You are an enrolled nurse working in an acute inpatient mental health facility. You have been allocated a new client who has just been admitted into the ward.
Ms Kiara Smith was brought into the emergency department by her sister who found her after she had attempted suicide by overdosing on antidepressants and Panadol. She also had attempted to cut into her wrists. Ms Smith has a diagnosis of depression, she is medically stable and has bandages on both her wrists. She is expressing a continued wish to die, and whilst in the emergency department, attempted to steal a scalpel off a medical tray. Subsequently she has been made an involuntary patient under the Mental Health Act, and has been placed on constant supervision (must be within arm’s length of a staff member at ALL times) by the treating Psychiatrist. There is no history of aggression, however Ms Smith is becoming agitated with the nursing staff, because they are performing regular observations on her.
Mood
Affect
Thoughts
Behaviour
Insight
Risks can be seen in mental health settings for both clients and staff. In the broadest sense of the term, behaviours related to risk include the risk of violence or harm to self and others. This can present as actual risks, or potential risks.
As part of the process in identifying if a situation is an emergency or not, identify two (2) questions you would ask Ms Smith, in both categories of self-harm and assessing risk for aggression.
Self-Harm: ‘Ms. Smith, have you ever tried to take your own life before?’
Aggression: ‘Do you have thoughts of harming or killing others?’
One essential element of a therapeutic environment and relationship that an EN would use is effective communication. Effective communication enhances dignity and respect of the client. Identify four (4) effective communication skills.
Therapeutic relationship is an essential requirement to productive communication between patients and health professionals that helps to transmit information and successfully addresses emotional processes that are activated by the communication process (Kourkouta & Papathanasiou 2014, p. 65).
Listening: it necessitates attention, concentration and mobilisation of senses for perception of non-verbal and verbal messages conveyed by individual patients. By listening, the care professionals could assess the original situation and associated problems, which in turn enhance the patients’ self-esteem and incorporate nursing care process and diagnosis at different levels.
Verbal: communication has value and content. The content depicts what is said and value shows how the message is communicated. This should never be unidirectional as in each interaction individual receiver becomes sender and vice versa.
Non-verbal: it is expressed by gestures, postures, facial expressions and so on. Under stressful situations it is difficult to observe changes in non-verbal messages expressed by the patients. Individual patients has own individual characteristics, which influence behaviour in communication process. This helps the nursing professionals to understand how to cooperate with the service providers and how to carry out health management.
Showing approval: constant communication with patients develops instant connection. Conveying the reasons behind admiration enables both the parties to involve in an effective communication process.
Management of problem behaviours, encompasses identifying triggers and using deescalating techniques. Identify two (2) expected outcomes of an aggression management plan.
Two expected outcomes would be quick response from service users and reduction of the loss of disability and functions that often happens due to severe mental illness.
Constant supervision means that the client must be within arm’s length of a staff member at ALL times, whilst maintaining the privacy and dignity of the client. Identify two (2) situations where this practice would be employed.
Ms. Smith expressed her wish to die. She attempted to steal a scalpel off a medical tray while in the emergency department. Also, her agitation was identified while the nursing staff were performing regular observations on her.
Briefly explain one (1) ethical challenge that the enrolled nurse would encounter, whilst providing care to Ms Smith.
Using restraints for Ms Smith could give rise to an ethical challenge as she can no longer exert control over her own behaviour, which on the other hand could be considered as violation of patient rights if applied as a means of staff convenience.
You are an enrolled nurse working in an acute inpatient mental health facility. You have been allocated a new client who has just been admitted into the ward.
Ms Kym Jones was brought into the emergency department by the police who found her swimming naked in the Brisbane River at 8pm, in winter. Ms Jones has had a previous diagnosis of Bi Polar Affective Disorder. However, as she is psychotic and responding to the voices of deceased Tahitian Kings and Queens, the doctors are questioning her diagnosis and considering a Schizo-affective Disorder. Ms Jones is elevated and promiscuous – she has tried to kiss and hug two (2) male staff members. She has not eaten, is dehydrated and, as she believes she is a Tahitian Princess, she is refusing food and fluids that are not part of her traditional diet. Ms Jones is speaking rapidly, often in her “native tongue,” and her words are difficult to understand.
Miss Jones is pacing in her cubicle and stating she cannot stay in hospital as there is nothing wrong with her, and she has a traditional custom she needs to perform.
Ms Jones has been made an involuntary patient under the Mental Health Act. She has allowed permission for her family to be advised of her admission, and requests they supply her “traditional” food, but refuses to allow them to have any other details.
An Enrolled nurse, working under the supervision of a Registered Nurse, can perform nursing roles as defined in their scope of practice. Using the information supplied in the case study, perform and document a Mental State Exam.
Write your responses under the headings in the progress note provided below.
Thoughts:
Thought Form loose associations, incoherent, neologisms
Thought content hallucinations, illusions
Perception: false, delusional
Sensorium and cognition: excessive motor activity like pacing
Speech: talkative
Behaviour: distinctive mannerism, hostile, irritable
Utilising the ICD10, provide a definition of Schizoaffective Disorder, manic type. (2 marks)
A disorder where both manic and schizophrenic symptoms are noticeable so that the occurrence of illness does not rationalize an analysis of either a manic episode or schizophrenia. This category requires to be used for both recurrent disorder and single episode, where majority of the episodes are schizoaffective, manic type (Apps.who.int. 2017).
Cultural factors can affect people with mental illness. Ms Jones believes she is a Tahitian Princess and is refusing food and fluids that are not part of her traditional diet. Ms Jones is speaking rapidly, often in her “native tongue. This is a delusional belief.
Despite the delusional belief, responding respectfully and sensitively to cultural beliefs, identify two (2) negotiation skills that could be used to resolve this conflict.
Engage with Ms Jones in conversation regarding her cultural beliefs. Another skill could be promoting calm conversation with Ms Jones, which further ensures understanding of her situation and compassion.
You are an enrolled nurse working in an acute inpatient mental health facility. You have been allocated a new client who has just been admitted into the ward.
Mrs Anne Green has voluntarily requested admission as her depression and anxiety has worsened. Her GP had reduced her medications as she had been on them for some time and this has caused a deterioration in her illness. Her GP had restarted her medications, but after three (3) weeks there is no change in her mental state. She remains depressed, crying often. Has no energy, is struggling to care for her family. She has lost 5kgs as she has no appetite and is skipping meals. Her anxiety has increased, she is having panic attacks if she has to leave the house.
Given the severity of her symptoms, it has been decided she will undergo a course of six (6) Electro Convulsive Therapy ECT (unilaterally). She has undergone a full physical as she will undergo anaesthesia to receive her treatment.
ECT involves the application of 2 electrodes to the head through which an electrical current is applied and causes a seizure. It is believed that the shock stimulates the brain chemistry to correct the chemical imbalance of depression. The shock is delivered whilst the patient is under an anaesthetic, so they are not awake. They are also given a muscle relaxant to greatly reduce the outward signs of seizure (tonic/clonic contractions). The shock when delivered causes seizure activity in the brain.
Describe the differences between bilateral and unilateral delivery of ECT, and identify why Unilateral is a preferred method of delivery.
In unilateral delivery of ECT one electrode is kept on the head’s crown and other on right temple. The patients who receive unilateral ECT may respond slowly than the bilateral treatments. It is related with lesser side effects. However, patients who do not adequately respond to unilateral ECT require to switch to bilateral ECT. In bilateral ECT electrodes are placed on both the temples and associated with acute memory side effects compare to unilateral ECT. The unilateral group experience lesser side-effect and factor recovery and verbal learning, which makes it a preferred method over bilateral ECT.
Preparation for ECT is similar to any outpatient minor surgical procedure. Identify three (3) pre anaesthetic checks you would undertake on Mrs Green.
The three pre-anaesthetic checks would be: a) documentation of thorough history, clinical investigation, special consultation and physical examination b) anaesthetic consultation along with signature in informed consent form c) nil by mouth for at least 6 hours prior the commencement of ECT.
Post ECT procedure Mrs Green may be confused or briefly disoriented. She will be tired, and may complain of a headache or sore throat. She may have her usual medications and eat if she is hungry. Mrs Jones may prefer to have a brief nap. Identify three (3) nursing actions you will undertake to care for Mrs Green in her post procedural state.
You are an enrolled nurse working in an acute inpatient mental health facility. You have been allocated a new client who has just been admitted into the ward.
Mr Paul Brown has been admitted via the community team. He has not been taking his medications as ordered and has therefore is experiencing an increase in his psychotic symptoms. Mr Brown has Paranoid Schizophrenia. He had been prescribed Olanzapine 20mg Nocte, but dislikes taking it as he has gained over 10 kgs, but also admits he often forgets to take it and can’t recall the last times he has. He also expressed a concern of looking like a zombie whilst on it, and doesn’t like how this makes people look at him
He is now experiencing auditory hallucinations. He hears voices telling him not to trust people. He is also paranoid and believes he is being watched. He has called the police to report unfamiliar cars in his street.
He has not checked his mail box for the last few weeks and subsequently has had his electricity cut off for not paying his bill.
He has a Mental health community case manager but has refused to open the door when she visits as he thinks she wants his money.
The community staff have attended the Multi-Disciplinary Team (MDT) meeting to participate in a review of Mr Brown. You are requested to attend as you are his primary nurse for the shift. The community team have provided his care plan with his identified goal of symptoms management. You advise them on a “coping with voices’ group being run on the ward, and after a collaborative discussion including Mr Brown, everyone is in agreement for him to attend.
At this meeting a discussion is held with Mr Brown regarding medications, and the treating team decide to start him on a depot injection – despite his desire to keep taking oral medications.
The EN, will report any relevant information to the RN. Being a part of the MDT, and liaising with the Community Nursing staff, from the information in the case study, identify two (2) pieces of information you would hand over to the case manager..
An outcome of the MDT is for Mr Brown to attend a group program on managing voices. This program explores psychosocial stressors as well as triggers for voices and develops skills to reduce the distress of voices. A secondary benefit to the group is socialising and normalising of behaviours. This has been identified, by Mr Brown and the treating team as part of his rehabilitation and recovery goals. Identify four (4) therapeutic outcomes of group therapy.
Acting as an advocate for Mr Brown identify two (2) examples from the case study, which could support him having a trial of oral medications.
As an enrolled Nurse, utilising non – discriminatory practices identify one (1) action you would undertake to minimise stigma and advocate on behalf of Mr Brown to respect and support his decision for oral medications.
As an enrolled Nurse, one should make sure that Mr. Brown understands and fully informed the decision regarding his treatment, especially oral medication and also understands the consequences of avoiding recommended medication
Using the Harvard style of Referencing (as per SARG guide for Careers Australia), list two (2) references used to complete this assessment.
Kourkouta, L & Papathanasiou, I.V. 2014, Communication in nursing practice. Materia socio-medica, 26(1), p.65.
Apps.who.int. 2017, ICD-10 Version:2010, viewed 11 April 2017, <https://apps.who.int/classifications/icd10/browse/2010/en#/F25.0>.
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