Clinical Reasoning Cycle – Health Promotion

Clinical Reasoning Cycle – Health Promotion Template (Workshop 1).
(Modified from Levett-Jones, 2013)
1. HEALTH PROMOTION PLAN
Stage
Response.
Determinants of Health
Initial.
Ruby Pascal is a 43 years old female admitted to the medical ward with the
complication of a severe anxiety attack. Other symptoms include nausea,
chest pain, and vomiting. Her height is 160 cms and a weight of 90 kg. Her
BMI is more than 35, which is abnormal. She has a past medical history of
general anxiety disorder. Along with this her another medical history states
that she has Type II diabetes that she manages by having Metformin SR, 2000mg.
However, she took professional treatment to cure her general anxiety disorder.
The treatment included non-pharmacological and pharmacological support.
Anxiety disorder induced by a medical condition involves signs of extreme anxiety
or distress triggered directly by a physical health problem. In her case, the anxiety
disorder intensified when her husband was diagnosed with bowel cancer for that she
has to move to Brisbane. In addition to this, in Brisbane, she developed unhealthy food
habits and did not prefer working out. She used to take valium 10mgs to reduce her

stress, and she feels that diabetes tablets are making her anxiety condition worse.
Interview, documentation,
observation.
Ruby Pascal's medical history stated that she has Type II diabetes. And she
had a history of general anxiety disorder. At present, her anxiety symptoms
are increasing along with physical symptoms. She is admitted to the emergency
department with nausea, chest pain, and vomiting. For general anxiety disorder
in the past, she had undergone professional treatment which included
non-pharmacological support from a visiting psychologist along with short-term
psychological treatment by her GP. For the treatment of diabetes, she takes
Metformin SR, 200 mg. In addition to this, she takes valium 10mgs, which dulls her
thinking and puts her to sleep. Valium is a medication that manages anxiety disorder
and gives short term relief to the physical symptoms. She is dependent on the
psychologists to reduce her stress level.

ASSESSMENT
Identify health concerns.
Identify patterns or
connections.
Ruby Pascal has developed anxiety disorder along with chest pain, vomiting, and nausea. Pascal has been
diagnosed with Type II diabetes for which she takes Metformin, an anti-diabetic drug. Chest pain, vomiting,
and nausea can be potential side effects of these drugs. Research has also found that diabetes sufferers are
more likely to be nervous. Several studies have specifically related insulin resistance to hormonal
imbalances in the brain and, as a consequence, the development of habits and symptoms similar to
depression and anxiety. Her intensified condition may lead to having intense, excessive, and persistent fear
about every day. This might comprise a sudden feeling of intense anxiety that reaches to peak within
minutes, which is regarded as panic attacks.
In this condition, it's necessary to improve her health condition by managing her diabetes and enhancing her
mental condition so that she can take care of her family.

Stage Response
Identify and prioritize
problems. Number them.
Type II diabetes is identified as a potential cause of anxiety disorder. Metformin, the anti-diabetic drug, can be the
reason for her chest pain, nausea, and vomiting.
Life conditions such as stressful events in people that are already susceptible to anxiety tend to cause anxiety
disorders. Hereditary characteristics may also be a factor. The complications that can arise due to anxiety disorders
are depression, substance misuse., social isolation, insomnia, digestive, headaches, bowel problems, chronic pain,
leading poor quality of life, and suicidal tendency. Three main consequences can be 1) Social Anxiety disorder 2)
Panic disorders 3) Post-traumatic stress disorder

Plan
Select the top 3 problems
and write goals for each
problem.
Social Anxiety disorder
This condition involves a paralyzing
fear of social environments and
criticism or embarrassment by others.
An extreme social phobia will leave one
feeling lonely and ashamed. Cognitive-
behavioral therapy (CBT) or medicine
is the only way to overcome social
anxiety — and sometimes both. Other
nursing interventions can be
establishing a trustworthy relationship
with the client and reassuring them
about their safety, along with it
encouraging them to participate in a
relaxation exercise.
Panic disorder
This triggers panic attacks, extreme
fear, terror, or imminent doom.
Physical signs include palpitations of
the back, chest pain, and shortness of
breath. Participating in therapy can
help a person with panic disorder
deal with symptoms, resolve
negative feelings, and develop
healthy behaviors. Along with this,
Panic disorder is treated by
cognitive-behavioral therapy (CBT).
The other intervention can be
considered as pharmacological
therapy.
. Treatment goals include:
 Reducing the frequency and
Poor management of Diabetes.
The primary goals of diabetes care are to
minimize immediate decompensation, to
eliminate or postpone the occurrence of
symptoms of late illness, to limit
mortality, and to preserve a good quality
of life. Given that psychosocial effect is a
precise predictor of mortality and
morbidity in patients with diabetes, the
incorporation of psychosocial factors at
all stages of diabetes care is critical for
better adherence to treatment to achieve
effective glycemic control. Psychosocial
interventions such as motivational
therapy, cognitive behavioral therapy
have shown proven results. Other than
this, another intervention is educating the

severity of panic attacks
Lowering anticipatory
anxiety and agoraphobic
avoidance
 Treatment of co-occurring
psychiatric conditions
 Achieving complete
symptomatic recovery
 Return to a premorbid
functional level
patient on diabetes and the administration
of medication.

Show the
actions/interventions to be
taken for the top 3
problems. Number them
clearly so that they
correspond.
Social-anxiety disorder care typically
requires the following interventions:
Evaluation: Learning to evaluate and
determine what particular
circumstances cause anxiety
Cognitive restructuring: learning to
recognize thoughts that are responsible
for excessive anxiety, and taking a
logical approach to investigating their
reality, subjecting them to rigorous
logic tests.
Training in mindfulness: learning to
attend to the moment instead of being
wrapped up in one's pessimistic
expectations of the future.
Systematic exposure: learning to
alleviate anxiety using mindfulness and
thinking skills by putting in anxiety-
In panic disorder, pharmacological
therapy is a necessary treatment;
antidepressants and anxiolytics can
provide treatment regimens)
Interventions for psychotherapy:
Specific counseling to learn about
panic and anxiety symptoms, stress
control strategies, and relaxation
skills like deep breathing exercises,
gradual muscle relaxation, and
visualization.
Practicing relaxation strategies and
monitoring mood, anxiety, causes,
and symptoms may consist of
homework assignments between
sessions.
Motivational enhancement therapy
(MET) reflects on growing intrinsic
motivation by raising awareness of an
issue, changing some self-defeating
thoughts about the issue, and growing
confidence in one's capacity to improve.
It has five motivational principles:
Express empathy, Develop discrepancy,
avoid argumentation, roll with
resistance, and support efficacy. In the
interview, the psychiatrist would usually
allow the client to discuss and examine
any questions they may have about a
common problem they are facing or any
assumptions someone may have had of
the person's actions in therapy. The
psychiatrist can frequently question a

Stage Mrs. Ruby Pascal.
Show the criteria (changes
in cues) you will use to
measure to show if each
goal was achieved.
CBT therapists track progress every
week by evaluating the symptoms of
the clients. Measurement of common
goal behaviors. Evaluating progress
against defined targets
The efficacy of a particular clinical
strategy can be measured in three
ways: testimonials from customers,
impressions from practitioners, and
empirical studies.
On analyzing the score of
empathy, motivational spirit,
asking open-ended questions to
help in tracking the progress.

E
In this case, as a registered nurse, I have noticed that negative stress can lead to anxiety disorder. Her history of
general anxiety disorder made her dependent on the psychologist. Her medicine to control Type II diabetes is
considered to be the potential reason for her chest pain, vomiting, and nausea. If all these symptoms persist, it can
lead to other traumatic symptoms. For this, the most recommended therapy to overcome this situation is cognitive-
behavioral therapy.
From the above case study, I realized that rapid treatment is necessary to avoid the complications of anxiety
disorder and enhance the rate of life expectancy of Ruby Pascal so that she could take care of her husband and her
children efficiently.
2. ESSAY
Health promotion is the method of growing people's influence and strengthening their health. Health promotion is the practice of allowing
individuals to enhance influence and improve their well-being over their well-being and determinants. Since the concept of health promotion was
widely accepted, a variety of specific strategies have been created to promote health (Hou, 2014). The health promotion strategies are highly
recommendable to treat the anxiety disorder of Ruby Pascal. Ruby Pascal has a medical history on general anxiety disorder (GAD) to overcome this
she was assisted by a psychologist who ensured her about her well-being. She is on anti-diabetic medication as she has Type II Diabetes. Five
approaches to health promotion have been detected, namely, medical approach, behavioral change, educational change, patient-centered approach, and
societal change (Fertman & Allensworth, 2016). Ruby Pascal's case study can consider these approaches as she was admitted to the emergency
department with severe anxiety disorder along with symptoms of nausea, chest pain, and vomiting. Mental health promotion is a constructive, proactive

strategy, including any activity or policy that improves the potential of the entire population for good mental health through intervention at the adult,
society, and systemic levels. On incorporating mental health promotion, Ruby Pascal might get benefitted from the intervention of health promotion
strategies. The prime benefits of mental health promotion comprise of improvements of personal and behavioral well-being, higher productivity
domestically, improved family relationships, and lower rates of drug abuse and other social indicators, including decreased crime and aggression.
Ruby Pascal intensified her anxiety disorder after her husband was diagnosed with bowel cancer and is under treatment. After dislocating from
her place to Brisbane for her husband's treatment, she experienced anxiety disorder, along with chest pain, nausea, and vomiting. After several visits,
she was admitted to the emergency department for better health outcomes. Her health history was documented, which suggests a history of a general
anxiety disorder (GAD). She was assisted by her psychologists, and she found it helpful to reduce the stress. Type II diabetes has also been noted for
which she took an anti-diabetic medication named Metformin to manage her glucose level. She also noted that she took Valium 10mgs that used to dull
her brain and put her to sleep. Less activity and unhealthy food habits deteriorated her condition more. This past mental health illness, along with
diabetes, worsened the present situation, which can lead to more adverse conditions. Three problems, like social anxiety disorder, panic disorder, and
diabetes, have been detected, which will create here anxiety disorder more intense. Two interventions for each of the problem has been recommended.
Two interventions for social anxiety disorder that has been detected are cognitive-behavioral theory and establishing a trustworthy relationship with the
client. The interventions for panic disorder has been identified as psychotherapy and pharmacological therapy. Cognitive-behavioral therapy is also
applicable, but other than this motivational therapy and educating diabetic patients on diabetes and administration of medication has been recognized
as two interventions of poor management of diabetes.
Cognitive-behavioral therapy is based on a psychopathology clinical paradigm. The cognitive model explains how circumstances impact

people's impressions of or random thoughts about their mental, behavioral (and sometimes physiological) reactions. Perceptions in people when
depressed are often skewed and unreliable. They learn to recognize and analyze their "inner impulses" (spontaneously arising auditory or abstract
cognitions), and to modify their perception in such a way that it becomes closer to reality. When clients do so, their agitation generally decreases, they
may respond more mentally, and (especially in cases of anxiety), their physiological anticipation abates.
A vast amount of literature has accrued on the efficacy and prevalence of cognitive-behavioral therapy (CBT) for anxiety disorders, comprising post-
traumatic stress disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder, generalized anxiety disorder, and severe phobia. The
aim of the article Kaczkurkin & Foa, (2015) is to provide an overview on the treatment of anxiety disorders by the use of two of the most widely used
CBT approaches (exposure and cognitive therapy), and to summarize and analyze the latest scientific studies on the effectiveness of these strategies for
each anxiety disorder. Besides, the study addressed the problems that occur when evaluating successful CBT therapies and suggested directions for
further study. It has been shown that cognitive-behavioral therapy (CBT) is beneficial for a wide variety of mental health conditions, including anxiety
disorders.
The efficacy and efficacy of cognitive strategies alone have demonstrated inconsistent outcomes for anxiety disorders:
Panic disorder
Interceptive exposure to panic disorder is also paired with cognitive skills such as understanding that physical stimuli are not always often dangerous
and understanding to reassess the nature of physical symptoms rather than disastrous (Barrera et al., 2014). A meta-analysis of panic disorder did not
find any distinction in efficacy whether or not cognitive therapy approaches were combined with exposure-based care. However, the author found
better results in patients with cognitive components (Kaczkurkin & Foa, 2015). Moreover, pharmacological therapy is a successful cure for panic

disorders; antidepressants and anxiolytics may be used as treatment regimens. The neuropsychiatric disorder causes panic attacks that usually respond
to SSRI antidepressants along with this relaxing exercise, meditating, deep breathing enhances the condition (Cuijpers et al., 2014).
Social anxiety patients
Throughout Hofmann's model of social anxiety, patients discover that social anxiety is partly preserved by maintaining negative self-, overestimating
the expense of a common illness, perceiving that one does not influence one's emotional reactions and belle ving that one's social skills are insufficient.
On the efficacy point, a meta-analysis found that individual CBTs were effective in managing social anxiety relative to waitlist controls. Additionally,
another meta-analysis of social anxiety disorder therapies comprising exposure, cognitive restructuring, and exposure plus cognitive restructuring
found no difference in outcomes between these therapies suggesting comparable effectiveness for cognitive therapy only (Kaczkurkin & Foa, 2015). In
addition to it, maintaining a kind and trustworthy nurse-patients is highly necessary to understand the needs of the patient with an anxiety disorder.
Therapeutic skills must be aimed at helping the client feel at ease since the nurse who is an unknown may pose a danger to the highly anxious client. In
the presence of a relaxed staff member, the client creates a feeling of comfort, which will help to relieve anxiety (Rørtveit et al., 2015).
Motivational interviewing focuses on offering tools to help diabetic patients decide for themselves what may or may not be significant, and how
progress may be accomplished. MI is a collective, goal-oriented communication form, with particular emphasis on the language of transformation. It
helps to strengthen personal motivation and dedication to a frequent target by recognizing and discussing the individual's motivations for improvement
in an environment of tolerance and compassion. The four processes of MI include planning, evoking, focusing, and engaging ( Ekong & Kavookjian,
2016). In addition to this, educating patients with healthier eating habits by dietary awareness, including food preparation, weight reduction techniques,
and other diet-specific therapies for diseases are another critical intervention (Ley et al., 2014). Establishing techniques and skills for problem-solving

to self-manage diabetes and tracking blood glucose and learning how to view the tests are highly recommended interventions.
From the above study, it can be concluded that Mrs. Ruby Pascal's condition is worsening day by day, which can lead to social anxiety disorder,
panic disorder, and diabetes. Two interventions for each of the problem has been mentioned. Cognitive- Behavioural therapy is identified as the most
important therapy that can treat all the above problems. For enhanced patient outcomes, establishing a trustworthy relationship with Mrs. Pascal will
improve her condition as she was new to that location and is not getting treated by her previous psychologist. A good nurse-patient relationship will
help her to open up and discuss her problems. Besides this, pharmacological therapy is highly recommended for better results along with CBT.
Motivational interviewing is another intervention to treat her diabetic condition along with that physical activity, and healthy eating habits are highly
recommended so that she could overcome the situation.

References
Barrera, T. L., Grubbs, K. M., Kunik, M. E., & Teng, E. J. (2014). A review of cognitive behavioral therapy for panic disorder in patients with chronic
obstructive pulmonary disease: the rationale for interoceptive exposure. Journal of clinical psychology in medical settings, 21(2), 144-154.
Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds III, C. F. (2014). Adding psychotherapy to antidepressant
medication in depression and anxiety disorders: a meta-analysis. Focus, 12(3), 347-358.
Ekong, G., & Kavookjian, J. (2016). Motivational interviewing and outcomes in adults with type 2 diabetes: a systematic review. Patient education
and counseling, 99(6), 944-952.
Fertman, C. I., & Allensworth, D. D. (2016). Health promotion programs: from theory to practice. John Wiley & Sons.
Hou, S. I. (2014). Health education: theoretical concepts, effective strategies and core competencies. Health promotion practice, 15(5), 619-621.
Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical
neuroscience, 17(3), 337.
Ley, S. H., Hamdy, O., Mohan, V., & Hu, F. B. (2014). Prevention and management of type 2 diabetes: dietary components and nutritional
strategies. The Lancet, 383(9933), 1999-2007.
Rørtveit, K., Hansen, B. S., Leiknes, I., Joa, I., Testad, I., & Severinsson, E. (2015). Patients' experiences of trust in the patient-nurse relationship-a
systematic review of qualitative studies.