8.4 Clinical Reasoning and Decision-Making for CNS Regulation, Mood, and Cognition

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.^[1] 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 when administering medications, it is always important to first think about what you are giving and why.

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 medication. 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 medication will likely look different than an assessment for other types of medication, because most of the assessments associated with CNS medication are done by collecting subjective data rather 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.

After reviewing the possible diseases connecting with the CNS system, 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.

Interventions

Next, plan (refine your hypothesis), and take action.

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. It is important to 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. Additionally, some medications require an assessment of lab values before administration. Many CNS medications may also have cumulative effects when used in conjunction with other medications, so careful assessment of the impact of the medications on one another is needed.

Evaluation

Finally, evaluate the outcomes of your action. 

It is important to always evaluate the client’s response to a medication. Some CNS medications will take weeks to become therapeutic for the client. It is key to teach the client about when the medication is expected to produce an effect. 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. Additionally, 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. 

Now that we have reviewed CNS basics and how to use the nursing process related to CNS medications, 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.