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Original Question
SECTION 2: CASE STUDY (Mapping matrix indicated as CS) Bill is a 45 year old man 75kg brought into the Emergency Department by his sister after intentionally lacerating one arm and his neck while heavily intoxicated on alcohol. Bill is separated from his wife and children, he has a history of domestic abuse due to his alcohol consumption and often is verbally abusive to his neighbors. Bill is currently unemployed due to the recent loss of his driver’s license for Driving Under the Influence (DUI). His sister lives 4 houses away from Bill and seems to be the only person that he will talk to, she is often away and only sees Bill occasionally. He is seen in the Emergency Department by the Mental Health Assessment Team (MHAT). Following assessment, Bill is admitted as a voluntary patient to the Mental Health Unit for assessment, observation and monitoring. Bill appears malnourished, dehydrated, and unwashed. He is flushed, ataxic and smells strongly of alcohol. His speech is slurred. He has a productive cough. He is given a provisional diagnosis of Major Depressive Disorder (MDD) and Substance Abuse (Alcohol). A few hours later, Bill attempts to leave the Mental Health Unit without a medical review or authority. He becomes verbally and physically threatening toward nursing staff who are trying to persuade him to stay and be treated. Security is called and they physically restrain Bill when he lashes out at them and the nurses. Following further assessment by the Medical Officer, Bill is placed on an involuntary Treatment Authority (TA) under the Mental Health Act 2016 (Qld). By this time, he appears physically exhausted, sobbing and stating that he wants to die. 1. Discuss five (5) signs and symptoms of a Major Depressive Disorder (MDD), as per the Diagnostic and Statistical Manual of Mental Disorders (DSM5), applicable to the case study information Timeframe re. presence of signs and symptoms: ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Discussion of five (5) Signs and symptoms Bill presents with: ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 2. Bills behaviour demonstrates to have a significant impact on his family/friend/neighbours re a person with Mental illness. 2a Identify four (4) behaviours Bill is showing that impact on his family / friends? ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 2b Bill could feel stigmatised by having a mental illness. Outline three (3) common misconceptions about mental illness which is reinforced by Bill’s behaviour. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 2c Bill will experience discrimination during his episode of care (hospital and community). Explain. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 2d For effective-evidence based practice in mental health nursing use a variety of sources to plan appropriate care delivery to Bill. Explain the importance of the consumer and carer perspective as sources of information when planning evidence based care delivery ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 2e Referring to the Mental Health Standards of Practice, discuss two (2) ways you as the enrolled nurse, the health team and careers can act to maintain Bill’s dignity and uniqueness. (Word limit max 60 – 80 words and reference) The following websites will assist: http://www.acmhn.org/publications/standards-of-practice State the selected Standard of Practices which refer to dignity and uniqueness in mental health care delivery ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Discuss two (2) ways you as the enrolled nurse, the health team and careers can act to maintain Bill’s dignity and uniqueness ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 3. Bill has already demonstrated aggression and continues to be potentially threatening to staff and patients. 3a. Consult the case study information and describe four (4) common triggers which can impact on Bill to present with aggressive behaviour. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 3b. Describe six (6) nursing interventions you as an EN may use to deflect triggers or de-escalate a patient who is agitated or aggressive – must include at least two (2) communication interventions, two (2) listening skills and two (2) other de-escalation skills. (Word limit max 80 – 100 words and reference) You may find information from the following to assist with this question Clinical key textbook – Evans, K. Nizette, D. & O’Brien, A. (2017). Psychiatric and Mental Health Nursing. Australia: Elsevier Mosby The following websites will assist: https://www.health.qld.gov.au/__data/assets/pdf_file/0025/665314/qh-gdl-452.pdf 3b1 Communication skills (2 skills) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 3b2 Listening skills (2 skills) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 3b3 Other de-escalation skills (2 skills) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 3c. To assist you with Bills issues and possible outbursts of aggressive behaviour who can you seek to obtain guidance or support? ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 4. Bill has been prescribed prn Diazepam (Benzodiazepine), PO additionally of his regular dosage of Diazepam 10 mg QID, PO as part of managing his alcohol withdrawal symptoms to prevent severe physical and emotional symptoms of withdrawal. The following websites will assist: https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/medicines/drugs-of-dependence?a=167070 4a. Identify the assessment tool used to administer the correct dose of prn Diazepam ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 4b. Provide health education to Bill regarding the administration of Diazepam Use: ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Two (2) contraindications to use diazepam ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Administration Route: Explain one (1) commonly used approach: ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. State five (5) Possible Adverse effects Bill could experience using Diazepam ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 4c Outline four (4) nursing strategies you may use to confirm that Bill understands the use, administration methods and possible effects of this medication (Word limit max 40 – 60 words and reference) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 4d. From the answers below choose 3 negotiation skills you as the EN could use if Bill becomes aggressive towards you Using a calm, gentle soft tone, tactful language and sensitive use of humour towards Bill Communication and engagement should be intermittent with Bill and ensure long periods of silence are used Speak clearly and slowly to Bill as Bill may be unable to comprehend information when agitated; you may have to repeat information several times. Validate Bills concerns where relevant and accepting that concerns are distressing for Bill (even if you may not agree with them) 5. Bill is experiencing oral health issues due to his disorder. From the case study: Develop two (2) nursing interventions to improve Bills oral health to contribute to care planning with the Registered nurse. Outline three (3) possible causes for his oral health issues Poor oral health Nursing interventions with rationale Possible causes of poor oral health 6. “Assessments are bound by time and context; that is, when you conduct an assessment, you are looking at the risk factors as they present in the current situation. While you do explore the client’s history and background, the main focus of risk assessment is what is happening for the client now. Bill is being admitted in a secured mental health ward due to being placed on an involuntary Treatment Authority (TA) under the Mental Health Act 2016 (Qld). Remember assessment is dynamic”. You as the EN are on Duty the afternoon that Bill is admitted to the mental health facility, you would be working with a RN. Using the information from the case study you are to complete the following risk assessment tool, the RN will review your answers once you have completed it (In this instance the RN will verify the marking of this paper) Categories of risk identified ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Detail any historical information that may indicate the potential for risk ( for example previous history or risk behaviours / threats ) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. What environment factors may contribute to risk ( for example, access to drugs alcohol, access to weapons) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Is there any current evidence to suggest “planned intent” to engage in risk – related behaviours ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. Are there any risk factors that indicate preferred staff allocation( for example danger to women, intimidation to men, need for 2 workers) ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. What strengths and opportunities can you identify, from the consumer and /or services as resources to support this plan ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. State specifically the identified risk ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 7. Contemporary mental health services are based on the recovery-orientated approach. The Australian National Framework for Recovery-oriented Mental Health Services: Policy and Theory identifies five practice domains and capabilities. The following website link will assist: http://www.health.gov.au/internet/main/publishing.nsf/content/67D17065514CF8E8CA257C1D00017A90/$File/recovgde.pdf 7a. List the five (5) practice domains and capabilities in relation to recovery-orientated practice and service delivery ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 7b. Select one (1) of the practice domains and explain how you could use the information when assisting with planning Bills nursing care ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 7c. Identify four (4) key recovery principles that will assist the interdisciplinary team and yourself in planning care for Bill to maximise his health outcomes. (Tick the correct answers) Enable Bill to be in and connected to communities Plan outcomes so that Bill feels like he is doing something worthwhile Outlining to Bill that recovery is a cure Plan ways for Bill to regain belief in oneself Planning strategies for Bill to be aware of the principles of recovery and that it is an attitude, a way of approaching day-to-day challenges and being in control Enabling Bill to understand that recovery has an endpoint and will solve his problems Bill has remained in the mental health care facility for 4 days and there is now talk of possible discharge. A case management meeting has been arranged to discuss a plan for moving forward 8. As the EN on duty you will participate in the case meeting for Bill, complete the following questions You may find information from the following to assist with this question Clinical key textbook – Evans, K. Nizette, D. & O’Brien, A. (2017). Psychiatric and Mental Health Nursing. Australia: Elsevier Mosby http://www.health.gov.au/internet/main/publishing.nsf/content/mbsprimarycare-caseconf-factsheet.htm 8a. State which five (5) members of the multidisciplinary team would possibly attend and why Members attending the case meeting Why? 8b Review Bills case study and name two (2) possible community based service providers that the Multidisciplinary team members could include in the case meeting, as selected by Bill when he is discharged. Explain your role as an Enrolled nurse to liaise with these services and how can they help Bill towards recovery (Word limit max 30 – 60 words per provider and reference) The following websites will assist: https://insight-prod.s3.ap-southeast-2.amazonaws.com/public/guidelines/1511827744_QH%20DD%20Clinician%20Tool%20Kit.pdf 8b1 Provide an example of one (1) community service provider which Bill might select to assist him when he is discharged. Explain how this service can help to support Bill’s recovery. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 8b2 Provide an example of one (1) community service provider that facilitates recovery in a group based environment, which Bill might select to assist him when he is discharged. Explain how this service can help to support Bill’s recovery. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 8b3 Explain the role of the Enrolled Nurse in liaising with service providers. Consider reporting relationships and enrolled nurse scope of practice in your response. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………….. 8c What would your role as the EN b
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