5.3 Clinical Reasoning and Decision Making V2
Clinical reasoning is a way that nurses think and process our knowledge, including what we have read or learned in the past and apply it to the current practice context of what we are seeing right now (NCSBN, n.d.). Nurses make decisions all the time, but making decisions requires a complex thinking process. There are many tools that are useful and found online that can support your thinking through to clinical judgments. This book uses the nursing process and clinical judgment language to help you understand the application of medication to your clinical practice.
Now that we have reviewed various CNS disorders and the anatomy and physiology underlying them, let’s review the importance of the nursing process and clinical judgment in guiding the nurse who administers CNS medication to treat these disorders.
Assessment
Although there are numerous details to consider prior to administering medications, we begin with an assessment. It is always important to first think about what is the health condition, con-current conditions, present and past assessments, overall goal of therapy, and medications or other treatments. Nurses must know what the medication is, how it works in the body, and the purpose of giving it.
First, let’s think of why? Recognizing Cues
When thinking about administering CNS medication, there are many things to consider. Each medication is given for a specific purpose for your client, and it is your job as a nurse to assess your clients and collect important data before safely administering medications. As a nurse, not only will you perform the skill of administering medications, but you will be expected to think critically about your client and the safety of any medication at any particular time.
A nursing assessment completed prior to administering CNS medications will likely look different than an assessment for other types of medications, as subjective assessment is paramount and in some circumstances, more important than objective data. For example, prior to administering a cardiac medication, a nurse will obtain objective data such as blood pressure and an apical heart rate. However, prior to administering CNS medication, a nurse will use therapeutic communication to ask questions to gather subjective data about how the client is feeling but may also use an objective rating scale. For example, the Patient Health Questionnaire-9 (PHQ-9) or the Patient Health Questionnaire Somatic Symptom scale.
After reviewing the possible CNS diseases, you probably noticed that there is usually an associated imbalance of a neurotransmitter. As a nurse, you cannot directly measure a neurotransmitter to determine the effects of the medication, but you can ask questions to determine how your client is feeling emotionally and perceiving the world, conditions which are influenced by neurotransmitter levels. An example of a nurse using therapeutic communication to perform subjective assessment is asking a question such as, “Tell me more about how you are feeling today?” The nurse may also use general survey techniques such as simply observing the client to assess for cues of behavior. Examples of data collected by a general survey could be assessing the client’s mood, hygiene, appearance, or movement.
General Assessment Questions
Assessment will include:
- What symptoms are they experiencing? What is going on in your life that may be contributing to how you are feeling?
- How long? (acute or chronic)
- Impact on ADLs, social functioning, impacting QOL?
- What are their supports? (family, friends, support groups)
- Any Substance use +/- (prescription, non-prescription, alcohol use, nicotine, caffeine)
- Potential for self-harm and suicide (ask specifically, see box below)
- Other physical symptoms
- Other health issues (may be related to the mental health issue or unrelated)
- Medications (past and present meds, prescription, OTC and herbal supplements)
Rating Scales
Mental health professionals use a number of different rating scales as part of the initial assessment, diagnosis of a mental health condition and for ongoing monitoring that assesses for symptom improvement or decline. They are only one part of a comprehensive assessment (Halter et al., 2018).
Mental Status Examination (MSE): is the equivalent of a physical exam to assess the clients mental health needs. Mental Status Examination (MSE) : Interior, BC : eMentalHealth.ca
Mini Mental State Examination (MMSE): used to systematically and thoroughly assess mental status. It is an 11 question measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall and language.
Patient Health Questionnaire-9 (PHQ-9): used for assessing depression risk. Highlights predominant depression symptoms.
Hamilton Anxiety Rating Scale: measures anxiety behaviours.
Interventions
Next, plan (refine your hypothesis), and take action.
Hypothesis: Are we concerned? What is the impact on functioning, severity of symptoms, safety.
Planning and Intervention:
Almost all mental health conditions, require non-pharmacological interventions for maximum effect. Interventions may include: Psychotherapy, Cognitive Behavioural Therapy, support groups, social and family support, spiritual supports
Other interventions include healthy behaviour strategies, such as sleep, exercise, nutrition, and relaxation.
Pharmacological Interventions:
Clients will often be on one or more medications to manage their moods and behaviour.
- With the administration of any medications, it is important to always perform the five rights (right patient, medication, dose, route, and time) and to check for allergies prior to administration.
- Anticipate any common side effects and the expected outcome of the medication.
- When you administer CNS medication, it is key to perform assessments before administering medication because many clients may have changing behaviors and habits that influence the way they think and feel about taking their medication.
- Some medications require an assessment of lab values before administration. For example, lithium levels may need to be drawn prior to the dose due to the narrow therapeutic range.
- Monitor for cumulative effects when CNS meds are used in conjunction with other medications, so careful assessment of the impact of the medications on one another is needed.
Evaluation
Regular monitoring and evaluation of effectiveness of meds:
CNS medications which modulate or change (inhibit/excite) a neurotransmitter, the therapeutic effect can take up to four weeks. Close monitoring for the therapeutic effect and side effects is important.
- Nurses should assess for mood, behavior, and movement improvement. If medications are effective, then clients should report fewer negative thoughts, worry, and symptomatic behaviors, as well as demonstrate fewer abnormal movements.
- Nurses also need to continually monitor for adverse effects, some of which can be life-threatening and require prompt notification to the prescribing provider.
- If symptoms are not improving or the client’s condition is worsening, the nurse should promptly notify the prescribing provider for further orders. For example, a symptom and/or adverse reaction of several CNS medications is increased thoughts of suicide. If a client is experiencing thoughts of suicide, immediate assistance should be obtained to keep them safe. For more information about suicide prevention refer to the Canadian Association for Suicide Prevention site.
- Monitor for compliance with taking the meds. Some meds have undesirable side effects that can be short term or long term. Tell the clients ahead of time that side effects are common, and provide help with managing them.
In the upcoming units, we will take a closer look at specific classes of CNS medications. We will review classes and specific administration considerations, therapeutic effects, adverse/side effects, and teaching needed for each class of medications.
References:
Halter, M., Pollard, C. & Jakubec, S. (2018). Varcarolis’s Canadian Psychiatric Mental Health Nursing. A clinical approach (2nd Ed.). Elsevier: Canada.
National Council of State Boards of Nursing (NCSBN). (n.d). NCSBN Clinical Judgement Measurement model. https://www.ncsbn.org/14798.htm
A way that we think and process our knowledge including what we have read or learned in the past and apply it to the current practice context of what we are seeing right now.
