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
- Multivitamin once daily
- Vitamin B once daily daily
XXXXXXX END OF THE CASE STUDY
For case study: The eight steps and what you need to consider in each is as follows:
1) Consider the person:
- Recognising changes in their condition and their present situation.
2) Collect, process & present related health information:
- Collect cues and information – Here you review the patients current medical/surgical history and gather, and making note of specific information about the present situation. In your case study recall relevant data (start to relate this to the pathophysiology, aetiology etc).
3) Process information:
- This is where you pull all your data and cues together to interpret what is relevant and what is not; to analyse and consider if there is any other information you need about the patients present situation. When doing this, try and discriminate between the present health situation that needs immediate intervention (priority), and changes in health that should be considered later in the plan of care. For your case study, research, linking back to the pathophysiology / aetiology, so that you understand what is happening. This will further help you to identify what the problem/issue actually is.
- Once you have processed the information you move to the next stage of the clinical reasoning cycle, to predict an outcome:
4) Identify the problem:
- Involves making a clinical decision about an actual or potential health problem that will determine the course of action that needs to be taken.
- This is where you will examine the facts, link the information and establish a definitive problem/issue. For your case study remember you will need to prioritise 3 problems/issues – and justify these with strong links to evidence.
5) Establishing the goals/s:
- Make a plan, this will be specific to each individual patient and focuses on achievable outcomes. For your case study you will need to prioritise care related to the identified problem / issue; a desired outcome, a time frame. (You may wish to use the SMART acronym to assist you to develop the goals here).
6) Take action:
- This is where you follow through with the decided goals and plan. For the case scenario this is where you will discuss the nursing care that would be implemented for your patient, linking this to the assessment data and history.
7) Evaluate outcomes:
- This is where you review the patient’s condition to see whether they have improved, and the goals of their plan of care have been met. For the case study remember that you will be evaluating the nursing care strategies to justify the nursing care provided.
8) Reflection:
- Consider the interventions implemented, and establish what you have learnt, what went well and what could be improved. For the case study assessment – Reflect on the patient’s outcomes.
As previously noted this framework is also good to employ while on placement, to help you with your clinical reasoning and clinical decision making.
I do hope that you are able to have some down time during the Easter break.