3807NRS: Clinical Reasoning Cycle Application in Mental Health Nursing

This essay presents a reflective analysis of a clinical incident, applying the eight stages of the clinical reasoning cycle to a patient experiencing a mental health disorder. The essay details the case of a 21-year-old female admitted to the emergency department following a suicide attempt, diagnosed with schizophrenia, and a history of substance abuse. It meticulously outlines the application of the clinical reasoning cycle, including considering the patient's condition, collecting cues through various assessment tools like the BPRS, PANSS, and NPRS, processing information to identify problems (psychotic symptoms, pain, tachycardia), establishing goals, implementing interventions (vagal maneuver, medications like atenolol, olanzapine, risperidone, and oxymorphone), and evaluating outcomes. The essay also includes a critical reflection on the nursing actions, highlighting strengths, weaknesses, and areas for improvement, and correlates the nursing practice with the Nursing and Midwifery Board of Australia standards of practice for registered nurses. The student nurse demonstrates a thorough understanding of the clinical reasoning cycle and its application in mental health nursing.

Running head: CLINICAL REASONING CYCLE
3807NRS Advanced Clinical Decision Making
Name of the Student
Name of the University
Author Note

1CLINICAL REASONING CYCLE
Introduction
According to Smith and Connolly (2019) the present-day healthcare environment has
been identified to be a dynamic one, and encompasses enduring types of nursing practice that
continuously evolve, in order to meet the essential opportunities and challenges of changing
time. Apart from addressing the physical ailments of people who seek care at hospitals, nursing
professionals also have the responsibility of formulating and delivering support, nursing, and
medical care to individuals who suffer from a plethora of mental health issues as well. It is
imperative for registered nurses to work collaboratively with the patients, their families, and
communities, in order to assess their immediate mental health needs, while accurately applying
the nursing process for evaluating, diagnosing, and treating such people of mental disorders
(Townsend & Morgan, 2017). Clinical reasoning cycle has been developed by Levett-Jones, in
order to provide assistance in professional practice, particularly to novice nursing students and
newly registered nurse, for enriching their problem solving and critical thinking capability,
besides fostering continuous learning (Levett-Jones et al., 2010). This essay will elaborate on the
application of the aforementioned steps in a clinical scenario that involved a patient suffering
from mental health disorder, and will also contain correlate the nursing practice with the Nursing
and Midwifery Board of Australia standards of practice for registered nurses.
Considering the patient
The first step of the clinical reasoning cycle places an emphasis on considering the
health condition of the patient who is being provided care, in order to obtain an initial overview
of the case (Levett-Jones et al., 2010). The patient X was a 21 year old female who was a student
at the University. She had been admitted to the emergency department of the healthcare

2CLINICAL REASONING CYCLE
organisation following a failed suicide attempt. At the time of admission, she was unconscious
and was accompanied by her sister. She had a history of substance abuse since the age of 16, and
demonstrated impairment in effective communication. There was a family history of
schizophrenia in her grandfather.
Collecting cues
The second step of the clinical reasoning cycle focuses on conducting a thorough and
comprehensive review of existing information about the patient decide assessing patient chart
results of test previous assessments and patient history (Levett-Jones et al., 2010). The NMBA
standards highlight the importance of conducting comprehensive health assessment in the
patient, with the use of a plethora of assessment techniques. Upon admission of the patient, she
was administered the Brief Psychiatric Rating Scale (BPRS) for evaluating her psychiatric
symptoms related to unusual behaviour, hallucinations, depression, and anxiety. High scores of 6
and 7 were found in several domains such as, self-neglect, hallucinations, disorientation,
suicidality, hostility, emotional withdrawal, uncooperativeness, and suspiciousness (van Beek et
al., 2015). Following uses of the scale, she was also subjected to the positive and negative
syndrome scale (PANSS) for obtaining an exhaustive explanation on how severe were her
symptoms, regarding the mental disorder that she was suffering from. High scores in the
positive, negative, and general psychopathology skills were respectively 21, 22, and 37
(Østergaard, Lemming, Mors, Correll & Bech, 2016).
Taking into consideration the fact that several clinicians have recorded the presence of
abnormal pain sensitivity amid patients who has been diagnosed with schizophrenia, the patient
was also ask to provide response to the verbal Numeric Pain Rating Scale (NPRS), in order to
provide an idea about the intensity of pain that she was suffering from (Horan et al., 2016). On

3CLINICAL REASONING CYCLE
evaluating the responses obtained from the patient it was found that she reported a pain score of
7, thus suggesting that the intensity of pain was higher than moderate (Castarlenas, Jensen, von
Baeyer & Miró, 2017). Any kind of deviation in vital sign helps in the immediate detection of
clinical deterioration. An assessment of her vital signs was also conducted and although she did
not demonstrate any abnormality in her blood pressure, body temperature, and respiratory rate,
she demonstrated a heart rate of 106 beats per minute, which has more than the normal value
(60-100 beats per minute) (Mok, Wang & Liaw, 2015).
Process information
In the third stage of the clinical reasoning cycle, the nurses are expected to interpret the
health data obtained from the knowledge that has been acquired, after conducting health
assessment (Levett-Jones et al., 2010). This stage is conducted with the aim of accurately
identifying the clinical condition of the patient and preventing the onset of any adverse health
outcomes. The initial concerns for the patient were relatively high scores in the PANSS scale,
BPRS scale, NPRS scale, and an elevated pulse. Research evidences elaborate on the fact that
high scores obtained from schizophrenia assessment scale highlight the presence of psychotic
symptoms and also suggest that the patient finds it difficult to concentrate, and experiences
abnormal normal perceptions and thinking that make him/her lose direct contact with reality.
Owing to the fact that she reported problems in thinking clearly, felt uneasy around other, lacked
self-care, and heard voices that wanted to harm her, the assessment scores called for the
immediate need of implementing interventions that would prevent further deterioration of her
mental health status (Leucht et al., 2019). In addition, NPRS scores also suggested that she
required immediate attention for pain management. The increased pulse was another concern
since it might result in inefficiency of the heart to effectively pump blood to the rest of the body

4CLINICAL REASONING CYCLE
and deprive the tissues and organs from oxygen, thereby resulting in major cardiovascular
complications (Kamel et al., 2016).
Identify problems and issues
The fourth stage of the clinical reasoning cycle focuses on synthesis of previously
collected information in order to develop a plan for the intended nursing interventions (Levett-
Jones et al., 2010). The three major problems that needed attention were namely, psychotic
symptoms, pain, and tachycardia.
Establish goal
In the fifth stage of clinical reasoning cycle, the treatment goals are clearly established
and arranged in order of priority (Levett-Jones et al., 2010). The immediate goal for the
treatment was to reduce the increased heart beat within six hours. This was followed by goal
establishment that were related to reducing severity of psychotic symptoms within 24 hours, and
decreasing the intensity of pain felt by the patient within 12 hours. All of the aforementioned
goals were in adherence to the “SMART” goal criteria, and comprised of the five components
namely, “Specific, Measurable, Attainable, Realistic, and Time-bound” (Bjerke & Renger,
2017).
Take action
This is the sixth stage of the clinical reasoning cycle and elaborates on the need of
implementing accurate interventions in order to accomplish the treatment goals (Levett-Jones et
al., 2010). With the aim of reducing high pulse rate, which was the primary objective of the
treatment, the patient was subjected to vagal manoeuvre, where she was assisted to follow some
steps in quick succession namely, (i) holding the nose, (ii) closing the mouth, and (iii) blowing

5CLINICAL REASONING CYCLE
the air out. This resulted in development of pressure on her chest and helped in activating the
vagus nerve, which runs from the brain till the abdomen and send vital signals to atrioventricular
node, located at the bottom of the upper right auricle, thereby controlling the heartbeat (Un,
Dogan, Uz, Isilak & Uzun, 2016). She was also administered 50 mg of atenolol orally, once in a
day for reducing the elevated pulse rate. This beta blocker acted by blocking the action of
epinephrine on the blood vessels and the heart, thereby reducing the heart rate and decreasing
any kind of strain on the heart, thus preventing cardiovascular complications (Jackson, Adin &
Lehmkuhl, 2015). In order to reduce her psychotic symptoms, she was administered 10 mg of
olanzapine, the antipsychotic drug, once in a day. This drug has been found effective in reducing
schizophrenia symptoms, besides preventing exacerbation.
According to Liang et al. (2019) the increased affinity for 5-HT2A serotonin receptors, in
comparison to the D2 dopamine receptors helped in management of the symptoms, by restoring
the balance between serotonin and dopamine that improved mood, behaviour, and thinking of the
patient. In addition, 2 mg of risperidone was also administered for reducing her suicidal
ideations, hallucinations, and emotional withdrawal, since the drug has proved its efficacy in
acting as an antagonist of the dopamine receptors, thus preventing psychotic symptom
manifestation (Sacchetti et al., 2017). 10 mg oxymorphone was also administered at an interval
of four hours, in order to reduce the pain. This drug helps in effective pain management by
binding to the μ-opioid receptor, followed by its activation (Kerr, 2016).
Evaluate outcomes
The penultimate phase of the clinical reasoning cycle encompasses assessing the efficacy
of the implemented nursing interventions (Levett-Jones et al., 2010). On conducting a
reassessment of the patient X after 12 hours, she reported a pain score of 3. Gradual

6CLINICAL REASONING CYCLE
improvement was also observed in the psychotic symptoms since she reported low scores in both
PANNS and BPRS scale after a day. Her pulse rate after six hours was 98 beats per minute,
which was within the normal levels. She was released after three days.
Reflection
In the final stage the clinical reasoning cycle requires all nurses to conduct an evaluation
of the interventions that had been proposed and identify the areas that required improvement or
could have been addressed differently (Levett-Jones et al., 2010). It has often been found that
nursing professionals who take adequate time to reflect on their clinical experiences are able to
gain a clear insight into the patients, demonstrate better understanding of nursing actions, which
in turn helps in development of their clinical skills and proficiency (Brown & Schmidt, 2016).
Therefore, the transformational process of reflection helps in increasing awareness amid the
nursing professionals about strategies that can be adopted to improve practical clinical
performance. Upon conducting a reflection on the actions that had been adopted during the
clinical scenario, I could recognise several strengths and weaknesses.
During the clinical scenario, I demonstrated the sound understanding of the fact that
conducting a comprehensive health assessment of the patient is an essential step in the
development of a treatment plant, with the aim of delivering excellent quality patient care.
Taking into consideration the fact that the patient was not only subjected to vital signs
assessment, but was also assessed for pain and the prevailing psychotic symptoms, it helped in
understanding the patients concerns and her overall health status. It has often been found that
utilisation of comprehensive psychometric measures is generally one of the most underutilized
components of mental health nursing (Shooshtari et al., 2017). Hence, I was able to realise that

7CLINICAL REASONING CYCLE
assessing the patients based on different psychometric skills offered enormous power and also
helped in easy identification of the issues that required immediate treatment.
However, I should have initiated conversation with the patient, in order to gain an insight
into events related to her childhood for identifying underline circumstances that might have
triggered the onset of schizophrenia and substance abuse. This can be accredited to the fact that
children who have been subjected to severe childhood trauma are more likely to develop signs of
schizophrenia at a later stage in their life (Schmitt et al., 2019). Furthermore, there was also the
need to administer drug abuse screening tools for gaining a sound understanding of the severity
of substance abuse that was prevalent in the patient. Hence, in future practice, on encountering
similar scenario, I would like to address the event in a different way.
Standards of practice
The NMBA Competency Standards for Registered Nurses (2016) have been formulated
in the form of an outline for guiding high quality and safe nursing care. The nursing
interventions had been implemented in accordance to standard 1 where nurses are expected to
critically think and analyse their practice. This can be accredited to the fact that the interventions
were based on contemporary evidences, and were the most effective interventions for addressing
individual health concerns. Adherence to standard 4 that focuses on comprehensive conduction
of assessment was also demonstrated as relevant health assessment had been conducted to collect
accurate health data (NMBA, 2016). The standard 5 focuses on developing plan for nursing
practice. This was also followed since the data obtained from the assessment scales were utilised
for formulating the care plan. Eventually, the standard 6 that highlights the need of providing
appropriate, safe and responsive care was also followed since the patient was treated within the

8CLINICAL REASONING CYCLE
scope of practice and all interventions were safe and of high quality, thus helped in
accomplishment of the agreed treatment objectives (NMBA, 2016).
Conclusion
Thus, to conclude the clinical reasoning demonstrated the fact that it is essential for a
nurse to demonstrate adequate problem solving and critical thinking skills, with the aim of
bringing about positive health outcome, while caring for patients who report poor health status.
The critical reasoning cycle comprised of eight stages that are namely considering the patient,
collecting necessary cues, processing the required information, understanding the health issue,
establishing treatment goals, implementing correct intervention, evaluating health outcomes, and
eventually deliberately reflecting on the entire procedure to enhance learning. Hence, the Levett-
Jones clinical reasoning cycle used in the essay demonstrated that while encountering the
scenario that involved the patient with schizophrenia, the competency standards were accurately
followed that guided the professional practice.

9CLINICAL REASONING CYCLE
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