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I need to answer these guided reflection questions on the scenario below on a Patient with Bipolar Disorder and the virtual inter Mental Health Case: Sharon Cole Guided Reflection Questions Opening Questions How did the simulated experience of Sharon Cole’s case make you feel? Talk about what went well in the scenario. Reflecting on Sharon Cole’s case, were there any actions you would do differently? If so, what were these actions and why? Scenario Analysis Questions* PCC What issues have you identified that could be barriers to a successful treatment for Sharon Cole? How would you address the manic state? PCC/I Identify a support group that would be beneficial to Sharon Cole’s husband. PCC/S What action should be initiated due to Sandra Cole’s medication regimen? Concluding Questions How would you apply the skills and knowledge gained in the Sandra Cole case to an actual patient situation in different acute care units (emergency room, intensive care unit, obstetrics unit, etc.)? Patient Introduction Location: Inpatient orthopedic unit Time: 14:00 Report given by charge nurse: Situation: Sharon Cole is a 31-year-old female who was admitted last night for surgical repair of a right ankle fracture. She went to surgery this morning at 08:00 and came back from the postoperative unit at 11:30. Background: Mrs. Cole sustained the injury when she fell from the stage in a bar. According to the paramedics who responded to the 911 call at the bar, she was ranting about the government and talking about how she was the only one who could help rectify Washington’s problems. She jumped up on the stage and grabbed the microphone from the band leader, and in the struggle that ensued, she fell off of the stage and fractured her ankle. Her husband was contacted by the emergency department, and he was here prior to her surgery. He and her sister had been searching for her for hours before the accident. He reported that she was diagnosed with bipolar disorder 6 years ago and that she had not been sleeping or eating much for the past 2 weeks. The family was worried that she was at risk of another manic episode, but she became irritable when they questioned her behavior or her compliance with her medication. Her husband reports that she is normally adherent to her medication regimen, which is lithium 600 mg twice a day. The last time she stopped her medications was 2 years ago, and she had a manic episode after that. A psychiatric consult was initiated, and her medications and diagnosis were confirmed by her regular psychiatrist. Lithium will be restarted this afternoon. Assessment: She has been very loud and verbal since she came from the postoperative unit. She is somewhat oriented; she knows that she’s in the hospital, but doesn’t really remember the details of the fall. She knows her name and recognized her husband, but her recollection of the events of last night is inconsistent as she relays the story to different staff members. She does not know what day it is. She is having grandiose thoughts, her speech is pressured, and she is talking constantly, exhibiting a flight of ideas, with thoughts ranging from issues in Washington to suggestions about running the hospital better. She has used the call light several times, saying that she needs to get out of here, and keeps asking whether she can use the unit phone to call Washington. So far, she has responded to redirection with irritability. She has a fentanyl patient-controlled analgesia (PCA) pump for pain control. Her vital signs are stable: temperature, 37.2°C (99°F); heart rate, 88 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/70 mmHg. She denies pain, but she says she never feels pain. She has threatened to take her intravenous (IV) line out to get rid of the pain medicine, which she says makes her feel like she’s “not herself.” So far, we’ve been able to talk her into keeping it. She takes small sips of water when it is directly given to her. There is a sitter present for the patient’s safety. Recommendation: There is an order for lorazepam, 2 mg, as needed for agitation. We have not given it yet, but you may need to do that. Please also complete an assessment. The provider wants to be called about assessments and her status. He expects she can be discharged later today, but she may need to be moved to the inpatient psychiatric unit. You checked scene safety. It was correct to check scene safety in order to maintain your own safety. You introduced yourself. You identified the patient. You washed your hands. You asked if the patient had any known allergies. You performed medication reconciliation. You asked the patient: Is it OK for your family to be here, while we talk? The patient said: Where is Allen? I need to talk to him. This is all his fault. He is keeping me from my work. He hates me and tries to poison me. Tell him to stay away from me! I’m not going to eat anything, not one bite.\nYou answered: I’ll sit and talk with you awhile. \nYou used the therapeutic technique of offering self. You asked the patient: What is your full name? The patient said: My name is Sharon Cole. You asked the patient: Have you taken your medication? The patient said: You bring me all those pills just to keep me quiet. I won’t take them; they make me blurry flurry. You can force all the others, but you can’t control me!\nYou answered: I am offering you medication to help you; however, I cannot force you to take it. \nYou used the therapeutic technique of giving information. You asked the patient: Can you tell me a little bit more about what’s going on with you today? It was appropriate to ask the patient what was going on with her to get an understanding of this. The patient said: There’s too much work to be done. I can’t do it here and you can’t make me stay here. I’m going to call the police and have you arrested. You are keeping me prisoner. I’m leaving now.\nYou answered: You are in the hospital for treatment. Please stay in the bed. \nYou used the therapeutic technique of giving information. You asked the patient: Over the past year, when did you feel your best? It was appropriate to ask the patient about when she felt her best. The patient said: You know, if I wanted to I could run this hospital. I know the president, and I can make it happen. I like you; you remind me of my family. You can come to dinner with us. I make the best BBQ pork in the world. Allen is not a good cook.\nYou answered: How can you run this hospital when you are a patient? \nYou used the nontherapeutic technique of challenging. You asked the patient: Is it OK for your family to be here, while we talk? The patient said: No, but thank you for asking. You asked the patient: Do you have any pain? The patient said: And you, because of you I can’t do my work. You keep me downtown all the time in this bed.\nYou answered: Mrs. Cole, I’ll be glad to sit with you and talk awhile. \nYou used the therapeutic technique of offering self. You asked the patient: Do you have chest pain? The patient said: You don’t care; my job is important and you are not able because of green.\nYou answered: I’ll sit with you and stay awhile. \nYou used the therapeutic technique of offering self. You asked the patient: Do you have chest pain? The patient said: No! You asked the patient: Where is your pain located? The patient said: It was you! You are the one who called the assassins to get me. You told them where I was, you bitch! You broke my foot. This is all your fault!\nYou answered: Mrs. Cole, I am a nurse here at the hospital where you had surgery. \nYou used the therapeutic technique of giving information. You asked the patient: What other pain management strategies have you used other than medications? The patient said: I don’t have any pain. You asked the patient: Would you like a tray with some food? The patient said: If you don’t bring me my car keys and help me get out of here, I’m calling your boss! I am your bossy boss. I own this hospital and I own you. When I get out of here, I’m going to make you pay! Where is my water? Can I have a soda?\nYou answered: You are a patient here. How can you own the hospital? \nYou used the nontherapeutic technique of challenging. You asked the patient: Would you like a prepacked sandwich to eat? The patient said: No thanks, I am not hungry right now. You asked the patient: Have you had any changes in your appetite over the past month? The patient said: That guy who took my blood pressure, now he’s a hot one! He got my blood pressure way up. Next time I see him I’m going to show him a thing or two about love.\nYou answered: He is the nursing assistant. You need to behave appropriately with hospital staff. \nYou used the therapeutic technique of giving information. You asked the patient: Have you had any changes in your appetite over the past month? The patient said: I haven’t needed much food. You asked the patient: Do you get hungry? The patient said: No. You asked the patient: How many meals do you eat each day? The patient said: I eat when I have time. You asked the patient: Do you eat between meals? The patient said: No. You asked the patient: Have you been eating much less or much more over the past few weeks? The patient said: I don’t remember the last time I ate. You asked the patient: Have you lost or gained weight over the past month? The patient said: I don’t know. You asked the patient: Do you notice that your clothes are fitting looser or tighter than they were a few weeks ago? The patient said: Where is my bag? Allen likes it when I dress up. This hospital gown is down, down, down. I can’t wear this in bed. I know I have a gown in here. Forget it, I’ll just take it all off. I bet the doctors will love me now. They won’t be able to stay out of my room.\nYou answered: That is not how a married person is supposed to talk. \nYou used the nontherapeutic technique of making value judgments. You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: I’m the type of person who can get everything done. I don’t need sleep; I’ll sleep when I’m dead!\nYou answered: Let’s talk more about the importance of sleep. \nYou used the therapeutic technique of focusing. You asked the patient: Do you nap during the day? If so, how often and for how long? The patient said: No, I have no time to sleep. You asked the patient: Do you have any trouble falling asleep? The patient said: No. You asked the patient: Do you wake up in the early hours of the morning and have trouble returning to sleep? The patient said: No. You asked the patient: Do you have nightmares or vivid dreams on a regular basis? The patient said: No. You asked the patient: Approximately how many hours of sleep do you get each night? The patient said: I don’t need to sleep. You asked the patient: Do you have energy to do the normal activities necessary to get through the day? The patient said: Let me use the phone and I’ll stay in bed as long as you want me to. I promise I’ll be good. You are so pretty. I’ll take my medicine and everything. I just need to make one little tiny phone call.\nYou answered: Now is not the time to use the telephone. \nYou used the therapeutic technique of giving information. You asked the patient: Do you have energy to do the activities that give you enjoyment? The patient said: The only activity I have to do is get to Washington to help. Don’t you people care about all the soldiers who are going to die? You asked the patient: I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care. These are questions I ask all of the patients I see. May I ask you these questions? The patient said: Who put all these wires on me? I don’t like them; they remind me of snakes. Take them off!\nYou answered: This is your IV for your medicine. Please leave it alone. \nYou used the therapeutic technique of giving information. You asked the patient: Do you feel alert to answer questions? The patient said: This little red button is a direct line to Washington. If I keep pushing it, then someone will come save me. Don’t tell anyone; it’s a secret.\nYou answered: That is your nurse call button. It calls the nurse’s station. \nYou used the therapeutic technique of presenting reality. You asked the patient: Please tell me your name. The patient said: Don’t tell the doctor about Washington. He’ll just put me on more medication.\nYou answered: Tell me more about your medications. \nYou used the therapeutic technique of exploring. You asked the patient: Can you tell me where we are? The patient said: Last night seems like a dream. I don’t think I was even there.\nYou answered: What seemed to lead up to you going to the bar? \nYou used the therapeutic technique of placing the event in time. You asked the patient: Please tell me what today’s date is. The patient said: I don’t know. All of the days go together. You asked the patient: How would you describe your mood? The patient said: My mood is great. You asked the patient: Have you lost interest in activities that you once enjoyed? The patient said: My only interest is getting to Washington. They are going to waste all the money on the wrong things! I have to get out of here! You asked the patient: Name an activity that you enjoy. The patient said: I love being an attorney, but you are keeping me in this place and not allowing me to help the people who need me. You asked the patient: Can you name the last five American presidents starting with Barack Obama and going back? The patient said: Barack Obama, George W. Bush…. They are in Washington, and I need to get there! You asked the patient: Can you tell me what you ate for breakfast? The patient said: I can’t believe you are doing this to me. This is all your fault. Why are you so mean?\nYou answered: Are you feeling that no one understands? \nYou used the therapeutic technique of translating to feelings. You asked the patient: Name an activity that you enjoy. The patient said: I love being an attorney, but you are keeping me in this place and not allowing me to help the people who need me. You asked the patient: Can you tell me what you ate for breakfast? The patient said: I don’t think I ate breakfast. You asked the patient: Do you have any thoughts or wishes to harm or kill yourself? The patient said: Look, I need to get out of here. The whole thing is going to fall apart. I can’t get to Washington. Don’t you people care about all the soldiers who are going to die without my help? Nobody can see it, but I can! They are going to waste all the money on the wrong things! I have to get out of here. Allen can drive there. This thing on my leg is in the way.\nYou answered: Mrs. Cole, I am your nurse today and I am here to help you. You just had surgery. Please stay in the bed. \nYou used the therapeutic technique of presenting reality. You asked the patient: Have you ever tried to harm or kill yourself? The patient said: No. You asked the patient: Do you think it would be better if you were not alive? The patient said: Of course not. You asked the patient: Do you have any thoughts or wishes to harm anybody else? The patient said: There was an assassin who pushed me last night. He pushed me off that building and broke my foot. Take this off me. I have to go find him and kill him before he gets to us.\nYou answered: You are in the hospital. Please stay in the bed. \nYou used the therapeutic technique of encouraging description of presenting reality. You asked the patient: Do you have any thoughts or wishes to harm anybody else? The patient said: Not unless they tried to assassinate me. You asked the patient: Have you ever tried to harm or kill somebody else? The patient said: No. You asked the patient: Can you tell me what a desired outcome of treatment would be for you? The patient said: I would be in Washington! You have to let me out of here before the whole thing falls apart! You asked the patient: How do you understand your problems? The patient said: Look, this is not my fault. I think someone tried to assassinate me. You asked the patient: Do you ever see or hear things that other people do not? The patient said: They are all just jealous because I am rich and smart and the president wants me to work for him! You are too slow! You want to be just like me!!\nYou answered: Mrs. Cole, please lower your voice. Let’s sit and take some deep breaths. \nYou used the therapeutic technique of giving information and offering self. You asked the patient: Do you ever see or hear things that other people do not? The patient said: No, I’m not crazy! You asked the patient: Do you find that you worry more than others? The patient said: Tell the president that I am ready to speak to him. I’ll be waiting here in the ballroom until he gets here. Get me my gown crown and some red. Off with you!\nYou answered: I understand you believe that; however, I see your situation differently. \nYou used the therapeutic technique of voicing doubt. You asked the patient: Are you frightened of anything? The patient said: If you come near me again, I’m going to cut myself with this fork. It’s true blue. I’ll do it…. Stay away!\nYou answered: Mrs. Cole, you will not hurt yourself. If you cannot control yourself, we will help you. \nYou used the therapeutic technique of giving information. You supported the patient about safety. You supported the patient about rest and healing. You supported the patient about racing thoughts. You supported the patient about going back to work. You educated about discharge. You educated about medications. You educated about the psychiatric diagnosis. You assessed the respiration. You checked the pulse oximetry. You checked the radial pulse. You measured the blood pressure. You measured the temperature. You auscultated the lung sounds. You auscultated the heart sounds. You checked the patient’s skin. You assessed the cast. You assessed the patient’s IV. You administered lorazepam. You called the charge nurse. You called the provider. You dimmed the lights. 20:59

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