychosis. She was instructed to follow up on her diagnosis with the local GP, which she has done. However, she has been showing unpleasant traits in the recent past. Also, she has claimed that hostile voices are causing her to self-harm. These voices, which are auditory hallucinations, often appeal to her when she is alone. They have made her angry and scared, leading to a relapse that appears such that her condition is caused by anxiety and stressful events.

Psychosis is a mental health issue characterized by “severe impairment in cognitive, mental disturbance, and social functioning” (Arciniegas, 2015, p.716). According to DSM-IV, primary psychosis is a neurodevelopmental disorder that occurs in a spectrum between the mild and severe ends – schizoid and schizophrenia. Arciniegas notes that previous versions of DSM defined psychosis­ as gross impairment in reality testing (2015 p.716). In that perspective, psychosis may be defined as both a psychiatric disorder or a neurologic condition. Its symptoms include hallucinations, delusions, and paranoia. Arciniegas adds that it identifies both hallucinations and delusions as the major symptoms (2015 p.717).

Clinical Reasoning

Assessment of Devi’s Situation

Before diagnosis and treatment, nurses assessed Devi to discover the abnormalities exhibited. According to National Institute for Health and Care Excellence guidance (NICE), “adults with psychosis or schizophrenia must receive a comprehensive physical health assessment, and this must be carried out as soon as possible” (2016, p.25). One may use an assessment method of choice between clinical interviews, clinical tests, and clinical observations. In this case, the clinical interview was adopted. At this assessment stage, according to Ardito and Rabellino (2011, p.2), it is essential to establish rapport to facilitate the development of a therapeutic relationship. Thus, the nurse needed to know the patient and develop a therapeutic relationship to make substantial and useful conclusions.

The interview was semistructured with the aid of the Brief Psychiatric Rating Scale (BPRS). The structure involves the semistructured interview, interviewees, and information collected from the interview (Newell and Gournay, 2000). The interviewer focused on identifying the chief complaint, Devis’s clinical history, precipitating factors, symptoms, affective, cognitive, physical, and her roles in the community. Devi was interviewed first, followed by her parents, after obtaining explicit permission for the contact using the Manchester Rating Scale as recommended (Hyde, 1989, p.45). With Devi, the interview took longer than with her parents since she mostly lost focus, and the nurse had to allow her time to organize information for every answer. The interviewing nurse was keen to gather as much useful information as possible, by critically assessing what she (Devi) said and how she said it. Questions asked made sure to follow Devi’s flow of thoughts and were open-ended with inviting more of her expression. They entailed how she felt, how long she had the feelings, how her parents were helping, and regarding her relationship with various family members.

Also, the nursing team applied the psychosocial framework during the initial assessment. This approach took into account the social benefits such as the utility of social skills, employment potential, and favorable working conditions, and family support (Smith, 2012, p.173). For instance, the assessment focused on finding how often the parents accompanied Devi to the GP, how much time they spend with her, whether she had friends with non-relatives, and what mattered to her most at the time. They also asked about her hobbies, interests, talents, and what she was good at in college and at home.

These approaches are essential non-pharmacological methods of mitigating withdrawal syndrome and self-isolation and promoting the social functioning of an individual. According to recent studies, the approaches are in line with the most effective psychosocial assessment, which is person-centered and collaborative (Trenoweth and Moone, 2017, p.11). In that perspective – the psychosocial approach, nurses inquired about the talents, hobbies, interests, and other social traits that would help in underpinning the cause of Devi’s condition. Besides, it was an ideal strategy to let Devi talk about herself, and the nursing team to identify critical areas requiring prioritized care. At the end of the assessment, the nursing team addressing her case had isolated three priorities. They would address the auditory hallucination, work on educating Devi’s family, and ensure that she followed up diagnosis with the community mental health team (CMHT).  

Care Prioritization

According to Standing (2014 p.126), before a nurse can make a decision, nurses must go through clinical reasoning, which involves assessing the potential consequences (risks and benefits) of potential alternative actions. In other words, the health outcome of a patient is partly determined by the clinical decisions of a nurse in charge.  According to Guerrero, clinical “reasoning is a skill that a real nurse must understand and apply to deliver a safe nursing practice” (2019, p.79). It is through such competencies that nurses identify and organize clinical priorities, and focus on critical issues of a patient. Treatment had to begin immediately as recommended by the NICE. That is, as soon as the nursing team meets the standard positive assessment for psychosis, treatment can be delivered immediately through the NICE-approved care package (NICE, 2016, p.6).  

Auditory Hallucinations: Auditory hallucinations were identified as a clinical priority from clinical assessment for Devi. From the assessment, the auditory hallucinations experienced by Devi were critical, as they had compelled her to self-harm severely. She explained that the hostile voices were more audible and compelling when alone. She followed what the voices said, which is especially significant since she could follow dangerous commands such as a suicide act or a homicide.

Hallucinations are defined as the loss or distortion of reality, accompanied by another aggressive sense of reality (Zielasek, Falkai, and Gaebel, 2015, p.10). Hallucinating people get sensory impulses for stimuli that are not present in their environment. According to studies, auditory voice hallucinations are the primary symptom of psychosis (El Haj et al., 2017, p.2; Laroi et al., 2012, p.725). According to the DSM-IV auditory verbal hallucination for one month, in addition to social dysfunction for six months, points to the diagnosis of schizophrenia, a spectrum within which psychosis is treated (Laroi et al., 2012, p.724). Therefore, as a characteristic symptom of psychosis, auditory hallucinations were a critical clinical finding to prioritize.

Besides, auditory hallucinations deteriorate rapidly, leading to severe clinical complications. According to El Haj et al. (2017, p.3), hallucinations are associated with an increased mortality rate of 78%. The rake may double for people experiencing both visual and auditory hallucinations. Also, hallucinations aggravate other health issues and are a risk to the overall health outcome of an individual. For instance, they lead to aggressive behavior, falls, and outbursts, and functional decline (Lerner et al., 1994, p.523; Scarmeas et al., 2005). Laroi et al. (2012, p.725) explain that the overall effect of hallucinations is a lack of onset and offset of experiences.

Therefore, nurses and relevant clinical practitioners prioritized Devi’s hallucinations, to restore her controllability and mitigate the intrusive hostile stimuli. She was administered second-generation atypical antipsychotics at the request of family members. There is no Medicines and Healthcare products Regulatory Agency (MHRA) approved antipsychotic medication for hallucinations, and that second-generation atypical antipsychotic agents may be used together with non-pharmacological approaches (Burghaus et al., 2011, p.155; El Haj et al. 2017, p.8). Nevertheless, Devi’s family had to agree, as they are also a critical element in clinical reasoning.

 Family Education: The role of the family in healthcare cannot be overemphasized. They are the primary caregivers to a patient. Therefore, like healthcare professionals, family members ought to have the relevant clinical knowledge, to foster patients’ improvement, and reduce readmission (Kripalani, Theobald, Anctil and Vasilevskis, 2014, p.5). From Devi’s case study, she had Devi has been receiving treatment from her local GP for two years. Therefore, the current situation is a relapse, which Peyrovi, Seyedfatemi, and Jalali (2015 p.191) attribute to an inadequate care home environment. Therefore, this priority aimed to educate Devi’s family members about psychosis and its prognosis. That way, they would be diligent in identifying onset signs and symptoms, understand the factors that deteriorate Devi’s condition, such as family stress, to avoid them (Mueser et al., 2015, p.6; Peyrovi, Seyedfatemi, and Jalali, 2015, p.191).

The nursing team on Devi taught her family members about psychosis, its signs and symptoms, and onset predictors. This reduces the misattribution of symptoms and corrects cultural misconceptions (Cabassa et al., 2018, p.651; Conner et al., 2014, p.335). For instance, Devi’s more conservative father believed that Devi had been put on a play and that she was not mentally ill. Also, the healthcare education ensured that they would improve their quality of care, reduce moments when Devi is alone, and solve all her concerns by assuring her that things will be okay. For instance, the wedding preparations for Devi’s sister could have increased the family pressures and lead to times when she was isolated or anxious moments. Also, they were to focus on her strengths so that she could enjoy her self and the things she is good at (Arciniegas, 2015, p.730). They would begin explaining to her that she was necessary and that she had a role in the family and the community. They would work on engaging Devi in activities and communication and combat any form of stigma.

Community Mental Health Team (CMHT): As mentioned from the case, Devi had followed through her diagnosis with the local GP. Up to the time of relapse, she had been following up with her diagnosis. Therefore, after treatment, discharge, she had to continue following up to mitigate readmission. The community mental health team had to follow up with the diagnosis and treatment from the hospital to devise an appropriate psychosis management plan for Devi. The community mental health team should comprise different professionals in health and social disciplines to address both Devi’s clinical and social needs. Within such a team, a registered psychiatric nurse would handle Devi’s primary issues and collaborate with other professionals where their services are needed. Also, the psychiatric nurse would help Devi in joining and engaging in community activities si that she can learn and perfect her social skills (NICE, 2016, p.21).

Within the multidisciplinary team, a community psychiatric nurse will be appointed to coordinate treatment and deliver different psychosocial interventions to Devi. The community psychiatric nurse would have to encourage her to engage in service and self-management actively. National Institute for Health and Care Excellence guidance (NICE, 2016, p.21) recommends that people using mental health services should be allowed to be actively involved in shared decision making and supported in self-management.  

Further Discussion

Devi’s case is ideal for illustrating the need for clinical reasoning and care prioritization in nursing. Firstly, the case reveals the importance of assessment in clinical practice. The correct assessment ought to result in correct conclusions and diagnosis. Secondly, nurses must understand the prognosis of diseases such as psychosis, to enable accurate assessment, diagnosis, treatment, and patient or family education.  Thirdly, critical reasoning is at the core of clinical assessment, and it is a critical competence through which nurses identify and organize care priorities. Concerning Devi, each of the three priorities plays a significant role in mitigating health deterioration, improving health outcomes, and avoiding readmission. For instance, the initial priority aimed at combating hallucinations to restore Devi’s cognition and controllability, the second priority sought to avoid relapse and readmission, and the last priority would improve her health outcome.

Conclusion

To sum up, clinical “reasoning is a skill that a real nurse must understand and apply to deliver a safe nursing practice” (Guerrero, 2019, p.79). Before making a decision, nurses must go through clinical reasoning, which involves assessing the potential risks and benefits of any nursing actions. Besides, nurses must identify and isolate critical cases to prioritise them as illustrated throughout the essay, regarding Devi’s case. From the initial assessment of her condition, three major priorities are identified. They include addressing the auditory hallucination, educating Devi’s family, and ensuring that she follow up diagnosis with the community mental health team (CMHT).  Nurses combat the hallucinations to avoid deterioration of her condition, educate the family to foster a better home environment for Devi, and ensure that she attends and follows up diagnosis with the Community Mental Health Team.

References

Arciniegas, D., 2015. Psychosis. CONTINUUM: Lifelong Learning in Neurology, 21, pp.715-736.

Ardito, R. and Rabellino, D., 2011. Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2.

Burghaus, L., Eggers, C., Timmermann, L., Fink, G. and Diederich, N., 2011. Hallucinations in Neurodegenerative Diseases. CNS Neuroscience & Therapeutics, 18(2), pp.149-159.

Cabassa, L., Piscitelli, S., Haselden, M., Lee, R., Essock, S. and Dixon, L., 2018. Understanding Pathways to Care of Individuals Entering a Specialized Early Intervention Service for First-Episode Psychosis. Psychiatric Services, 69(6), pp.648-656.

Carvalho, E., Oliveira-Kumakura, A. and Morais, S., 2017. Clinical reasoning in nursing: teaching strategies and assessment tools. Revista Brasileira de Enfermagem, 70(3), pp.662-668.

Connor, C., Greenfield, S., Lester, H., Channa, S., Palmer, C., Barker, C., Lavis, A. and Birchwood, M., 2014. Seeking help for first-episode psychosis: a family narrative. Early Intervention in Psychiatry, 10(4), pp.334-345.

El Haj, M., Roche, J., Jardri, R., Kapogiannis, D., Gallouj, K. and Antoine, P., 2017. Clinical and neurocognitive aspects of hallucinations in Alzheimer’s disease. Neuroscience & Biobehavioral Reviews, 83, pp.713-720.

Guerrero, J., 2019. Practice Rationale Care Model: The Art and Science of Clinical Reasoning, Decision Making and Judgment in the Nursing Process. Open Journal of Nursing, 09(02), pp.79-88.

Hyde, C., 1989. The Manchester Scale. British Journal of Psychiatry, 155(S7), pp.45-45.

Kripalani, S., Theobald, C., Anctil, B. and Vasilevskis, E., 2014. Reducing Hospital Readmission Rates: Current Strategies and Future Directions. Annual Review of Medicine, 65(1), pp.471-485.

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Lerner, A., Koss, E., Patterson, M., Ownby, R., Hedera, P., Friedland, R. and Whitehouse, P., 1994. Concomitants of visual hallucinations in Alzheimer’s disease. Neurology, 44(3, Part 1), pp.523-523.

Mueser, K., Penn, D., Addington, J., Brunette, M., Gingerich, S., Glynn, S., Lynde, D., Gottlieb, J., Meyer-Kalos, P., McGurk, S., Cather, C., Saade, S., Robinson, D., Schooler, N., Rosenheck, R. and Kane, J., 2015. The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components. Psychiatric Services, 66(7), pp.680-690.

Newell, R. and Gournay, K., 2000. Mental Health Nursing: An Evidence-Based Approach. 1st ed. Edinburgh, etc.: Churchill Livingstone.

NICE, 2016. Implementing The Early Intervention In Psychosis Access And Waiting Time Standard: Guidance. [online] Nice.org.uk. Available at: <https://www.nice.org.uk/guidance/qs80/resources/implementing-the-early-intervention-in-psychosis-access-and-waiting-time-standard-guidance-2487749725> [Accessed 29 August 2020].