NRSG139: Case Study Analysis of Patient Interview and Care

This case study analyzes a patient interview conducted by a nursing student, utilizing the Levett-Jones clinical reasoning cycle to assess a patient's mental and physical health concerns. The interview took place in an outpatient mental health assessment ward, using a semi-structured approach to gather information about the patient's anxiety, physical symptoms (chest congestion, breathlessness, swelling), and medical history, including a previous cardiac arrest. The student collected vital signs and conducted a physical assessment, revealing severe depression and congestive heart failure. Based on the assessment, the student prioritized interventions, including consultation with a cardiologist and psychotherapist, and provided health literacy sessions. The case study highlights the student's ability to assess patient needs holistically, addressing both physical and mental health challenges, and emphasizes the importance of a multidisciplinary approach to patient care, particularly for individuals facing social isolation and cardiac health issues. This case study showcases the application of theoretical knowledge to a real-world clinical scenario and the formulation of appropriate nursing interventions.

Running head: CASE STUDY ANALYSIS
NURSING ASSIGNMENT- CASE STUDY ANALYISIS
Name of the study
Name of the university
Author note

1CASE STUDY ANALYSIS
Introduction
Reporting and patient healthcare concern documentation are the most crucial
healthcare process, which is conducted by the healthcare professionals while caring for
patients who are suffering from mental or physical trauma. This paper would discuss one
such patient interview session, in which Levett- Jones clinical Reasoning Cycle was used to
understand the patient concern and process those information to provide effective
intervention to the patient (Levett-Jones & Bourgeois, 2015, pp. 123).
Consider the patient situation (CR1)
For this clinical interview process, I was assigned with the responsibility to assess the
patient her mental and physical health concerns so that depending on the assessment.
Effective interventions could be provided to her. In the outpatient wards, mental health
assessment ward, I decided to conduct the interview as this place was safe, secure and
inaudible to others which would enable the patient to freely convey her mental and physical
health concern. Besides this, while choosing the method of patient communication, I chose a
semi- structured interview process. As per Cridland, Jones, Caputi and Magee (2015, pp. 81-
82), the primary aim of patient communication is to understand the mental, physical,
behavioural and emotional aspect of patient and then depending on them make a connection
between the events described by the patient. Affecting her mental peace and strength. Hence,
I chose the semi- structured interview process, because I wanted to know about the patient’s
mental strength, cognitive abilities and constructive thought process, which would help her to
overcome her physical health conditions upon application of interventions (Kallio, Pietilä,
Johnson & Kangasniemi, 2016, pp. 2960).

2CASE STUDY ANALYSIS
Collect cues and information (CR 2)
Upon entering the room I greeted the patient and asked her to sit across the table
comfortably. I offered her water but she refused. The patient was constantly fidgeting on her
chair and was unable to make eye contact with me. I introduced myself as a clinical
professionals with whom she can discuss all her mental and physical concerns. She had a
nervous and closed body posture, with shrieked shoulders and unmindful behaviour. I asked
her about her concern, and she replied, “I feel very anxious about my life I don’t know how
to overcome it”. This indicated towards her mental condition and hence, I asked her to
provide me the detail, upon which she said, “I am suffering from congestion in my chest, I
am unable to walk, feel breathlessness and feeling that my hands and legs are swollen”.
Hence, I asked about her previous health conditions so that I could related her current
situation, to her medical history. Upon this, the patient informed that 3 years ago she was
admitted to the hospital due to cardiac arrest and was discharged after 1 month. She
mentioned that she lives alone as her three children have abandoned her because of her
illness.
Process information (CR 3)
After the interview process, I asked the patient politely for the consent of her vital
signs, so that I could help her for her present physical complications. I made her believe that I
would provide her with a multidisciplinary team of carers, who would help her to overcome
her physical and mental ailments (Bartunek et al., 2016, pp. 167).
Her vital signs are as follows:
Blood pressure 176/93, respiratory rate was 25 breathes per minute, Heart Rate 67
beats per minute and SpO2 level was 93%. The patient had 76 kg weight and was 176 cm tall.
Further, the physical assessment indicated that she is suffering from swollen ankles and toes,

3CASE STUDY ANALYSIS
which indicated toward accumulating of fluids. Further, I applied the MSME evaluation so
that her stress and depression level could be assessed.
After conduction of all these assessment I found that she is suffering from severe
depression syndrome and suffering from severe congestive heart failure due to which, her
heart rate, blood pressure, elevated and she suffered with shortness of breath (Bartunek et al.,
2016, 168). Further, fluid accumulation in her ankles and toes indicated that her congestive
heart failure increased her risk factor of suffering from severe cardiac disorder.
Therefore, depending upon her vital signs, MSME evaluation, and physical
assessment, I decided two priorities of care for the patient. The first priority would be
providing her with interventions so that her congestive heart failure could be treated and for
that I asked her to consult the cardiologist of the healthcare facility (Ackley et al., 2019, pp.
32-33). I asked the patient to consult our psychotherapist and took an appointment for a
counselling session so that her isolation and discrimination related mental trauma could be
addressed (Vasiliadis, Milan, Guerra & Fleury, 2018, pp. 45). Further, I also provided her
with a health literacy session with a counsellor so that she could understand the health
complication, she is suffering from and could take preventive measures at home to reduce the
severity of it (Batayeh, Artzberger & Williams, 2018, pp. 20).
Conclusion
While concluding the interview session, I would mention that this experience of
patient interview was an effective aspect of my clinical practice as I was able to assess the
patient’s mental and physical ailments. The patient was abandoned by her children and hence,
was socially isolated and depressed. Further, her myocardial infarction related history and
congestive heart failure related symptom indicated towards her crucial cardiac health.

4CASE STUDY ANALYSIS
Therefore, I utilized a holistic approach for the care process of the patient to help her
overcome her physical and mental illness.

5CASE STUDY ANALYSIS
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6CASE STUDY ANALYSIS
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7CASE STUDY ANALYSIS
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