Mental Health Assessment 2023

Assessment Task 3: Case study – Mental Health
Introduction
Clinical reasoning cycle is the enhanced pathway to discover the actual nursing diagnosis,
nursing goals and the nursing interventions for the betterment of the patient. It also improves
the knowledge and skill of health professionals. Mr. Jim Gray is admitted in the mental health
unit with the history of failed suicide attempt who is diagnosed with major depressive
disorder. The nurse caring for Jim has to plan nursing care to ensure optimal nursing care for
him to recover and to prevent further complications. Aim of the assessment is to execute the
nursing care based on the eight stages of the clinical reasoning cycle. The assessment begins
with considering the patient situation, collection of health information, Identification of three
nursing problems, Establishment of nursing goals, discuss the nursing interventions with
rationale, evaluation of the nursing strategies, and the reflection of the person outcomes. The
assessment based on the clinical reasoning cycle helps the nurse to simplify the nursing
process and expect a better outcome.
Consider the patient situation
Mr. Jim Gray is the 28-year-old unmarried male admitted in the mental health unit with the
medical history of failed suicide attempt and he has been diagnosed with major depressive
disorder. He is from a rural community (Betz, 2016). The cause for depression is the financial
crisis due to recent drought in his village. Jim's present problems are lack of food intake, lack
of social activities, unwilling to speak to anyone, even with the health professionals, and
repeated suicidal thoughts (Cost, 2019). He needs to care for the physical bruising and broken
skin in his arms and legs. The nurse needs to consider various factors while planning nursing

care for Jim (Klemanski,2017). The nurse has to consider his literacy level, cultural safety
and respect, level of understanding, and persistent suicidal thoughts in the nursing practice
based on the clinical reasoning cycle (Betz, 2016). The patient is diagnosed with major
depressive disorder which needs close monitoring and well-planned nursing interventions for
the better outcome of the patient (Davis, 2017).
Collection of information
Collection of information helps the nurse to narrow the nursing goals and nursing
intervention. It helps to analyze the severity of the mental condition of the patient. Mr. Jim
Gray is a young farmer presented with the history of one episode of a failed suicide attempt.
He lives out of the city in a rural community, who was drastically affected by the
longstanding drought in his village. His family is in financial crisis and Jim was expected to
take over the family farm and his family since his Dad is no longer able to work (Betz, 2016).
His present situation and the loaded responsibilities significantly affect his psychological
condition which results in the depression. His signs and symptoms show that he is in severe
depression and he needs more attention and nursing care planned based on the causes of the
depression (Davis, 2017).
Processing gathered information
Processing the gathered information is the third stage of the clinical reasoning cycle, which
helps the nurse to gather the needed information to create an actual nursing diagnosis, nursing
goals, and nursing interventions. Jim is diagnosed with the severe depressive disorder;

treatment plan needs to be executed according to his physical condition and mental status
(Davis, 2017). He shows lack of interest in food and avoids the food intake, but his physical
condition is normal (Cost, 2019). His vital signs are stable and he has no signs and symptoms
of weakness due to decreased food intake. (Serin, 2018).Alarming signs and symptoms show
that he suffers from the persistent suicidal thoughts and there is chance of him attempting
suicide in the hospital environment (Betz, 2016). He is prescribed with Venlafaxine for
depression during the time of admission. The nurse has to plan the nursing care focusing the
persistent suicidal thoughts. He is from rural community, where people actively involved in
one-to-one activity and other social activities but Jim refuses the communication and social
activities which needs to be considered in nursing care (Kupferberg, 2016).
Identify the problem
Jim's present condition, his past medical and family history, and clinical manifestations help
the nurse to identify the actual psychological problem. Identification of the nursing problems
aids in the establishment of the goals, and implementation of the nursing intervention. Three
nursing problems are identified based on the present condition of the patient and his clinical
manifestations.
Nursing Problems
 Persistent suicidal thoughts
Jim is presented with the one episode of failed suicidal attempt and persistent suicidal
thoughts. This is the high priority nursing problem which may lead to self-harm. The nurse
has to find the root cause of the identified nursing problem to plan effective nursing care

(Betz, 2016). The major cause for the persistent suicidal thoughts is because Jim was
overloaded with financial responsibilities. He needs to take over the farm and also his family
since his father is unable continues the farming. The nurse needs to consider the cause of the
clinical issue and plan the nursing interventions for better outcomes.
 Unwilling to take food
Jim shows lack of interest to take food and he was prescribed with multivitamin tablets which
shows that he is eating pattern is significantly disturbed due to the disease condition of the
patient (Cost,2019). A potential cause for the altered eating patterns can be low-self esteem,
feelings of unworthiness, lack of interest in food and hopelessness. The nurse has to consider
the causative factors while planning the nursing intervention to improve his eating pattern
(Lohman, 2016).
 Lack of social interaction and activity
The nursing assessment shows that the patient avoids one-to-one communication and social
activities. Lack of social interaction and activity is the critical clinical manifestation which
hurdles the health professional in finding thoughts of the patient. Social interaction and
activity help the nurse to assess the patient’s condition and the progress. Lack of social
interaction is the alarming sign that forbid the patient from expressing his thoughts. The nurse
has to plan nursing care with the support of evidence-based literature to help the patient to
overcome severe mental disorder.
Establishment of goals