Using The Levett-Jones Clinical Reasoning Cycle For Identifying Care Priorities In A Clinical Scenario

Consider Patient Situation

Community nurses are entrusted with responsibilities of maintaining positive health outcomes within the community and hence, must considered multiple dimensions to a patient’s health other than physiological consequences of diseases, such as emotional, psychological and social well being (Bain & Chilton, 2017). The following paragraphs aim to shed light on the role of the community health nurse in the management of the case of Jenny Peterson, using two nursing priorities of: Management of seizures and Maintenance of Positive Health Outcomes through eradication of minor gastrointestinal illnesses, with the help of the clinical reasoning cycle (CRC). The CRC is the nursing process of patient information collection, processing of patient data, consideration of the patient’s issues, planning of interventions prior to implementations, evaluation of outcomes and engagement in nursing reflective practice (Levett-Jones, 2017). .

This is the initial stage of the CRC and necessitates the nursing process of observation and noticing the concerned patient closely for the detection of the key problems and issues to be considered. Recalling that this process is the pre-requisite for the determination of patient assessment and treatment methods, nurses must evaluate the situation of the patient without any bias or judgment and engage in empathy, patient listening and insightful observation (Levett-Jones, 2017). The nurse must consider that the patient in question, Jenny Peterson,  is suffering from a frequent problem of seizures after a recent injury to her brain following a car accident. Despite observed to have regulated the occurrences of these symptoms, her epileptic symptoms have resurfaced resulting employment and financial hindrances – which the community nurse must consider as pre-requisites for improvement social wellbeing and patient empowerment. Jenny is observed to exhibit frequent illnesses in the form of gastrointestinal disturbance such as diarrhea, nausea as well as common cold. The community nurse must consider improvement of Jenny’s wellbeing for future occupational engagement and care of her daughter Samantha (Strandås & Bondas, 2018). 

This step of the CRC is characterized by the community nurse collecting relevant patient information through assessments and screening tools for the purpose of formulating a nursing diagnosis (Levett-Jones, 2017). Considering that Jenny’s symptoms of epilepsy have been reported to resurface, the community nurse may need to work collaboratively with a neurologist and psychiatrist to undertake assessments relevant for seizure screening, since these are beyond her scope. These include electroencephalogram (EEG), neuro-imaging procedures such as Magnetic Resource Imaging, Computer Tomography and neuro-psychological assessments in the form of tests assessing memory, reasoning or thinking such as Mini-Mental Status Examination (MMSE) (Sidhu, Duncan & Sander, 2018).  Considering that stress is positively linked with incidence, the nurse and associated psychologist may work collaboratively to administer a Personal Wellbeing Index in order to assess Jenny’s level of satisfaction with her life, job, personal relationships, community and future (Australian Center on Quality of Life, 2019).  Jenny’s relapse of a seizure may be linked to a cerebrovasvular accidence or a transient ischemic attack since these have been linked to cause epilepsy. The nurse must collaboratively work with a cardiologist to perform a cardiovascular assessment (Pitkänen, Roivainen & Lukasiuk, 2016). The nurse may work with a gastroenterologist to conduct an abdominal assessment to detect any blockages in her gastrointestinal tract which may contribute to her nausea and vomiting (Hall, 2017). The community nurse can collect information on possible side effects of Jenny’s present medications on sodium valproate and lamotrigine using evidence based research (Blond, Detyniecki & Hirsch, 2016).

Collect Cues/Information

Process Information: The community nurse in this step is required to link the results obtained from the above assessments and link the same with previously acquired knowledge through experiences and evidence based research (Levett-Jones, 2017). Hence, upon detecting high levels of stress or poor results of satisfaction or wellbeing the nurse may link the Jenny’s epileptic symptoms with detrimental psychological wellbeing since stress life events have been documented to cause epileptic seizures (Van Campen et al., 2016). Further, the nurse may process Jenny’s level of stress by linking it to the significant events in her life, like separation from her husband and distress concerning her daughter’s health and wellbeing (Shoemaker et al., 2016). Further, assessments of side effects of Jenny’s medications may reveal causative mechanism underlying her frequent association with colds, diarrhea and vomiting since medications like lamotrigine and valproate include diarrhea, nausea, vomiting and fever (Grevers et al., 2016). Abnormalities in structural changes in the brain, detected through EEG, neuro-imaging of MMSE can aid the nurse in processing Jenny’s relapse by associating these with an aggravation of her epileptic condition, hence, necessitating alternative or more comprehensive treatments in the future (Vogt et al., 2017).

The community nurse will henceforth utilize her clinical knowledge in the identification of key problems prevalent in Jenny’s condition of epilepsy (Levett-Jones, 2017). The prevalence of stressful life events have aggravated the reoccurrence of epileptic symptoms in Jenny as evidenced by her reduced levels of wellbeing and satisfaction and detected cerebral abnormalities, epileptiform discharges and MMSE results, possibly attributable to distress concerning her daughter and separate from her partner (Gélisse et al., 2015). It must also be considered that Jenny’s prevalence of gastrointestinal illnesses and colds have emerged in the form of health implications of her present medications since sodium valproate and lamotrigine have been attributed to side effects such as abdominal cramping, nausea, vomiting, diarrhea and fevers (Bryant & Knights, 2014). Further, Jenny’s relapse of her epileptic symptoms may indicate inefficiencies of her current treatment hence necessitating alternative therapies or altered medications, along with targeting the mitigation of the above mentioned problems (Ou et al., 2018). 

The nurse will be required to prioritize the problems identified above for Jenny and hence proceed with the plan of treatment (Levett-Jones, 2017). One of the key problems faced by Jenny is her recurrence of epileptic seizures which are affecting her occupational activities and contributing to financial distresses. Further, an additional problem which is notable in Jenny is her constant acquisition of minor illnesses such as colds, diarrhea and nausea which are affecting her overall sense of wellbeing. Further, additional problem which must be considered is the possibility of Jenny’s condition relapsing again which may indirectly impact Samantha’s safety and wellbeing in the future. Hence, the community nurse must plan Jenny’s care procedures by considering the following SMART goals:

1. To reduce Jenny’s occurrence of seizures through alternative epileptic treatment procedures and reduction of stress within the next 3 weeks.
2. To improve Jenny’s wellbeing and occurrence of minor illnesses through alternative epileptic medications or their respective dosages within the next 3 weeks.
3. To reduce the possibilities of further epileptic relapse and ensure familial wellbeing through provision of a nurse monitoring and care bundle/package.  

Process Information

Stress and the psychological or emotional consequences of stressful life events have been linked with the reoccurrence of symptoms in patient suffering from epilepsy (den Heijer et al., 2018). Hence, considering the fact that Jenny’s symptoms of seizures have resurfaced along with consideration her constant stress concerning her daughter’s wellbeing and the lack of support from her husband, it can be implied that such challenging life events have contributed to this situation. Hence, the nurse must consider the possible ineffectiveness of present pharmacological interventions, the observed side effects and the administration of treatment techniques to mitigate Jenny’s epilepsy as well as her levels of psychological distress (Dubé et al., 2015). 

A multidisciplinary care approach can be considered where the community nurse may have to work collaboratively with a psychologist who will administer psychotherapeutic and counseling techniques targeted at Jenny’s stress reduction such cognitive behavioral therapy (CBT), mindfulness and self-reflection techniques (Valeta, 2017). Complementary therapies such as massages and mediations have been implicated to be effective in the management of epilepsy and life stresses which the nurse may consider via interpersonal and inter-professional communication with the psychologist or Jenny’s general practitioner (Farrukh, et al., 2018).  Secondly, considering the links between the side effects of valproate and lamotrigine and Jenny’s issues with diarrhea, nausea and colds, the nurse must collaboratively communicate with a neurologist for dosage alteration and replacement with complementary or behavior modification therapies since the side effects of epilepsy medications have been known to reduce upon dosage reduction or withdrawal (Moura et al., 2016). To further prevent reoccurrence, reduce Jenny’s distress and hasten her joining of her job, the community nurse and community health organization can collaboratively work with support groups who can visit Jenny weekly or engage in telephonic conversations to enquire about her condition and administer self-reflection, resilience or self-reflection techniques to increased her sense of self-esteem and self-empowerment (Wood et al., 2017).

The community nurse must conduct another cycle of the CRC to assess treatment outcomes (Levett-Jones, 2017). The nurse may be required to collaboratively engage in administration of neuro-imaging, neuro-psychological and quality of life measurements to evaluate Jenny’s present level of stress, satisfaction and seizure possibility (Anderson et al., 2016). In case of another occurrence of seizure, a cardiovascular assessment may be required to detect strokes considering its associations with seizures. A patient centered approach through personal discussion with Jenny can help the nurse to identify her needs, preferences and opinions about the care plan (Nursing and Midwifery Board of Australia, 2019). 

Identify Problems/Issues

Managing the case scenario of Jenny Peterson, was an influential experience during my working as a community nurse. The case was reported to our organization in the form of Jenny’s relapse of seizures and minor illnesses of colds, diarrhea and nausea. As a community nurse, I successfully engaged in collaborative working in a multidisciplinary team to manage Jenny’s multi morbid scenario. Considering Jenny’s case, I learned that the nurse must consider emotional and psychological wellbeing of a patient to ensure positive health outcomes (Jakimowicz & Perry, 2015). However, I lacked significant knowledge on alternative therapies or causative factors underlying epilepsy. Hence, for future practice, I must conduct evidence based research concerning the same and collaborative with relevant health professionals. 

References

Anderson, J., Hill, J., Alford, M., Oto, M., Russell, A., & Razvi, S. (2016). Healthcare resource utilization after medium-term residential assessment for epilepsy and psychogenic nonepileptic seizures. Epilepsy & Behavior, 62, 147-152. doi: https://doi.org/10.1016/j.yebeh.2016.06.004.

Australian Center on Quality of Life. (2019). Australian Centre on Quality of Life. Retrieved from https://www.acqol.com.au/instruments.

Bain, H., & Chilton, S. (2017). The role of the community nurse in mental health. In A Textbook of Community Nursing(pp. 147-162). Routledge. doi: https://www.taylorfrancis.com/books/e/9781498725385/chapters/10.1201/9781315157207-8.

Blond, B. N., Detyniecki, K., & Hirsch, L. J. (2016). Assessment of treatment side effects and quality of life in people with epilepsy. Neurologic clinics, 34(2), 395-410. doi: https://doi.org/10.1016/j.ncl.2015.11.002.

Bryant, B., & Knights, K. (2014). Pharmacology for Health Professionals ebook. Elsevier Health Sciences. doi: https://www.elsevier.com/books/pharmacology-for-health-professionals/bryant/978-0-7295-4170-1.

den Heijer, J. M., Otte, W. M., van Diessen, E., van Campen, J. S., Lorraine Hompe, E., Jansen, F. E., … & Zijlmans, M. (2018). The relation between cortisol and functional connectivity in people with and without stress?sensitive epilepsy. Epilepsia, 59(1), 179-189. doi: https://doi.org/10.1111/epi.13947.

Dubé, C. M., Molet, J., Singh-Taylor, A., Ivy, A., Maras, P. M., & Baram, T. Z. (2015). Hyper-excitability and epilepsy generated by chronic early-life stress. Neurobiology of stress, 2, 10-19. doi: https://doi.org/10.1016/j.ynstr.2015.03.001.

Farrukh, M. J., Makmor-Bakry, M., Hatah, E., & Tan, H. J. (2018). Use of complementary and alternative medicine and adherence to antiepileptic drug therapy among epilepsy patients: a systematic review. Patient preference and adherence, 12, 2111. doi: https://dx.doi.org/10.2147%2FPPA.S179031.

Gélisse, P., Genton, P., Coubes, P., Tang, N. P. L., & Crespel, A. (2015). Can emotional stress trigger the onset of epilepsy?. Epilepsy & Behavior, 48, 15-20. doi: https://doi.org/10.1016/j.yebeh.2015.05.010.

Grevers, E., Breuer, L. E. M., IJff, D. M., & Aldenkamp, A. P. (2016). Mental slowing in relation to epilepsy and antiepileptic medication. Acta Neurologica Scandinavica, 134(2), 116-122. doi: https://doi.org/10.1111/ane.12517.

Hall, C. (2017). Back to basics: Abdominal assessments. Australian Midwifery News, 17(2), 17. Retrieved from: https://search.informit.com.au/documentSummary;dn=929839608457890;res=IELHEA. 

Jakimowicz, S., & Perry, L. (2015). A concept analysis of patient?centred nursing in the intensive care unit. Journal of advanced nursing, 71(7), 1499-1517.

Levett-Jones, T. (Ed.). (2017). Clinical reasoning: Learning to think like a nurse. Pearson Australia. Retrieved from: https://books.google.co.in/books/about/Clinical_Reasoning.html?id=rwc0MwEACAAJ&redir_esc=y.

Moura, L. M., Carneiro, T. S., Cole, A. J., Hsu, J., Vickrey, B. G., & Hoch, D. B. (2016). Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy. Patient preference and adherence, 10, 2197. doi: https://dx.doi.org/10.2147%2FPPA.S119973.

Nursing and Midwifery Board of Australia. (2019). Nursing and Midwifery Board of Australia – Professional standards. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx.

Ou, S., Xia, L., Li, R., Wang, L., Xia, L., Zhou, Q., & Pan, S. (2018). Long-term outcome of seizure-free patients and risk factors of relapse following antiepileptic drug withdrawal. Epilepsy & Behavior, 88, 295-300. doi: https://doi.org/10.1016/j.yebeh.2018.09.028.

Pitkänen, A., Roivainen, R., & Lukasiuk, K. (2016). Development of epilepsy after ischaemic stroke. The Lancet Neurology, 15(2), 185-197. doi: https://doi.org/10.1016/S1474-4422(15)00248-3.

Schoemaker, M. J., Jones, M. E., Wright, L. B., Griffin, J., McFadden, E., Ashworth, A., & Swerdlow, A. J. (2016). Psychological stress, adverse life events and breast cancer incidence: a cohort investigation in 106,000 women in the United Kingdom. Breast Cancer Research, 18(1), 72. doi: https://doi.org/10.1186/s13058-016-0733-1.

Sidhu, M. K., Duncan, J. S., & Sander, J. W. (2018). Neuroimaging in epilepsy. Current opinion in neurology, 31(4), 371-378. doi: 10.1097/WCO.0000000000000568.

Strandås, M., & Bondas, T. (2018). The nurse–patient relationship as a story of health enhancement in community care: A meta?ethnography. Journal of advanced nursing, 74(1), 11-22. doi: https://doi.org/10.1111/jan.13389.

Valeta, T. (2017). Psychological Treatments for Epilepsy. In The Epilepsy Book: A Companion for Patients (pp. 119-126). Springer, Cham. doi: https://doi.org/10.1007/978-3-319-61679-7_18.

Van Campen, J. S., Hompe, E. L., Jansen, F. E., Velis, D. N., Otte, W. M., Van De Berg, F., … & Zijlmans, M. (2016). Cortisol fluctuations relate to interictal epileptiform discharges in stress sensitive epilepsy. Brain, 139(6), 1673-1679. doi: https://doi.org/10.1093/brain/aww071.

Vogt, V. L., Äikiä, M., Del Barrio, A., Boon, P., Borbély, C., Bran, E., … & Dimova, P. (2017). Current standards of neuropsychological assessment in epilepsy surgery centers across Europe. Epilepsia, 58(3), 343-355. doi: https://doi.org/10.1111/epi.13646.

Wood, K., Lawrence, M., Jani, B., Simpson, R., & Mercer, S. W. (2017). Mindfulness-based interventions in epilepsy: a systematic review. BMC neurology, 17(1), 52. doi: https://doi.org/10.1186/s12883-017-0832-3.