Healthcare Assignment: Case-Based Analysis Relating To Clinical Practice
This healthcare assignment requires you to answer a series of questions related to clinical cases provided (below), integrating relevant and contemporary literature to support your responses.
Read the following case study and answer the questions below.
Michael is a 46-year-old man who is being treated in an adult inpatient unit. He was brought into hospital by Police after he was found in Queen St Mall – he was shouting the “bikies are out to get me” and appeared to be distressed and afraid, running aimlessly and often looking behind. He was not wearing shoes, and his only clothing was a towel wrapped around his lower body. He appeared gaunt and very disheveled, his hair was matted and dirty, as were his hands and feet. There were multiple cuts to his hands, some of them deep. When the Police approached Michael, he was challenging to engage, not re-directable, speaking out of turn, intrusive and looking all around him with a startled expression. He also appeared to be paranoid about hospital staff being “undercover bikies”. He told Police he did not want to go to hospital as he feared the nurses would poison him and be able to “read his thoughts”. He very reluctantly agreed to attend hospital for assessment.
Background information: Michael has a diagnosis of Paranoid Schizophrenia, which was diagnosed when he was 19 years old. Michael finished year 12 although found it very challenging to maintain concentration and often lacked motivation to engage with study, his family, and his peers. He started using cannabis to “sleep and relax” and has been using this ever since. Michael moved out of his parent’s home when he was 20 years old and has been living in shared accommodation. Michael is currently homeless as he was evicted from his shared unit as he did not pay his rent. Michael has in the past worked as a labourer in construction, however ceased this after becoming unwell. He has been unemployed for the past two years and receives a Disability Support Pension (DSP).
Michael has had multiple admissions for the care of his illness (the last one was 1.5 years ago). He has been prescribed depo anti-psychotic medication and did not present for his last depo and has disengaged with his case manager.
Michael’s parents try to remain in contact (they also live in Brisbane). However, this is hard as he does not have a phone. Michael has a younger brother, and they see each other when Michael goes home for a few days at Christmas. Michael’s grandfather also had schizophrenia and committed suicide aged 50 years. Michael had a long-term partner however she died of an overdose five years ago. They had no children. You meet Michael for the first time following his admission yesterday. You introduce yourself to him and take him to a quiet place to have a conversation. He appears confused and tells you he does not know why he is in hospital, saying: “there is nothing wrong with me, it is all the bikies’ and the nurses, you are all out to get me”. He is not aggressive towards you however he is not happy to be in hospital. He tells you he has not slept well or eaten for a few days as he is “worried about the bikies’ finding him”. He appears under the weight and very thin. His cuts have been cleaned and bandaged.
Question 1a. Identify and describe what symptoms of paranoid Michael is demonstrating. [Approximate- 150 words}
Question 1 b. Identify and justify two immediate priorities for Michael’s nursing care (priorities should be non-pharmacological). [Approximate –200 words].
Question 1c. Describe the nursing interventions required to address each of the above priorities, drawing on peer-reviewed evidence. [Approximate - 200 words].
Question 1d. Argue why it is important to consider ‘insight’ (refer to the MSE component of insight) in Michaels’ treatment and recovery planning. [Approximate -200 words].
Read the following case study and answer the questions below.
Aliah is 28-year-old female who was brought into the psychiatric emergency department by her husband yesterday, after he experienced concerns about her safety and wellbeing.
Background: Aliah was born in Syria and came to Australia as a refugee six years ago with her husband Khalid. Aliah’s background is traumatic, and she witnessed both her parent’s death in Syria when she was young. She has no siblings. She has been married to her husband Khalid for the past eight years. They have no children. Aliah has been attending University to become a teacher however has deferred the present semester as she feels low and unable to concentrate on her studies. Aliah has two close friends but has not seen them for the past three months. She is not linked with any transcultural services in the community.
Aliah has suffered from depression since the loss of her parents ten years ago. She has also been diagnosed with Post-Traumatic Stress Disorder (PTSD), and she experiences distressing flashbacks to her parent’s death. She attempted suicide by overdose some years ago (this led to a short medical admission and an admission to an acute psychiatric unit, for stabilisation of her mental state and mitigation of risk). When Aliah feels low, her sleep is often limited to 5- 6 hours per night and her appetite is poor. She has been taking ant-depressant medications for the past six years and Khalid states her GP also referred her to a psychologist who specialises in trauma. She has attended several sessions but stopped going about three months ago, after the 10th anniversary of her parent’s death. Khalid tells staff on admission thatshe “does not talk to him much anymore” (relationship was good until three months ago). He is concerned about her risk for suicide and suspects she may not be taking her antidepressant medication.
Aliah does not drink or smoke and is otherwise in good health.
You meet Aliah in her room the morning after her admission the previous day. She presents as withdrawn, her replies are limited, and she looks at the floor as you speak. When you ask whether she feels safe to assess suicide risk she looks down and says, “what is the point anyway, Khalid will be better off without me, he can meet someone else and be happy”. She is unable to confirm her safety on the ward.
She confirms she has not taken her medication for four months and says she feels low “all the time”.
Question 2a. Identify and describe what PTSD symptoms Aliah is demonstrating. [Approximate- 150 words]
Question 2b. Identify and describe two nursing interventions you would use in addressing Aliah’s acute suicide risk [Approximate -200 words].
Question 2c. Discuss and justify two possible multi-disciplinary interventions or referrals (interventions should be non- pharmacological) for Aliah. In your answer identify why each intervention or referral is important to achieve person centered care? [Approximate -200 words]
Watch the video on ‘Harm minimisation’, in Australia
Question 3a. Define the term ‘harm minimisation approach’.
Question 3b. Identify one strategy implemented in Australia to address ‘harm minimisation’, with alcohol or drug addiction.
Question 3c. Discuss if this strategy has been effective drawing on academic current peer reviewed sources.
Considering the case study and the medical situation of Michael within this healthcare assignment, it has been noted that he is suffering from Paranoid Schizophrenia and is showing symptoms of paranoid. According to DSM (Diagnostic and Statistical Manual of Mental Disorder) listed in the paper “Substance Abuse and Mental Health Services Administration” (2016, p-24), paranoid schizophrenia mainly deals with hallucination and delusion. Early symptoms of schizophrenia include socializing less with family and friends, which has been observed in Michael. He is also facing sleeping complications and irritability, which is also a major symptom of paranoid schizophrenia. Besides, Michael also had an issue in maintaining concentration and often experienced lacked motivation while studying as a symptom. Besides, the early symptoms, Michael is also having warning signs of paranoids, which includes Seeing or hearing things that others do not, for instance talking about bikies in this case. He is also suspicious and has a general fear of the nurse’s intentions and has withdrawn from friends or family, as he was isolated from his parents’ long way back and as his long-term partner has died as well. Besides, a significant decline in health is also observed along with unusual and persistent thoughts or beliefs and difficulty thinking.
Answer 1 b.
Addressing immediate health priorities is very important for proper care of quality health care without having any delay that can lead to further health deterioration. Considering the case study, the two immediate health priorities are, seeing and hearing things about bikies, and signs of self-harm.
Seeing and hearing things: Michael is at the doubt regarding a group (Bikies), who wants to harm them according to him. He is also doubting upon the nurses about the same and as a result, they are not able to handle him properly and are having a hard time convincing the patient, which will impact his treatment.
Signs of Self-harm: There were several signs of cut were found on Michael’s hand, which indicates his intentions to harm himself. It needs to be immediately addressed, as avoidance of it might increase the risk of an attempt at suicide or death, as it is majorly observed among patients experiencing paranoid schizophrenia (Buck et al., 2018, p-7).
The above-referred priorities are considered as an immediate non-pharmacological health priority, as both of them are directly impacting the mental, physical as well as social wealth health, negatively impacting the ongoing treatment and increased risk of further health deterioration.
Seeing and hearing things: As mentioned above, Michael doubts nurses and other health care staff of being Bikies, and hence they are unable to treat them. To ensure proper treatment, effective trust and rapport need to be established. To do that, a consistent and accepting approach is needed (Lincoln & Peters, 2019, p-12-13). The patient's family will also be included in this patient-centred intervention. Besides, short and repeated contacts along with the use of unambiguous language should be used. Further to deal with the hallucination, the content of his hallucinations should be explored without arguing about it.
Signs of self-harm: For this health priority also, family involvement will be encouraged to ensure avoidance of any further self-harm risk at home. Besides, during the hospital stay, special consideration will be taken regarding the objects that can be used by the patient to harm himself such as, sharp objects (Mudgal, Rastogi, Niranjan & Razdan, 2020, p-1). Michael's family member or the carer will be also be educated about the same and other strategies that can be considered while taking care of him. As Michael has isolated himself from everyone, his social skills need to be promoted by providing support in supporting Michael to adapt and learn social skills. In addition to that, a 24 hour will also be implemented for proper monitoring of the patient.
Insight, in the case of mental state examination (MSE) context, denotes the capability of an individual to comprehend that they are experiencing mental health complications and whatever they are experiencing is not normal and needs to be treated (Zahodne et al. 2015, p-138). There are several mental health complications which in this case is paranoid schizophrenia, where patients lose insight into their problem, and in such cases, it becomes very difficult for the nurses and the other healthcare staff to treat the patient. In such a treatment process, the patient tends to react reluctantly or does not engage and participate in the intervention positively, as according to them they are perfectly fine, there is nothing wrong with them and hence no treatment is required. Therefore, considering the case scenario, the same thing has been observed with Michael as well which indicates his ignorance regarding his hallucination and other complication, hence it is important to consider ‘insight’ in Michaels’ recovery and treatment planning. Though, before considering the ‘insight’ in Michaels’ care plan, its level and severity needs to be assessed by asking several questions such as, "what according to you is a problem?', "what is the cause of the problem?", "do u feel any need of help right now with your problem?" and other to him to ensure according to treatment.
Post-traumatic stress disorder (PTSD) is a type of mental health complication that tends to be triggered by a startling event, either witnessing it or experiencing it. In this case, Aliah has witnessed her parents’ death in Syria and also had to leave her country due to the situation, which triggered the event of stress and led to post-traumatic stress disorder (Ben-Zion et al., 2018, p-2). She is also witnessing several symptoms which include negative thoughts about herself, no hopes about her future, getting emotionally numb, and difficulty in maintaining a relationship with her two close friends, as he has not contacted them in the last three months. She is also feeling detached from her husband and is having difficulty in experiencing positive and cheerful emotions as she admitted that she is feeling low all the time (Kakaje, Al Zohbi, Aldeen, Makki, Alyousbashi & Alhaffar, 2021, p-2). Besides, mood and emotional fluctuation, she is also experiencing physical reactions which include Self-destructive and suicidal behaviour, trouble in concentrating due to which she left her studies, angry outbursts, irritability, aggressive behaviour, and sleeping complication.
Considering the case study, the two-nursing intervention that can be implemented in case of Aliah to reduce the risks for suicide includes:
- Rendering close supervision of Aliah by supporting awareness as well as observation all the time. As Aliah stated that, she is feeling low all the time and in the past, she has even tried to harm herself, there is a high risk of self-harm. Besides, Suicide may be an impulsive act in her case with no or maybe little warning, therefore in such case close and continuous supervision is necessary to avoid the risk of any further complication (Bryan, 2016, p-2-3).
- Instead of providing a close environment, the risk of suicide persists, and to ensure care in such a setting, it is important to give an overall safe environment. To do that, weapons such as sharp medical objects or needles needs should be removed. Besides, any pills that might cause any harm should also be removed in the hospital setting as well in the home by involving the friends or family in the care plan (Flynn et al., 2017, p-2242). Removing any harmful or sharp objects that increase the potential risks of self-harm will help to prevent Aliah from sudden or acting self-destructive instincts.
As Aliah is suffering from PTSD, nursing intervention alone cannot be considered to be effective enough to treat her condition. Therefore, in such a case multidisciplinary team is required which includes:
Psychotherapist: A psychotherapist with the use of psychological methods will help Aliah to modify and change her behaviours. One of the major issues observed in the case of Aliah is her mood fluctuation, which can be overcome by talk therapy. With the help of Cognitive therapy along with exposure therapy, a type of talk therapy, a Psychotherapist will help Aliah to recognize her ways of thinking that is the cognitive patterns, which are keeping that are her stuck (Holder et al., 2018, p-84-85). For instance, negative beliefs about herself or the risk of the same traumatic things again, losing attachment with the closed ones.
Nutritionist: As per the case study, it is highlighted that Aliah's appetite is poor, which is also leading to her emotional fluctuation. According to Tyson and Hodges-Chaffee (2018, p-82-83), a good and healthy diet is considered an effective treatment for PTSD. A referral to a Nutritionist can help her diet, which will be rich in whole grains and fibre. These diets help to lower down the risk of such mental health complications and also will assist in minimizing the likeliness to experience recurrent episodes of PTSD.
The harm minimization approach according to the Australian Government Department of Health (2021), is a policy approach taken by the Australian government to minimize any harm due to the excessive intake of drugs or any abusive substance. To make the approach successful, three pillars have been considered which include, supply control, demand reduction, and harm reduction. Supply control deals with the reduction in the supply of drugs through customs, laws, liqueur licensing, and policies (Australian Government Department of Health, 2021, p1-2). Demand reduction assists in the prevention of drug use by different strategies such as school-based programs, alcohol and drug treatment, and others. Lastly, harm reduction is taken into consideration when the other two pillars fail to act effectively and people tend to use drugs (YouTube, 2021). It tends to recognize the drugs or abusive substances that carry substantial risks to harm to the ones who require a range of support from the community or the family member for harm reduction.
This program taken by the Australian government involves strategies that include policies and programs that specifically target to reduce the harm directly that is caused due to drug use. One such effective program as per YouTube (2021), is Needle and Syringe program. This program helps to provide clean and sterilized injecting equipment to the ones who inject drugs. For this, one supervised injecting centre in Sydney, king cross. The program aims to decrease the spread of any blood-borne viral infections, specifically HIV as well as hepatitis C among the ones who frequently inject drugs (Australian Government Department of Health, 2021, p-41).
The above-referred strategy (Needle and Syringe program)is effective, as according to the video "Harm Minimisation in Australia" YouTube (2021), Australia has the lowest number of HIV cases in the world. Besides, for every dollar spent on this program, approximately seven dollars in the cost of the treatment related to HIV and hepatitis C is saved. It indicates that there is a significant return on the investment done by the government on this program. Due to the success of this (Needle and Syringe program) and another program including labelling on the packs of cigarettes, controls on gambling, safe injecting rooms, methadone maintenance programs, peer education programs, and labelling on alcoholic beverages, Australia is considered as the world leader in the harm minimization policy (Australian Government Department of Health, 2021).
Australian Government Department of Health (2021). An overview of needle and syringe programs (NSPs). Retrieved on 13 October 2021 from: https://www1.health.gov.au/internet/publications/publishing.nsf/Content/illicit-pubs-needle-return-1-rep-toc~illicit-pubs-needle-return-1-rep-2
Australian Government Department of Health (2021). Harm minimisation. Retrieved on 13 October 2021 from: https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-front9-wk-toc~drugtreat-pubs-front9-wk-secb~drugtreat-pubs-front9-wk-secb-2~drugtreat-pubs-front9-wk-secb-2-1
Australian Government Department of Health (2021). National Drug Strategy 2017–2026. Retrieved on 13 October 2021 from: https://www.health.gov.au/sites/default/files/national-drug-strategy-2017-2026.pdf
Ben-Zion, Z., Fine, N. B., Keynan, N. J., Admon, R., Green, N., Halevi, M., ... & Shalev, A. Y. (2018). Cognitive flexibility predicts PTSD symptoms: observational and interventional studies. Frontiers in psychiatry, 9, 477. Retrieved on 13 October 2021 from: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00477/full
Buck, B., Hester, N. R., Pinkham, A., Harvey, P. D., Jarskog, L. F., & Penn, D. L. (2018). The bias toward intentionality in schizophrenia: Automaticity, context, and relationships to symptoms and functioning. Journal of abnormal psychology, 127(5), 1-20. Retrieved on 13 October 2021 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051707/pdf/nihms967977.pdf
Bryan, C. J. (2016). Treating PTSD within the context of heightened suicide risk. Current psychiatry reports, 18(8), 1-7. https://doi.org/10.1007/s11920-016-0708-z
Flynn, S., Nyathi, T., Tham, S. G., Williams, A., Windfuhr, K., Kapur, N., ... & Shaw, J. (2017). Suicide by mental health in-patients under observation. healthcare Assignment Psychological medicine, 47(13), 2238-2245. Retrieved on 13 October 2021 from: https://www.research.manchester.ac.uk/portal/files/55586254/Final_Revised_Manuscript_Feb17.docx
Holder, N., Holliday, R., Williams, R., Mullen, K., & Surís, A. (2018). A preliminary examination of the role of psychotherapist fidelity on outcomes of cognitive processing therapy during an RCT for military sexual trauma-related PTSD. Cognitive behaviour therapy, 47(1), 76-89. https://doi.org/10.1080/16506073.2017.1357750
Kakaje, A., Al Zohbi, R., Aldeen, O. H., Makki, L., Alyousbashi, A., & Alhaffar, M. B. A. (2021). Mental disorder and PTSD in Syria during wartime: a nationwide crisis. BMC psychiatry, 21(1), 1-16. Retrieved on 13 October, 2021 from: https://link.springer.com/article/10.1186/s12888-020-03002-3
Substance Abuse and Mental Health Services Administration (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health, DSM-IV to DSM-5 Schizophrenia Comparison. 19-34. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22/
Lincoln, T. M., & Peters, E. (2019). A systematic review and discussion of symptom-specific cognitive behavioural approaches to delusions and hallucinations. Schizophrenia research, 203, 1-37. Retrieved on 13 October 2021 from: https://kclpure.kcl.ac.uk/portal/files/85930510/A_systematic_review_and_LINCOLN_Publishedonline17Janua
Mudgal, V., Rastogi, P., Niranjan, V., & Razdan, R. (2020). Rare case report of Van Gogh syndrome in a patient with paranoid schizophrenia. General psychiatry, 33(1). Retrieved on 13 October 2021 from: https://scholar.google.com/scholar?output=instlink&q=info:KGeBtF4BVo4J:scholar.google.com/&hl=en&as_sdt=0,5&as_ylo=2017&scillfp=961815
Tyson, E. P., & Hodges-Chaffee, C. (2018). What Doctors, Dietitians, and Nutritionists Need to Know. Trauma-Informed Approaches to Eating Disorders. 80-83. Retrieved on 13 October 2021 from: https://books.google.co.in/books?hl=en&lr=&id=JFtVDwAAQBAJ&oi=fnd&pg=PA75&dq=dietitian+in+ptsd&ots=-oKgchVPzq&sig=sTT0tf7ffv51QawejuKYWXddB3A&redir_esc=y#v=onepage&q=dietitian%20in%20ptsd&f=false
YouTube (2021). Harm Minimisation in Australia. Retrieved on 13 October 2021 from: https://www.youtube.com/watch?v=vHfv1-FEayY
Zahodne, L. B., Ornstein, K., Cosentino, S., Devanand, D. P., & Stern, Y. (2015). Longitudinal relationships between Alzheimer disease progression and psychosis, depressed mood, and agitation/aggression. The American Journal of Geriatric Psychiatry, 23(2), 130-140. Retrieved on 13 October 2021 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3858495/pdf/nihms507251.pdf