NRSG262: Nursing - Professional Portfolio - Mental Health - Case Study - Assessment Answer

Nursing Assignment

Assignment Task

Case Study:

Ellen Hawkbridge is a 57-year-old woman, who was brought into the Emergency Department by police. She was found intoxicated at the local RSL club, harassing patrons and refusing to leave premises when requested by club security. Ellen’s husband, Simon, was notified by police of her behaviours; he arrived at the hospital approximately 30 minutes after Ellen and police. Simon reports that Ellen had been diagnosed with bipolar disorder when she was 23, with numerous admissions over the years; her last admission to hospital 18 months ago, for a depressive episode, a phase of her Bipolar disorder. At this time she was commenced on Sertraline 100mg mane. Ellen’s medications have been reviewed, and lithium carbonate 500mg BD and zulcopenthixol decanoate 150mg IMI 2/52 have been prescribed by the treating team.

Background in context of this admission: Ellen reports spending excessive amounts of money from her Disability Support pension on cigarettes, brandy and items from television shopping channels; Simon states, that little funds are left available following these purchases for her groceries. Simon says that the local community mental health team, had recently reviewed the need for Ellen’s Community Treatment Order, and due to her level of adherence to treatment and stability over the past 18 months, the order was ceased.

Family History: Simon reports that he and Ellen have a son, Jason (23 years old), who lives interstate. Jason has not been in contact with Ellen over the last few weeks due to her behaviour and deterioration in mental state. Jason is “embarrassed” by his mother and finds her too aggressive to talk to over the phone when she is in her “mood”.

Ellen presents with heavy bright coloured make-up on her face. She is dressed in clothes that, while appropriate for the cooler weather, are mismatched, unkempt and unwashed. She is noted to be overfamiliar towards others, especially younger male staff members. Ellen describes that she has not slept for days; she has not felt the need for sleep at night and that she is too busy. Her speech is loud, pressured and slurred. On interview her mood is elevated and labile. Ellen’s affect is congruent to her mood. She has periods of increased irritability, especially when her requests for perceived needs, are not immediately met by others. There is evidence of flight of ideas as her thoughts go from one topic to another and derailment is evident in conversation. Content of thoughts are grandiose, flirtatious and underlying sexual innuendo in conversation at times. Ellen denies any perceptual disturbances: nil evidence of behaviours suggestive of responding to perceptual disturbances. Ellen not oriented to time, (unsure of day/date), however is orientated to person and place. There is evidence of poor levels of concentration (unable to complete serial 7’s). Her memory not formally tested at this stage due to intoxication, some blurring of recount of events. Assessment notes limited insight into her illness, as she stated, “there is nothing wrong with me”, “stop giving me the drugs, lithium brings me down and stops me enjoying life!”. Judgement is impaired.

Questions:

Identify and describe the following four (4) key components of the mental state, as they relate to Ellen’s presentation:

• Mood
• Thought Content
• Thought form
• Insight

2. Identify and describe two (2) areas of risk for Ellen in relation to her current presentation.
3. Discuss four (4) nursing care priorities for Ellen and provide a nursing intervention and a rational for each intervention identified.
4. Identify one (1) recovery principle (as per the National Framework for Recovery-Oriented Mental Health Services).Describe how this recovery principle can assist in Ellen’s care?

• Identify and describe the following four(4) key components of the mental state, as they relate to Ellen’s presentation:

- Mood: Mental state examination of a patient includes the evaluation of mood. Mood is also understood as the feeling of the patient. It is generally enquired data that ho patient is feeling (happy, sad, elevated, euphoric, depressed, angry, or irritable) (Akiskal, 2016). The client’s description about their emotional state is called as mood. The evaluation of mood is important as it can explain the potential risks, which client can create for self or others (Akiskal, 2016). According to the case study, Ellen’s mood is elevated and labile, which represents presence of mania and a symptom of bipolar disorder. It is also known as the component of euphoric.

- Thought Content: Thought content is the thinking of the person and what is going inside their mind. The problem of mental disorder results in distorted thought content. Thought content of the client is observed as well inquired (Forbes, & Watt, 2015). It helps the healthcare professionals to understand if the patient is suffering from delusions or hallucinations. The amount of thoughts and rate of their production are analysed through rate, depth and speed of speech. Thought content in general refers to the theme that occupy the thoughts of patient and perceptual disturbance. According to the case study thought content of Ellen is grandiose (flight of ideas), flirtatious and underlying sexual innuendo.

- Thought form: Thought form is considered as the verbal record of the thoughts in the patient suffering with mental disorder. It is determined through rate of speech, flow of speech, logical association of topics, flight of ideas and goal directedness of thoughts (Forbes, & Watt, 2015). In the case of Ellen, her speech is found to be loud, pressured and slurred. She has a loose association of thoughts as she goes from one topic to another, which shows manic symptoms of flight of ideas. The illogical shifting of ideas is called as loose association of thoughts, thus explains the though form of the patient (Forbes, & Watt, 2015). It is important to be evaluated to identify if patient suffer from suicidal tendency or perceptual disturbance. However, Ellen denied any kind of perceptual distractions.

- Insight: Insight and judgement are very important in mental state examination, as it helps in making appropriate decisions about patient’s safety. Insight is often understood as the patient’s ability to have awareness about their disease or mental problem (Akiskal, 2016). Evaluating the insight is also important so that to understand that would patient be able to understand the prescribed treatment and will be able to comply with given medications. According to case study, Ellen suffers from poor insight, as she has no awareness about her condition and even denies that she is ill. She also displays poor judgement by stating that lithium medication stops her from enjoying her life, thus she is not able to make responsible decision for herself.

Identify and describe two (2) areas of risk for Ellen in relation to her current presentation.

Mood and Thought Process Disturbance: Mood and thought process disturbance could be a major risk factor for Ellen. This may result in disorientation, flight of ideas, decreased level of concentration (as seen in Ellen’s case), rapid and pressured speech. Mood disturbance can lead her to more severe depressive episodes and harm to self and others. Fluctuation of mood can result in aggression that could be potentially harmful for care givers and other patients in hospital (Geddes, & Miklowitz, 2013). Thought process disturbance results in reduced concentration and lack of orientation, due to which she could lose the hold over reality and her condition can worsen in future.

Self-care Deficit: Being self care deficit is another risk factor for Ellen. She is not able to take care of herself. She was found in the clothes, which were mismatched, unwashed and unkempt. This displays her impaired ability to dress herself and complete appropriate dressing activities. She spends most of her money in alcohol and cigarettes. She is not aware about her health and hygiene. This could also be risk factor because she has impaired judgement about her mental health condition and also suffers from hyperactivity (Townsend, 2014).

Discuss four (4) nursing care priorities for Ellen and provide a nursing intervention and a rational for each intervention identified.

Mood and Thought Process Disturbance

The first intervention would be applied controlling the thought and mood of the patient. It will be done by providing quite and comfortable environment to the patient and avoiding any kind of triggers that can disturb mood and thought process of patient.

Rational: Physical safety of the patient is very important. Quite and safe environment will help patient to relax and rest. Relaxing environment will control the mood effects and will help nursing staff to control the agitated and irritable mood of patient (Keltner, 2013).

Second nursing intervention is to increase the environmental stimuli and reorient the patient by informing about date, time and place. This will be done by calling patient’s name and informing that where they are.

Rational: The patient’s coping skills are impaired, thus decreasing environmental stimuli will help in reducing mood agitation. Re-orientation is important to make the patient aware about reality (Keltner, 2013). To stabilize the condition, reality check is very significant.

Self-Care Deficit

Patient is self care deficit thus, requires more support in maintaining the proper balance of diet and calorie intake. Nurse would monitor the diet and nutrition intake of the patient and will encourage patient to take more nutritional diet and increase fluid intake.

Rational: nutritional diet is very important for stabilizing the mental state of a patient. The patient must be aware of their physical needs and must not ignore the feeling of thirst and hunger (Sarris et al, 2015).

Nurse will encourage patient to take rest and sleep. If necessary, physician can also recommend medication for sleeping. Nurse would assist patient in personal hygiene such as bathing, laundering clothes and dressing.

Rational: Sleeping is very important for the patient suffering with bipolar disorder. Ellen has not slept for quite a long time, which has reduced her mental capacity of coping. Sleeping is important for increasing mental capacity and reducing fatigue (van der Voort et al, 2015). Personal hygiene is very important for fostering the feeling of well-being and sense of worth (Keltner, 2013).

Identify one (1) recovery principle (as per the National Framework for Recovery-Oriented Mental Health Services).

Describe how this recovery principle can assist in Ellen’s care?

One of the important recovery principles as per the National Framework for Recovery-Oriented Mental Health Services that would be most relevant for Ellen is Dignity and Respect (Principles of recovery oriented mental health practice, 2010). For the purpose of recovery from the mental health problem, it is very important to acknowledge the dignity and respect of the patient. The patient suffering with bipolar disorder may display agitated or flirtatious behavior like Ellen, but healthcare professionals should treat them with respect. The healthcare professional should offer respectful, courteous and honest interaction, as it will help patient to develop confidence and understand self-worth (van der Voort et al, 2015). Healthcare professionals should also respect that values, beliefs and cultural aspects of the patient, as mental health is often influenced by cultural beliefs and values and providing culturally competent care helps patient’s to develop trust for healthcare service (Principles of recovery oriented mental health practice, 2010). Healthcare professionals should also avoid any kind of discrimination and consider every patient as individual. This kind of care can help in fast recovery of Ellen.