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Essential SkillsFor mental health care
Dr Jim Crabb
13th September 2007
Introduction
Introductions Housekeeping Our aims, your aims Agenda Quiz Questions
Assessing someone
Important questions to ask• Personal details
• Presenting complaint
• History of the presenting complaint
• Golden questions
• Medical history
• Physical illness & allergies
• Safety questions
The mental state examination
Appearance Behaviour Speech Mood Thoughts Perception Cognition Insight
The physical health check
Pulse Temperature Blood pressure Capillary refill test Breathing rate Physical examination Urine tests Blood tests Alcohol tests
Get the whole story
Ask permission Speak to their family Speak to the person on their own
Bio-psycho-social treatment model
1. Medicines
2. Talking cures (psychological treatments)
3. Building the best life possible (social treatment)
1) Medicine
Use medicine when:• You know exactly what the mental illness is
• It is a serious mental illness
• It is a common mental illness that has not improved despite psychological / social treatment
Do not use medicine:• Just because the family expect it
• Because you do not know what else to do
1) Medicines: golden rules Stick to the lowest dose and the right dose Use one medicine Be patient Do not stop taking the medicine suddenly Managing side effects Use the right medicine Some medicines should not be mixed Medicines and pregnancy / breast feeding Medicines and children Medicines and the physically weak Medicine and alcohol Medicine and food
2) Talking cures a) Problem solving b) Relaxation c) Crisis planning d) Counselling e) Coping strategies f) Looking at a situation differently The therapeutic alliance
• Showing warmth• Showing empathy• Showing positive regard
a) Problem solving work
Derry’s story• Not enough money to buy food
• Owes his friends money
• Does not have a girlfriend
The plan• Wash and shave at a friends house
• Borrow clothes
• Work for free / work for food
• The plan worked! Derry was offered a job!
a) Problem solving
Activity!! Get into 4 groups Read your case study Make a plan Present your ideas
b) Relaxation: Activity!!
2) Talking cures
c) Crisis planning d) Counselling e) Coping strategies f) Looking at a situation differently The therapeutic alliance
• Showing warmth
• Showing empathy
• Showing positive regard
3) Building the best life possible
Getting the right balance• Daily routine
• Sleep hygiene
• Diet
• Exercise
• Pleasant activities
• Work Working with a persons family Managing stress Relapse prevention
Break time
The types of mental illness
Mental illness due to a physical illness.
This is called organic mental illness.
Mental illness due to the use of alcohol or illicit drugs. This is called substance misuse.
Where a person loses touch with reality.This is called psychosis.
Where a person is too sad or too happy.The mood disorders.
Where a person is worried or afraid The anxiety disorders.
Organic mental illness: Delirium
What are the key features• Partial loss consciousness
• Disorientated
• Not able to sleep
• Strange / odd behaviour
• Restless, aggressive, suspicious, fearful
• Forgetful
• Lack concentration
• Visual auditory hallucinations
• Sudden onset over days or hours
Organic mental illness: Delirium Who gets delirium
• Anybody with a physical illness• Very old, young
What causes delirium• Dehydration• Fever, infection• Abnormal levels sugar / salt• Head injury• Substance misuse• Medicine
Delirium activity!!
If you suspect delirium Group 1: What questions would you ask? Group 2: What would the mental state
examination show? Group 3: What would the physical observations
show? Group 4: Once diagnosed, what would you do
with this person?
Present ideas
Delirium treatment
Treat the physical illness• Monitor physical observations
• Give fluids
• Treat infection
• Lower dose medicines for mental illness
At the same time• Keep away from noise
• Reassure and remind
• Care for by one person
Lunch time
Organic mental illness: Epilepsy
What are the key features? Generalised seizures
• Becomes unconscious
• Fall down
• Bite tongue
• Become stiff and shake
• Eyeballs roll upwards
• Froth at the mouth
• Pass urine
• Lips become blue
• Feel drowsy afterwards
Organic mental illness: Epilepsy
What are the key features?• Partial seizures
• Awake but not aware• Aura• Jerky movements in one part of their body• Smack lips• Repeated movements
• Hysterical seizures• Fall to the ground and shake• Will not
• become unconscious• Bite tongue• Pass urine
Organic mental illness: Epilepsy Who gets epilepsy
• 1 / 100 people
• Under 30 years
• More common in men and people with mental retardation
What causes epilepsy• Withdrawal from alcohol
• Infection
• Abnormal levels of salt / sugar
• Bleeding / tumour in the head
• Delirium
Assessing someone when you suspect epilepsy
Questions to ask: Brainstorm!! Things to do
• Test for confusion
• Physical health check
• Check blood sugar – give sugary drink
• Make sure it was a seizure not a faint
What to do if someone has a seizure
Make the area safe Recovery position
• Remove objects in their mouth
• Loosen belts / ties
• Do not restrain
• Do not give medicine
• Protect the head
• Wait 5 minutes
• If not recovering….
What to do if someone has a seizure
Give medicines1. Insert airway
2. 100mg thiamine plus 50% dextrose soln
3. 10mg diazepam (wait 5 min)
4. 5mg diazepam (wait 5 min)
5. Repeat 5mg diazepam until• Seizure stops
• You have given 20mg diazepam
What to do if someone has a seizure
Check physical observations Move with a sheet
Long term treatment
Medicines• 2+ generalised or partial seizures
• Best medicines to use
• Sodium valproate
• Carbamazepine
• Side effects
• Hysterical seizures
• Do not give anti-psychotics or anti-depressents
Talking cures
Long term treatment
Building the best life possible• Sleep and wake at regular times
• Avoid alcohol
• Avoid extreme physical exercise
• Avoid stress
• Avoid triggers: flashing lights What next?
• Take medicines
• Do not swim alone, drive, operate heavy machines
• Tell doctor if planning children
Organic mental illness: Dementia
The key features of dementia• Forgetful
• Wander
• Angry and irritable
• Strange behaviour
• Make little sense
• Sexually inappropriate Who gets dementia?
• Over 65
• Younger people with HIV
Dementia
Cause• Disease of the brain
• Stroke
• Infection
• Alzheimer's disease
• Under active thyroid gland
• Drinking too much alcohol
• Low vitamin levels (folate, B12)
Assessing when you suspect dementia
What questions should you ask? Activity! What should you look for and do?
• Test for confusion
• Check sight and hearing
• Check to see if a physical illness is causing it
• Depression or dementia?
Treating dementia
Medicines• Treat the physical illness
• If no physical illness present: avoid medicines
• Haloperidol can be used to calm (short term)
Talking cures• Counselling
• Warmth and empathy
• Speak slowly, use simple words
Treating dementia
Building the best life possible• Work out a daily time table
• Keep tasks simple
• Give regular sight / hearing tests
• Identity bracelet
• Signs around the home
• Lock doors to prevent wandering
• Medicine What next
• Talk to the family - be honest.
Quiz
?
See you tomorrow