Keiser University

Associate Degree Nursing

Program

NUR 1035C Advanced Adult Health (Mental Health)

Mental Health Nursing Case Study

DIRECTIONS: This assignment will enable you to demonstrate the use of the Nursing Process in caring for your client. Please complete all areas of this form. R e m e m b e r t o a t t a c h m e d i a t i o n s h e e t s , p r i n t a n d s u b m i t .

SECTION 1. ASSESSMENT

A. Data Collectio n : Admission

1. What bought the client into an “in-patient “setting?

Father was taking him to WMC, he didn’t want to go so he exited the vehicle at a stop light and ran away. He was reported as a missing person and was brought to COC after being found by the PD.

2. What is the Admission Diagnosis?

Psychotic D/O NOS, Asperger’s D/O

3. Give a brief description of this primary condition.

Psychosis is a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality.

Data from Present Problem (Chief Complaint, S/S, Duration, Self-treatment and/or Prescribed treatment)

Clinical Significance

Client was brought in on a 52 (baker) by police, after he ran away from his father’s vehicle. Psychosis – Potential Harm to himself.

Client displayed signs of psychosis and catatonic paranoid state. He needs continuous medication therapy and frequent psychiatrist evaluations.

B. What data from the Past Medical History (PMH) are significant to the nurse, and may affect this presentMEN T AL HEA L TH complaint?

Client has a history of psychosis, one previous inpatient hospitalization in 2010. He has since controlled his psychosis with the help of an outpatient psychiatrist (Dr. Gates). He has a history of ETOH use but has reported no drinking within the last few years due to health reasons.

C. Current Medical History and Physical Result s : Include rationale and implications for abnormal results here. Are results better or worse since admission? Which results are clinically significant?) What other MEDICAL or CHRONIC conditions may also affect their psychiatric care?

Complete information Requested. Also indicate if (N) Normal or (AB) Abnormal Assessment – (B) Better or(W) Worse since Admission

Indicate (CS) if clinically significant and state Rationale for Abnormal Results

Current Vital Signs: T,P,R,BP, O2 Sat, PainScale

T- 97.5°F, P- 60, R-18 BP- 106/74, O2 Sat- 100%, Pain- 0

WNL

General appearance: Normal

Neurological Normal

Respiratory Asthma Not clinically significant for his mental diagnosis.

Cardiac Normal

GI Normal

GU Normal

Integumentary Normal

Musculoskeletal Normal

Psycho/Social/Pain Asperger’s – Unmet intimate need (10 years)

The fact that he has not had a romantic relationship in 10+ years causes him severe depression that escalates to anger. This causes outbursts and threats directed toward his family, friends and himself.

D. Mental Health Assessments1. What are the MULTI-AXIAL ASSESSMENT SCORES? How do they correlate with the data collected in A, B, and C above?

(Refer to Article and Handouts: GAF Scale).

Axis I—Psychotic D/O NOS, Asperger’s D/OAxis II— None Axis III—AsthmaAxis IV—NoneAxis V—34

2. Mini Mental Health AssessmentAttach the “Mini-Mental Health Assessment Form (may be different for each facility) for your client.

N/A

3. Mental Status AssessmentDirections: Refer to PowerPoint Slides in Mental Health Clinical Folder for assistance in completing the following:

Primary Affect Noted: Appropriate Affect

Disorder of Motor Aspects of Behavior Specific Examples

No psychomotor agitation or retardation.

Disorders of Perception Specific Examples

Denies hallucinations, illusions, and other perception disorders.

Disorders of Thought Specific Examples

Loose Associations “Hail storm. All hail the chief.”

Disorder of Memory Specific Examples

None. He is able to recall even minor details of events that happened several years ago. He is also able to recall short term events.

Describe in Detail any Pathology noted in: Give Specific Examples

Judgment

Does not make rational decisions. He ran away at a stop-light through traffic because he didn’t want to go to the hospital for his evaluation.

Insight Give Specific Examples

Does not understand own illness. Client was unable to explain or name his illness but he did know he had some type of mental illness.

Defense Mechanisms Give Specific Examples

Intellectualization He spoke in detail about all of the medical procedures his grandfather was having done, rather than the fact that his grandfather is dying.

4. Suicide Evaluation Sheet(Every “Yes” answer increases the possibility of suicide)

# Assessment Areas Evaluation Findings

Yes NO

1 Has the client sustained a recent loss (of job, friend, family member, home, status, or part of body)?

X

2 Is s/he isolated from others socially; without friends? X

3 Has s/he ever attempted suicide? X

4 Has a member of their family attempted suicide? X

5 Has s/he ever been treated for mental illness? X

6 Is s/he old, bereaved, or in physical pain? X

7 Does s/he view suicide as a release? X

8 Is s/he diagnosed as psychotic? X

9 If so, does s/he hear voices telling him to kill himself? X

10 Is s/he depressed? X

11 Has s/he said he wished to die or has failed to perform life-saving acts? X

12 Does s/he have a history of self-destructive behavior (consistently reckless, accident prone, addicted to alcohol or other drugs)?

X

13 Does s/he lack a religious background that enjoins against suicide? X

5. Suicidal Assessment - SAD PERSONS ASSESSMENT(Utilization of this SCALE will help with decision making regarding hospitalization)

Category Present Absent Assessment Details

Y N

S SexMen kill themselves 3x more than women, although women make attempts 3x more than men.

X Male

A AgeHigh-risk Groups: 19 years or younger 45 years and older.

X 32

D Depression35-79% of those who attempt suicide manifest a depressive syndrome.

X Admits depression

P Previous AttemptsOf those who commit suicide, 65-70% have made previous attempts.

X No previous attempts

E ETOH (Ethanol)ETOH is associated with up to 65% of suicides. Heavy drug use is also considered in this category.

X No longer drinks alcohol

R Rational Thinking LossPeople with Psychoses (functional or organic) are more apt to commit suicide than those in the general population.

X Psychotic

S Social Supports LackingA suicidal person often lacks significant others, meaningful employment, and religious support. Access all three of these areas.

X No job, religious support or romantic relationship.

O Organized PlanThe presence of a specific plan (date, place, and means) signifies a person at high risk.

X Denies plan or intention.

N No SpouseThose persons who are widowed, separated, divorced, or single are at greater risk than those who are married.

X Single

S SicknessChronic, debilitating and severe illness.

X No sickness or injury. Pt suffers from a mild case of

Asthma.Total 5

Guidelines for Action

Total Points Proposed Clinical Action Your Assessment

0-2 Send home with follow-up. Client claimed and appeared to be depressed due to not having a romantic relationship. He admitted loneliness that leads to anger.3-4 Close follow-up; Consider hospitalization.

5-6 Strongly consider hospitalization.

7-10 Hospitalize or commit.

Source/Citation: Patterson, W., Dohn, H., Bird, J., Patterson, G. Evaluation of suicidal patients: The SAD PERSONS scale. Psychosomatics, April 1983, Vol. 24, No. 4.

E. Diagnostic and/or Laboratory T ests and Procedure s :1. What diagnostic tests would indicate, confirm, or preclude suspected diagnosis.

Test Result Rationale for Abnormal Results and Implications

None

2. What laboratory tests would indicate, confirm, or preclude any suspected diagnosis?List the lab test and findings, rationale for abnormal results and the implications. Especially note which tests support current or past medical diagnosis. Are results better or worse since admission? Which results are clinically significant?)

(In addition to the CBC and BMP, which tests are pertinent for this client)?

Adm. results

High/low/ WNL

Most Recent

Rationale for Abnormal Results and Implications

Sodium 141 WNL

Potassium 3.7 WNL

Glucose 77 WNL

BUN 23 HIGH May indicate Impaired Kidney Function or Dehydration

Creatinine 1.12 WNL

WBC 7.37 WNL

RBC 5.28 WNL

HGB 15.7 WNL

HCT 43.3 WNL

Add’l lab work (A1C, LFTs)

Platelets

MCV

F. Medication Reconciliation

1. Correlate medication treatment with present, past, or current diagnoses. Clearly state which medications treat which conditions? Are these medications continued in the hospital? If medication reconciliation was not done at time of admission by facility, this section should still list ALL psychotropic medications patient is taking. This section will NOT be left blank.

Diagnosis Medication Cont’d

Depression Serogruel 100 mg Yes

Anxiety Paxil 20 mg Yes

Panic Disorder Klonapin 0.5 mg Yes

Psychosis Zyprexa 10 mg Yes

Depression Prozac Yes

2. For each medication current being given, create a list including drug classification, dosage, mechanism of action ,three (3) major side effects, nursing considerations, client teaching information and rationale for why this client is currently receiving this medication. (Use ATI Med. Template or a table may be made to include medication, classification, purpose, dose/frequency/route, side effects, adverse effects, and nursing considerations).

SECTION 2. NURSING PROCESS

1. Nursing DiagnosisCompile a list of Actual and Potential-At-Risk Nursing Diagnosis, appropriately written to include Nursing Diagnoses with etiology statement and with As Evidenced By subjective and objective supporting data. (Minimum of 5, Maximum of 10).List them in priority order by considering ALL pertinent diagnoses, abnormal findings and potential complications.

1. Risk for suicide; r/t depressed mood and feelings of hopelessness

2. Knowledge deficit; r/t cognitive limitation; AEB Client admits he does not know what his illness is.

3. Anxiety; r/t interpersonal conflicts; AEB Insomnia, Feelings of helplessness

4. Ineffective Coping; r/t inadequate psychological resources; AEB Chronic Depression, Insomnia, Irritability

5. Sleep Pattern Disturbance; r/t Anxiety/Fear; AEB Insomnia, Irritability

6. Sexuality Patterns, Altered; r/t Absence of Partner; AEB Expressed dissatisfaction with sexuality

2. Nursing Care PlanComplete the following table for the two (2) priority actual diagnoses and one (1) highest priority potential diagnosis. List highest priority first. Fill in Interventions, Rationale and Evaluation for each problem identified.

Nursing Diagnosis (List 3)

Expected Outcome

Nursing interventions

Rationale Evaluation

Risk for self-violence r/t

delusional thinking and impulsivity

Client has experienced no physical harm to

self. Denies suicidal ideations.

Create a safe environment for the

client.

Maintain close observation of the client in frequent, irregular intervals.

Client safety is highest priority.

Necessary to ensure client does not harm self

in anyway, and makes staff surveillance from becoming predictable.

Client denies plans and desire to harm

himself.

Knowledge deficit, r/t cognitive

limitation, AEB Client admits he

does not know what his illness is.

Pt verbalizes understanding of

illness.

Provide a quiet atmosphere without

interruption.

Focus teaching sessions on a single

concept or idea.

This allows patient to concentrate more

completely.

This allows the learner to concentrate more

completely on material being discussed. Highly

anxious and elderly patients have reduced

short-term memory and benefit from mastery of one concept at a time.

Pt is interested in learning and is able to

read and write.

Anxiety; r/t interpersonal conflicts; AEB

Insomnia, Feelings of helplessness

Patient is able to recognize signs of

anxiety.

Determine how patient copes with anxiety.

Reassure patient that he or she is safe. Stay

with patient if this appears necessary.

This assessment helps determine the

effectiveness of coping strategies currently used

by patient.

The presence of a trusted person may be

helpful during an anxiety attack.

Pt describes a reduction in level of

anxiety.

3. Client Resources and Personal Strengths

Identify 5 Client Strengths. State how these can be used to help with treatment options.

1. Capable of ADLs. Client has some pre-established independence.

2. Client has access to mental health services. Client will be more likely to successfully continue therapy after discharge.

3. Client has interpersonal relationships and support. Family will help facilitate support after discharge.

4. Client has a history of compliance while in structured environments. Client will adhere effectively to treatment while in facility.

5. Client expresses motivation to get better and go home. Will help facilitate client adherence to therapy programs.

4. Discharge Planning – What is the clients discharge plan? (Discharge to home, Rehab Center, Group home…)

Client was discharged in the afternoon.

5. Client Education1. Complete an Educational Assessment on your client:

Client is interested in learning, he can read and write.

2. Discharge Education Priorities:What needs to be included in discharge teaching instructions?

Teaching Need Teaching Instructions/Rationale Methodology for Presenting

Relaxation Techniques Relaxation techniques are a great way to help with stress management.

Verbal education and printed material.

Information on the client’s illness, he does not know what specific illness he suffers from.

When patients are provided with a solid knowledge base about their disease process and treatment, the outcome is more favorable.

Verbal education and printed material.

3. Attach teaching materials or describe handouts given client (Ex. AA Step Booklet, Self –Esteem Packet as part of Psycho-education Teaching).

SECTION 3. EVIDENCED BASED PRACTICE

A. Attach an article from a nursing journal that is supportive of your client’s care. (Use a peer reviewed NURSING article related to the CARE you have given.) Remember to attach Reference Sheet at back of Paper. Also remember to cite sources throughout paper.

B. State how content from this article was applicable to the care you provided?

The cognitive-behavioral therapy (CBT) approach for treating Psychosis helps to minimize exacerbations and calm patients Before their psychotic episode gets out of control.

SECTION 4. STUDENT/CLIENT INTERACTION Directions: This must be a minimum of five (5) minutes/five recordings and be a record of the interaction (or an excerpt of an interaction) Include both verbal and non-verbal observations/behaviors. Label your nursing interventions (including specific names of communication techniques). Evaluate in detail specific psychopathology, defense mechanisms, mood, etc. Evaluate the effectiveness of your intervention. Make comments about interventions you neglected to use but would include if you could interact with client again. Refer to textbook and A TI companion book .

Student Client Assessment/Evaluation Client and Self

Ex. I said:(My non-verbal, thoughts, feelings) Technique used (Broad opening, Reflection, Restatement ..)

Client said:(Client non-verbal, mood, behavior)

What I think was going on, what techniques I could have used differently. What went well. What I would change. I should have said “xxxxx”

Student Client Assessment/Evaluation Client and Self

I introduced myself to D.G.

NV: Smiling and making eye contact.

“Hi. My name is Chrystal and I am a nursing student. I was wondering if I could talk to you for a little while.(Broad Opening)

NV: Made eye contact, smiled.

Appears excited, smiling.

“Yeah, let’s go in here, this is where I sleep.”

NV: Starts walking toward his room.

Trying to establish rapport. Client seems excited to have someone to talk to. Focusing on his comfort with my presence.

I directed the location of the conversation to be outside of his room.

“Oh, well that’s nice but how about we sit right here and talk?”

NV: Gestured toward a table and sat down.

He seemed hesitant but agreed.

“Oh, well, ok.”

NV: Sat down in the seat across from me.

Maintained a safe environment for our conversation. Tried to ensure his comfort as well.

I inquired about his hobbies.

“So what do you like to do for fun?”

NV: Smiling, Leaning in, and maintaining eye contact.

He answered my question.

“You mean outside of here? I like to go hiking, I used to surf when I lived beach side but I live in Palm Bay now so I don’t surf as much anymore.”

NV: Rarely makes eye contact, but is very talkative.

Trying to build rapport by showing interest in the client. Still keeping the conversation focused on him.

I continue to show interest in the client.

“So you like to do outdoors activities?”

NV: Smiling, maintain eye contact and continue to lean in.

He is very excited.

“Yeah, well I used to be a surfer, I dressed like a surfer, talked like a surfer, and I did all the things surfers like to do.”

NV: Uses a lot of hand gestures, still only making eye contact after he finishes speaking.

Tried to build the client’s trust by showing a genuine interest in him.

Shifted the conversation to more personal topics.

“Tell me about your family. I know you live with your father, is there anyone else at home?”

NV: Facing client squarely, maintaining eye contact, and smiling.

He appears a little nervous but answers my question.

“Yeah, I live with my father, my stepmother and my brother. He’s older than me and I think I embarrass him because, ya know, little brothers.”

NV: Shrugged his shoulders when referring to his brother.

Establishing client comfort and rapport, tried to go deeper in the conversation to gain more knowledge about the client.

SECTION 5. JOURNALING

DIRECTIONS: This assignment will enable you to focus on YOUR THOUGHTs, FEELINGs and BEHAVIORS experienced during each clinical experience to identify changes in your attitudes, as well as identify your growing edges in understanding mental health.1. Answer the following questions regarding your MENTAL-HEALTH CLINICAL EXPERIENCE.2. The following weblinks may be used to cultivate this section.

https:// ww w .youtube.com/watch?v=cRMogDrHnMQ Zig Ziglar https:// ww w .youtube.com/watch?v=pfWGoLj1JCM Will Smith

1. In what sense does the quote, “It’s not your aptitude that determines your altitude but your attitude

that determines your altitude” (Zig Ziglar), apply to your (a) personal, (b) academic and, (c) professional

growth?

Response: I think this quote is very true. The smartest person in the world wouldn’t achieve anything if they had the wrong attitude. Aptitude does play an important role but it is not the deciding factor on how far you will go in life.

2. Did you find that you were able to use your “voice” during the mental-health rotation? Describe?

Response: Yes I do, I think I was a bright spot in my client’s day. The fact that someone took the time to focus on him made him very happy.

3. Did you have any “Significant Learning Opportunities” (SLO) moments where you either learned a new life lesson or learned something about yourself?

Response: I learned a lot about the psychotic client. In some cases, if properly medicated, a psychotic client can seem like any other person. There were a few instances in my conversation with D.G. that I almost forgot we were at COC, I felt like I was talking to a person who had no mental illness. Of course, there were several instances in the conversation that was not true as well.

4) In what sense were you “Challenged”?

Response: I was more challenged at first, I felt a little scared when we first arrived at COC. I didn’t know what the environment was going to be like and how ill the patients were going to be. After a few minutes of being there and talking to a few clients I quickly gained a certain comfort level. Although, I was never fully comfortable the entire time I was there.

5) a. What did you identify/uncover as your personal strengths?b. How can you apply them in the academic setting and also with your future patients?

Response: I identified I am able to not react when a client acts in a way that might be funny to another person. I can apply that with almost every patient. People are the most vulnerable when they are in a health care setting so there will almost always be an instance when it would be easy to laugh or smile in response to a patient, I now know I can keep a straight face and give the client a great level of care even in their worst situations.

6) a. What did you identify/uncover as your limitations?b. What strategies, utilizing the personal strengths you have identified in the prior question, can

you use to overcome these limitations in the academic setting and also with your future patients?Response: My biggest limitation is shyness. I can use my strength to overcome my limitation

by seeing them as people and not patients.

2. Answer the following questions regarding your Daily Clinical Experience

Clinical Day/Date Thoughts (Cognitive Learning

Feelings (Affective Learning)

Actions (Behavioral Understanding)

OrientationEx. What I learned today was …. I was able to apply …….

EX. I saw a change in my feelings ……

EX. I noticed a change in my posture and in my approach toward clients….

Clinical Day #1 What I learned today is that people with psychosis can appear perfectly normal. I was able to apply active listening while speaking with my patient.

I saw a change in my feelings after speaking to my first patient. At first I was nervous and a little scared. After speaking to him I felt understanding and empathy.

I noticed a change in my posture and in my approach toward clients. I was more open and less guarded.

Clinical Day #2 I was unable to attend my second clinical day due to an emergency outpatient surgery that had to be performed on my daughter.

3. Complete the following: (If attaching support group reflection this box may be omitted.

Directions: You are to attend one (1) support group, outside of your scheduled clinical experiences. After attending the meeting, record the following information:

Date, T ime and Address of Meeting Brief Evaluation of the Meeting

Support Group #1

Already turned in.

SECTION 6. DOCUMEN T A TION METHODOLOGY Effective communication is essential for optimal client centered care and continuity of care for your client. Summarize your shift report in the SBAR format.

Situation: Client is a 32 yr old white male, who was brought in on a 52 (baker) by police after running away from his father’s vehicle at a stop light.

Background: He has a history of depression and psychosis.

Assessment: He seems very pleasant and cooperative. He understands why he’s here. He has good speech and medicine compliance. He is socially active and talkative.

Recommendations: I recommend this client is properly educated regarding medication. I also recommend education regarding seeking help early in a crisis and not waiting as long as he did. He will need to learn the signs and symptoms of exacerbation.

SECTION 7. RESOURCES - Attach APA references to case study.