Introduction Clinical reasoning is linked to sound and evidence-based clinical judgment, to problem solving and decision-making, and to critical thinking. Critical thinking in the nursing profession is in turn defined as the “purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation” of contextual variables (Benner, Hughes & Sutphen, 2008, p. 1). Therefore, clinical reasoning is central to promoting a high quality of patient care and in ensuring positive and goal-driven patient outcomes.

The clinical reasoning cycle provides a standard framework for critical thought in healthcare, and can be used by nurses in every patient sector. This current case study illustrates the importance of taking into account a multitude of variables, in order to achieve patient outcomes in a holistic manner. The clinical reasoning cycle minimizes biases, assumptions, and prejudices, allowing healthcare providers to remain open to a number of different options and possibilities. Description of the facts at hand, collection of information, information processing, identification of main problems or issues, establishment of goals, taking action, assessing outcomes, and reflecting on the process are the essential components of the clinical reasoning cycle. This critical appraisal essay applies the clinical reasoning cycle to the case study of Emily and identifies core nursing priorities.

Emily’s case study highlights the specific issues related to mental health and psychiatric care. Mental health issues do not occur in isolation of ancillary events, circumstances, or issues. Social, physiological, and situational variables all impact a patient’s mental health and externalizing behaviours. In this case, Emily demonstrates suicidal ideation, suicidal behaviour, anxiety, self-harm, and disordered eating. Rather than focus on the symptoms of Emily’s behaviour, a skilled mental health care worker would address the totality of Emily’s experiences, including her healthcare background, her family and social history, and her physical health.

The case of Emily also demonstrates that mental illness does not always occur as a singular event. Presenting symptoms might also be misread or misunderstood, confused with other physical or mental health issues. The rigidity of the medical model often entails leaping to conclusions prior to making a full investigation of the patient’s background and current context. Furthermore, Emily shows how important differential diagnoses are for providing the highest possible quality of care. Particularly when working within the holistic nursing model, the emphasis should not be on initial presenting symptoms or prodromal presentation, but on problem solving and solutions that address root causes and patient-centric goals. The recovery model of care must also be considered as the ultimate objective in healthcare treatment, offering nurses an effective framework for patient advocacy, autonomy, and self-determination.

Step 1: Description of Patient Situation

Emily is a 19-year-old female, brought into the Emergency Department at 1700 by her parents and with her consent. Vital signs are normal and stable. Initial presenting symptoms indicate a high degree of anxiety or agitation, linked to her having taken an overdose of over the counter analgesics including paracetamol and ibuprofin. Emily is compliant and although distressed, cooperative. However, her speech is agitated and she has difficulty completing sentences, speaking negatively and self-deprecatingly.

During the intake interview, Emily freely admits she had taken an overdose of 9 paracetamol...

Further questioning by the nurse revealed Emily has a history of suicidal ideation and suicidal behaviour. For example, Emily stated that she has been considering the overdose for the past week and states that she made the decision to take the overdose today if her end of semester results were not “good.” As she was not pleased with the results of her academic performance, Emily went through with her decision to take the over the counter medications, which she purchased from Woolworths the day before her admittance. Furthermore, Emily admits that her intention in taking paracetamol and ibuprofin was not actually to commit suicide per se, but to gain attention and to “make others know how she was feeling.” Emily also states that she is “embarrassed” for having taken the drugs.
Step 2: Collecting Cues

Emily lives with her mother Ruth, her father, Robert, and her younger brother Harry. Harry has mild autism. Emily also has a boyfriend, Daniel, who she phoned immediately after receiving her failing grades. She told Daniel that she intended to kill herself, which is why Daniel phoned Emily’s parents.

Emily has seen a psychologist in the past, but her counselling sessions are no longer covered under the provisions of her parents’ insurance policy. She also used the Headspace program, but only completed 6 out of 10 sessions and was told the program may not be enough for her.

Emily remains financially dependent on her parents, with a job that only offers her 12 hours per week of work. Furthermore, Emily has felt pressure both from her parents to find a more viable career or personal development path and from her friends, who want to travel with her during a 2018 gap year.

Emily has no history of drug or alcohol abuse. She is not sexually active, does not take birth control, and has never been pregnant. Emily reports no sleep problems. She has a flat affect upon assessment, but when asked, Emily states that she “thinks too much” at night when alone in her room.

Emily weighs 55.4 kg, and her height is 165 cm; her BMI is 20.3 kg.m2. The patient has lost 2 kilograms of weight in the past month alone. When asked, Emily states she has not been hungry. However, further inquiries reveal she has been purging to consciously lose weight, and that her purging behaviours have increased in frequency over the past week. She states her goal weight of 49 kilograms. Emily has no history of an eating disorder. Emily has been self-harming. She started cutting herself two years ago, and has also bruised herself and burnt herself. Emily claims that she currently does not self-harm and does not feel the need to either cut herself or take overdoses.

Step 3: Processing Information

The disordered eating and self-harming behaviours are externalizations of internal issues, including acute but undiagnosed anxiety and depression. It is suspected that a mood disorder may be present, based on the patient’s expression of an extreme lack of energy and motivation, as well as a sense of being overwhelmed. Social pressures and a lack of direction are adding to Emily’s high level of anxiety. At the same time, Emily does have a significant amount and degree of social supports, including her family and her boyfriend. The presenting symptoms and behaviours like disordered eating and self-harm can be mitigated through an effective and holistic intervention and care program. It is also presumed that initial self-regulation of emotions may help Emily to return to Headspace.

Step 4: Establishing Goals

It is important to point out that Emily is willing…