Case Study 1 Mental Health

Poly Pharmacy OD The important things to get across in this case are: • When Urine measurement becomes important • Knowing side effects of overdosed medication • Vital sign monitoring in normally healthy adult will show early deterioration • What vital signs should be measured

This patient has had a poly pharmacy overdose. Some of the key side effects include: • Sertraline – GI upset, urinary retention • Diazepam – hypotension, drowsiness, nausea & vomiting, urinary retention • Metaclopramide- nausea, drowsiness • Diclofenac – nausea & vomiting, acute renal failure, cardiac failure

Physiological changes include: • Renal failure due to overdose and effect of medications • Dehydration due to nausea • Decreased BP due to decreased stroke volume due to dehydration and/or side effects of

medications • Increased HR to compensate for decreased stroke volume • Increased RR due to acidosis and decreased oxygen delivery • Increased Creatinine due to renal failure

COMPASS© 09/04/2018

Facilitator Card Aim: To recognise a deteriorating medical patient Learning Objectives:

• Obtain adequate history • Obtain relevant vital signs using appropriate

equipment • Recognise limitations of electronic

equipment • Refer appropriately • Communicate effectively

Equipment:

• Facilitator Card • Player 1 Card – Mental Health Consumer • Player 2 Card - RN • IV Cannula • Medication Chart • Blood Test results • Observation chart • Fluid balance chart not available • Communication Card • Scribing Code Blue Form (Optional)

Roles in the scenario: 1. Consumer 2. Registered Nurse 3. Team Leader 4. Registrar 5. Optional extras:

a. Additional Nurses b. RMO c. Consultant d. Relative

Scenario Jack Brown UR 148766 Jack is a 46-year-old male consumer, admitted via ED after a polypharmacy overdose. The consumer was brought in by ambulance after taking sertraline, diazepam, metaclopramide and diclofenac (non-steroidal anti-inflammatory) medications. Hx of major depression and previous attempts at self harm. He was admitted 4 days ago. The last 2 days he has complained of nausea and that he has not passed urine. He was reviewed by the JMO and encouraged to drink fluids. Today he is complaining of abdominal pain. To start the scenario: 1. Assign roles to each player 2. Set up room with the consumer in a chair 3. Give the first player card to the player designated as the Consumer 4. Give the Second player card to the player designated as the RN 5. When the RN Phones the Intern place the two players (RN & Intern) back to back to simulate communication via the phone. 6. Allow the scenario to build on itself prompting other players to enter as called for or prompt if necessary 7. Supply players with further information such as medication charts, observations or blood results when asked

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During the Scenario: Part 1

If the RN needs prompting: • What are your first actions?

Suggested Responses • Talk to patient brief history • Full set of vital signs • Oxygen • Refer to Team Leader

Who would you notify?

• Team leader • RMO

The RN should discuss the case face-to-face with the Team Leader (ISBAR)

Communication should be clear expressing concerns and what he/she would like the TL to do

If the T/L needs prompting: • What are your first actions? &

Why? • Oxygen • Vital signs • Blood sugar level

Who would you notify? • RMO

If the RMO needs prompting: What further information do you require & what assessment would you do? • Full examination • History • Fluid balance • Vital signs • Medication chart What tests would you order? • Repeat Bloods • ECG

What is your management plan for this consumer? • Oxygen • IV Access • IV Fluids • Bloods • Ongoing vital sign orders • Notification of Medical

Registrar/Psychiatric Registrar • Transfer to appropriate medical

environment

To summarise • Ask the group: • What they thought went well?

• What suggestions would they

make to improve their roles?

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ECG will show Sinus Tachycardia Medications: Sertraline po mane Diazepam 14 mg nocte Olanzepine 5 mg nocte

Blood Results Normal Range Sodium 136 137-145 Potassium 7.0 3.2-5.0 Creatinine 1437 60-110 Urea 52.2 2.5-7.5 Hb 141 115-160 g/L WCC 8.1 4.0-11.0 x 109 /L Plat 162 Glucose 4.2 3.5-5.5

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Player 1 Consumer You are Jack Brown, a 46-year old male consumer currently in the AMHU. You are in the AMHU undergoing treatment for depression and previous self-harm. The nurse will find you on one of the lounge chairs. You are currently in the foetal position. Please note: If required, you may prompt the nurse by saying “you have not asked me any questions that I can answer”. Answer, only when you are asked a direct question. Listed below are some possible answers that you may provide to the nurse: I feel sick, I want to throw up. I have pain in my stomach. I do not remember the last time I went to the toilet, it definitely wasn’t yesterday or today. Listed below are some possible answers that you may provide to the doctor: I am on lots of tablets, I had all of them before I came here. I did not know that I was not supposed to take so many tablets all in one go. You may add any other information, as long as you are asked. Player 2 Nurse You are caring for Jack Brown, a 46-year old male consumer currently in the AMHU. He was admitted four days ago for depression and previous self-harm. Jack is currently on one of the lounge chairs in the foetal position. You approach him to assess him. What assessments will you conduct? You will need to ask Jack some questions, but he will not answer you unless your questions are direct and specific.

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Player 3 Doctor You are caring for Jack Brown, a 46 year old male consumer currently in the AMHU. He was admitted four days ago for depression and self-harm. The nurse has contacted you regarding your patient. The first item on your agenda: You need to make sure the communication provided to you by the nurse is clear. Below is an ISBAR communication of information that should have received. Anything that is not clear, you need to clarify before you can progress. Please refer to the ISBAR provided to help you clarify the information from the nurse. ------------------------------------------------------------------------------------------------------- At this point you should be satisfied with the information provided to you by the nurse. Additional information: You were the admitting officer for Jack Brown, so you are also aware Jack had a polypharmacy overdose, eventuating in his admission to the AMHU. What assessments will you conduct? Ask the patient any questions that you have. If you have no other thoughts on how to progress, who else is the multidisciplinary team could you involve? ISBAR (guide only) Identify: Nurse, doctor, patient. Situation: Nausea and abdominal pain. Has not passed urine. Vital Signs/MEWS. Background: Days of admission. Depression and self-harm. Assessment: Concerns about Jack. Recommendation: Investigate abdominal pain etc.

COMPASS© 09/04/2018

Player 4 Pharmacist (You are possibly involve resulting from suspicion of poly-pharmacy overdose) If you are involved in discussion, share some of the side-effects with the group. Zoloft (sertraline): Palpitations, nausea, vomiting. Maxolon (metoclopramide) Nausea, bowel disturbance. Valium (diazepam) Hypotension, cardio-respiratory depression. Voltaren (diclofenac) Nausea, vomiting, diarrhoea, renal failure.

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COMPASS© 09/04/2018

COMPASS© 09/04/2018