Assessment 3: Nursing Report on Patient Care and Clinical Reasoning

This nursing report examines the case of a 37-year-old male patient, Job, diagnosed with schizophrenia, type 2 diabetes, and clozapine-induced myocarditis. The report details the patient's history, including drug and alcohol abuse, and the progression of his conditions. The primary focus is on the nursing issues and therapeutic interventions implemented to manage his complex health problems. Key aspects include the management of clozapine-induced myocarditis, involving interventions to reduce chest pain, rapid heart rate, and shortness of breath. The report also addresses nursing goals for schizophrenia, such as managing thought disturbances, defensive coping mechanisms, and impaired family relationships. Additionally, it covers the nursing interventions for type 2 diabetes, emphasizing lifestyle changes. The report concludes with an analysis of a clinical reasoning error related to the use of clozapine and reflects on the care process, demonstrating advanced nursing knowledge and adherence to the clinical reasoning cycle. The report is designed to provide insights into patient care, clinical decision-making, and the application of nursing principles in managing complex patient conditions. This report is designed to provide insights into patient care, clinical decision-making, and the application of nursing principles in managing complex patient conditions.

Running head: ASSESSMENT 3
ASSESSMENT 3
Name of the Student:
Name of the university:
Author Note:

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Introduction
A 37 year old male patient, named Job, was brought to the hospital because he was experiencing
pain in his chest, arrhythmias, shortness of breath both during the resting period and also when
engaged in physical activity. 17 years ago, after experiencing an episode of psychotic symptoms,
the patient was diagnosed with schizophrenia, since he was experiencing delusions and
hallucinations for over six months. Additionally Job also got diagnosed with type 2 diabetes. The
diagnostic tests like glycated haemoglobin (A1C) test was performed for the detection of type 2
diabetes in the patient. Along with this, the C-peptide level and the circulating insulin level in the
blood of the patient was also subjected to measurement to be sure that the patient did not have
LADA. The medication he was being prescribed for his diabetic condition was metformin. Job
had a habit of consuming unlimited alcohol and also abusing drugs like opiates and cannabis.
After his diagnosis with diabetes, he stopped using the drugs but continued to smoke about 10-15
cigarettes per day along with occasional drinking in the social occasions. Job is registered with
the disability support pension scheme presently. The community mental health services keep
track of Job’s healthcare progress and status.
After getting admitted to the hospital, it was found that one of the current medication of Job, was
clozapine for his schizophrenic condition, which he was regularly taking for 22 days. The
clozapine was only prescribed to him after there was no visible improvement in his condition
after the administration of risperidone, quetiapine XR and olanzapine, which are some other
drugs that are used in the treatment of schizophrenia. He was prescribed with 12.5 mg of the
medication, which was supposed to reach about 300 mg in the oncoming weeks, after it is
ensured that he is not experiencing any side effects of the medication. A team from the
community mental services, monitored the health condition of Job very closely for the symptoms

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of myocarditis, like tachycardia, chest pain and flu-like symptoms. After his admission into
hospital for 5 days, he was found to be experiencing transient mild tachycardia with about 200
beats per minute and constipation. On the sixth day, he was found to be suffering from the pain
in his chest, severe tachycardia with 350 heartbeat per minute along with experiencing dizziness.
He got admitted to the emergency department of the hospital, where it was found that the
troponin level in the patient was high and there is an elevation in the ST segment in the ECG
report of the patient, suggesting the possibility of clozapine induced myocardia.
Nursing Issues in the Patient and Therapeutic Interventions
From the above introduction, it can be decided that the patient have mainly three health
conditions, which are Schizophrenia, Type-2 diabetes and the Clozapine induced myocardia.
Among all three conditions, the last condition, that is, the Clozapine induced myocardia presents
the highest challenge to the health condition of the patient, since the symptoms associated with
this health problem are most severe and put the patient’s life in an immediate risk.
Clozapine Induced Myocardia:
The patient was experiencing chest pain, shortness of breath and tachycardia, which are
the symptoms of myocarditis (Engler et al., 2015). Even though the risk of myocarditis is high
enough in the alcoholic patients, in this case another higher risk causative agent was found in this
case study. Clozapine is a drug that is used in the treatment of schizophrenia. Though it has been
found in many studies that this drug clozapine can often be associated with myocarditis and it is
considered to be a risk factor for inducing myocardia in the schizophrenic patients (Hatton, Bhat
& Gandhi, 2015). Since in this case study, Job was a schizophrenic patient, who was prescribed
with clozapine drug and the symptoms of myocarditis were only observed after he started to take
that medication, it could be concluded that Job has encountered Clozapine induced myocardia.

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The nursing goal for this condition in the patient was to reduce the severity of the
symptoms in patient. The symptoms include chest pain, rapid beating of the heart and shortness
of breath. All those symptoms was brought under control within few hours and thus providing
relief to the patient. The measurement of improvement was done by enquiring the patient on the
level of pain he is experiencing and by observing the patient for discomfort.
In order to lower the chest pain in the patient, various medications antianginal was used,
since they are known to lower the myocardial workload by providing sedation (Padala et al.,
2017). To lower the rapid heart rate in the patient, beta-blocker drugs was used (Otto, 2016). To
help the patient with his shortness of breath, oxygen was administered. Along with this the
patient was also sedated and was prevented from excitement.
The outcomes of the action was evaluated by checking the heart rate of the patient, which
was supposed to be lowered to normal, which is about 100 per minute. After that the patient was
observed for any discomfort he might be experiencing. The check for the shortness of breath in
patients, the pulse rate was subjected to measurement along with observing the patient for any
show of discomfort.
Schizophrenia:
A patient is said to have schizophrenia, if they seems to be having any two of the
following five symptoms, which are, abnormality in speech, delusions, hallucinations, catatonic
behavior and negative speech (Hallak et al., 2013). In this case, the patient was experiencing
anxiety, hallucination and delusions for about six months. When consulted with a physician, Job
was diagnosed with schizophrenia. The assessment was done as per the consideration of his
symptoms along with using various assessment tools such as, PANSS, SANS, SAPS, CGL-SCH
and NSA-16 (Kumari et al., 2017). Schizophrenia is a complicated mental disease, which affects

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an individual’s ability to carry out day to day activity by themselves. The reason behind this is
that the people with schizophrenia loses the sense of reality and often find themselves lost. The
causal factors behind schizophrenia is not understood properly yet. It can be a few environmental
factor or even some genetic factors (Frith, 2014). In this case study, it seems Job’s habit of
excessive alcohol consumption, drug abuse and smoking can be a causal factor for him to
develop schizophrenia.
The nursing goals for helping a patient with schizophrenia involve various aspects. The
main goal is to help the schizophrenic patients to develop a stable mental state to carry out their
day to day activity on a regular basis and to relieve the family of the patient from the additional
stress, which results from inexperienced handling of a mentally challenged patient. The time
period to achieve this goal was set as six months, though the progress of the patient was
subjected to assessment in every week.
There are about three aspects of schizophrenia is present in the case of Job, that requires
nursing actions. The first one is the disturbance in the thought process. In order to help the
patient with this condition, the nursing staff closely observed the patient during his delusional
stage. The rationale behind this course of action was to understand the possible feelings of the
patient that is causing the anxiety and fear in the patient. Upon acquiring the information, the
nurse performed proper mental counseling of the patient, which helped him to calm down more
easily during one of those hallucinating or delusional phases. The nurse maintained a proper
communication with the patient showing him empathy in order to encourage him to improve his
life style by stopping alcohol consumption and smoking (Bernard et al., 2013). The second
aspect, where the nursing action was required was the defensive coping. In this case the nurse
explained to patient briefly about the actions she was going to perform, while the patient is

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around and promoted a least surprising environment for the patient. The rationale behind this
action was, in order to reduce the defensive behavior of the patient, which resulted from severe
anxiety and fear, creation of a fear-free atmosphere was necessary (Escalada-Hernández et al.,
2015). The third aspect was impaired family relationship. In order to help with this aspect, the
nurse made an assessment on how much knowledge the family of the patient has on the disease
and helped them understanding it better. She also taught them the proper care methodology for
the patient, so they would understand everything and their anxiety would be lower, while
interacting with the patient (Onwumere, Grice & Kuipers, 2016).
The expected outcome of these interventions was evaluated by tracking the span of time
the patient spend staying in the delusional or hallucinated state. Then the readiness of calming
down during an episode of anxiety can be also be subjected to recordings, while making an
assessment on the evaluation of outcome. The improved family relationship of the patient was
assessed by interviewing the both parties about their stress level.
Type 2 Diabetes:
Type 2 diabetes or diabetes mellitus is a disease condition, where the ability of the body
to produce sufficient insulin is hampered and as a result the blood has a high level of glucose
(Ozougwu et al., 2013). In this case study, the patient was diagnosed with type 2 diabetes 17
years ago. The symptoms of type 2 diabetes involve blurry vision, increased thirst but unusually
frequent urge for urination. The type 2 diabetes has many common symptoms with LADA
(Latent Autoimmune Diabetes of Adulthood) (Hernandez et al., 2015). Since LADA is an
autoimmune disease, in case of this condition, there is a high level of C-reactive proteins in the
blood in case of its occurrence (Kumar & de Leiva, 2017). The confirmation test that was
performed to detect type 2 diabetes was the glycated hemoglobin test (A1C test) and the blood

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test checking for the level of C- reactive protein in the blood sample of the patient (Li et al.,
2015).
The type 2 diabetes is considered to be a life style disease (Asif, 2014). Thus the nursing
goal for this condition of the patient was to make him habituated with a healthier life style. The
time period set for convincing the patient along with helping him to adapt the new lifestyle was 6
months.
The first nursing intervention for the achievement of this goal was to make the patient
understand the requirement of changing his current life style by continuous counseling. The
second intervention was to set a proper diet plan for the patient in order to keep the blood sugar
of the patient in control. The third nursing intervention was setting up a proper exercise plan for
the patient to follow, in order to keep his body weight under control.
The evaluation of the outcome of these interventions was done by measuring the blood
glucose level of the patient on a monthly basis and measuring his body weight on a weekly basis.
The Clinical Reasoning Error:
The error in this case study was the use of clozapine in the treatment of the
schizophrenia, while the risk of the development of myocarditis associated with this medicine is
well established. However, the patient was not administered with the clozapine drug at first. He
was administered with risperidone, quetiapine XR and olanzapine prior to this medication. Only
when it was observed that those drugs are not having any effect on the patient in lowering the
symptoms of schizophrenia, clozapine was administered with a dose of 12.5 mg. The dose was
supposed to increase to 300 mg gradually every week, if the patient can take it without suffering
the side effects. However the patient developed the severe symptoms of tachycardia and chest

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pain on the sixth day. Thus it was an erotic intervention adopted by the healthcare professionals,
who were involved in Job’s care.
Conclusion:
Hence it can be concluded that Job had three main physical conditions, which are myocarditis,
schizophrenia and type 2 diabetes. The myocarditis condition of the patient was induced by a
medicine named clozapine in the patient, which was used to control his schizophrenic condition.
There are various nursing interventions presented to deal with every condition of the patient. The
clinical reasoning error identified in this case study was the use of clozapine in the patient.

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Referencing:
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trial. JAMA psychiatry, 70(7), 668-676.

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Hatton, J. L., Bhat, P. K., & Gandhi, S. (2015). Clozapine-induced myocarditis: recognizing a
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