Rachael Tomkins is 55 years old and is a certified practising accountant. She works part time and lives with her husband Paul, aged 64 and daughter Marie, aged 17. Her grandmother Jean aged 90, lives in a small flat at the back of their house and her mother Mary, aged 72 lives in an Over 55s housing unit nearby. In her early 20s Rachael’s father, a Vietnam Veteran, committed suicide. Rachael is described by her family as reliable and caring. She has a small group of friends from her local parish church. Rachael has regular contact with her GP to manage her Diabetes Type 2. She is prescribed metformin and has been trying to lose weight. She also sees a psychiatrist Dr Lianne Yu for management of her symptoms of schizophrenia. She is prescribed Olanzapine and Lithium. She was diagnosed with schizophrenia in her early 20’s when she was studying at university. She was hospitalised with acute psychosis several times before her symptoms were stabilised. She was able to complete her university degree and has worked part time. The last time she experienced acute psychosis was 17 years ago, just after the birth of her daughter. Her symptoms stabilised, and she has been maintained in recovery for almost 15 years. This year has been a particularly challenging year for Rachael. Both her husband’s parents passed away within months of each other, her daughter commenced Year 12 and her grandmother had an infection in her middle toe, which resulted in a series of trips to the doctor, hospitalisation and finally amputation of the affected toe. Rachael has become irritable with her family, and has developed erratic sleeping patterns, a lack of interest in grooming, and avoided social interactions with her friends or family. She complained to them that her neighbours were spying on her. In the 48 hours before she was admitted to hospital two incidents escalated Rachael’s need for professional help. In the first episode she yelled and threatened the neighbour across the fence. She accused him of spying on her with a ‘trackamanometer’. Her husband intervened and took her back into the house. In the second incident later that day, Rachael started screaming at her family to evacuate the house because they would be bombed. Rachael insisted the news reader on the TV was giving her this important information and they must all get out of the house. Rachael ran onto the road. A concerned neighbour called the police, who were able to convince her to accompany them to the hospital. She was met by her psychiatrist Dr Yu who reports the following -Rachael is dishevelled, dressed in pyjama top and tract pants, no shoes, she has an exacerbation of auditory hallucinations, with persecutory delusions and disorganised thinking. Rachael agrees to be admitted because she says ‘I’m frightened’. Rachael is admitted for inpatient psychiatric care.
In hospital, Rachael is argumentative and resistive to staff interactions and interventions, and her family are frightened and bewildered by her dramatic deterioration.
I. Identify, from the case study, the positive, negative and cognitive symptoms of schizophrenia experienced by Rachael at this presentation to the mental health service and discuss her prognosis and recovery;
II.
III. Considering the case study, outline some common challenges and nursing interventions associated with the clinical presentation of a person who has been diagnosed with schizophrenia;
IV.
V. Identify the two psychotropic medications prescribed for the treatment of the symptoms of schizophrenia experienced by Rachael, and consider the importance of effective monitoring, consumer experiences (side effects) and safety factors;
VI. Summarise key features for Rachael and her family and their environment (identify family and community connections, strength and quality (supportive/not supportive) of connections between individuals and community support networks/institutions( Refer to the required text Chapter 22 for more information about Genograms and Ecograms).;
VII. Develop three questions you would ask Rachael during an interview to complete an MSE. They could be from any MSE area. Explain the reason you would ask these questions.
VIII. Complete a risk assessment (static risk factors, dynamic risk factors- internal + external );
VII. Rachael will be admitted to the mental health inpatient unit. Write a nursing care plan based on a nursing diagnosis. And nursing interventions
Week 4
Josh Wallace
Demographic data
Josh Wallace is an indigenous 20-year-old second year university student. He likes to write music and plays several musical instruments, including the digeridoo. He is studying music at university and hopes to compose music for orchestras. Josh works part-time as a barista in a coffee shop and performs with an indigenous dance group. He lives in the city with his mother’s sister, her three teenage children and Uncle Bill, the brother of his grandmother. Josh’s parents live in a large regional town. His parents are teachers who work in a ‘flexi-school’. He has two younger siblings. His parents are very active in the local indigenous community.
Past Medical- Surgical and Psychiatric history.
At the age of 14, Josh experienced mental health issues because of problems at home. Firstly, his uncle, a man in his early 50’s, completed suicide. And then both his parents experienced illness. His mother was diagnosed with depression several months after his father recovered from a life-threatening illness. After Josh returned to school where he was a boarder, he found himself crying in his room at night because he felt sad all the time. He began to self-harm. He didn’t want to talk to his friends because he thought he might be considered weak, and he didn’t want to worry his family. His Year 9 Coordinator, Mr Adams, noticed a change in Josh, who was usually an outgoing and active participant in the school community. Mr Adams arranged a meeting, and at that time he noted the cuts on Josh’s arms. Josh was referred to the school counsellor and the school nurse, and he was eventually referred to Child and Youth Mental health services (CYMHS). He was seen on a regular basis by a team including a mental health nurse. He was prescribed Fluoxetine 20 mg. With support from family, the school and CYMHS, he put in place strategies to benefit his recovery. He was discharged from CYMHS when he turned 18. He decided to accept support from the services offered at Headspace and attended three appointments over a 6 - month period when he was 19.Mid last year, Josh has experienced the death by completed suicide, of his 21-year-old cousin Luke. His cousin lived in a regional area, and Josh was unable to join family members because of his study commitments. At present, he is enrolled in a summer intensive unit, because he failed a unit in the second semester. The tutor is dismissive of students who do not speak up, and Josh has been targeted for comment on several occasions. Josh is the only indigenous student in the tutorial group, and he does not know anyone else. Josh also misses his girlfriend Aimee. She is on placement for four weeks, and Josh does not have a car to visit her. Josh has experienced shortness of breath and chest pain during rehearsals with his dance group. He hadn’t told anyone, believing it was probably muscle pain. Last night he experienced the chest pain prior to leaving the house to attend rehearsals. It became so bad he thought he was going to die and alerted his Aunt Alice for help. He was transported to the local emergency department for assessment. Josh is told he has experienced a panic attack. No physical abnormalities were detected in ECG or bloods, and he will be referred to his GP, and to Headspace for follow up appointments.
Presenting History
Josh arrives for his appointment at Headspace. He is accompanied by his Aunt Alice. Josh is unkempt, dishevelled and looks sad. His voice is monotone and flat, and he has poor eye contact. He tells you “I am sorry to worry everyone; it was just a panic attack- I can never get things right.” He says he feels worried and on edge all the time, and has difficulty concentrating. His Aunt tells you Josh has been isolating himself in his room and has missed a couple of shifts at the coffee shop and some tutorials on campus. He also becomes easily irritated, yelling at his cousins and his Aunt. This is not his usual behaviour.
I. What historical and cultural issues need to be considered when caring for Josh;
II. What are the signs and symptoms of depression? Considering the case study, describe the different types of behaviour and verbal responses, that may indicate Josh may be experiencing depression;
III. What is meant by culturally safe practice and what are the key skills that nurses need to develop to provide culturally safe practice for Josh?
IV. Identify the psychotropic medication previously prescribed for the treatment of the symptoms of depression experienced by Josh, and consider the importance of effective monitoring, consumer experiences (side effects) and safety factors;
V. Develop three questions you would ask Josh during an interview to complete an MSE. They could be from any MSE area. Discuss some strategies that nurses can use to foster engagement with an adolescent who is sullen and guarded.
VI. Complete a risk assessment for Josh. Identify some of the protective factors that enable Aboriginal Australians to survive and thrive in society today?
Erin is a 19-year-old university student in her second year at university. Erin is bright and has always been a high achiever at school, and her parents have been keen to prompt her to follow her dreams and encourage her pursuits. Erin loves cooking for her family, particularly her older brother Josh. In order to achieve the best possible Year 12 score, Erin’s parents decided to move her to a private school for girls that had a good reputation for university acceptance. Erin’s mother took on extra work to pay for the school fees. While Erin was sad to leave her old school and friends, she agreed that this was the best choice for her academically. Things did not go as well as planned, however, and Erin was subjected to distressing bullying from the beginning of Year 12 until she finished the school year. Erin has always been conscious of her health and weight but was targeted because she had ‘fat legs’
and the bullies sent her text messages of ‘fat people’ and memes with derogatory messages about her. Because her parents had made sacrifices for her to attend this school, Erin didn’t want to tell them that she was being bullied, so she kept it to herself. This bullying had a devastating impact on Erin’s self-esteem, and she began dieting. People would comment on how great she looked, so she continued dieting. She felt she had some control over what she ate, and this made her feel better. When her local gym had a special rate for new members, Erin joined. When she wasn’t at the gym, she was studying. Because she was working out so much, and restricting her diet, Erin became seriously constipated. So, she went to her local pharmacy and began buying laxatives. Erin noticed that they helped with her constipation, but they also reduced her weight (Erin would weigh herself daily), so she began taking them all the time. It got to the point where her local pharmacy would not sell them to her anymore, so she began buying them from multiple pharmacies and online. Despite the turmoil at school, Erin did well academically and achieved exceptionally high marks in her final exams. She got her first preference for courses and enrolled in a Bachelor of Dietetics at a well-regarded university. Recently, however, wearing baggy clothing and restricting her food intake has been causing suspicions. Her mother has told her she is too thin, and her brother and father have expressed concern about her –but Erin doesn’t see it this way. When Erin looks in the mirror, she sees the fat girl who was bullied in Year 12. Erin has collapsed at her gym several times, and staff have expressed concern about her weight. Erin worried that as with the pharmacy, she will need to find another gym. At 1.62 cm tall and weighing 41 kg, Erin’s BMI is 15.6.
I. What are some of the physical risks associated with Erin’s behaviours?
II. Erin is exhibiting many different behaviours consistent with ED. Describe what these are;
III. EDs can be upsetting for family and friends of the consumer, and family members who are concerned about their loved one are almost always correct in their ED concerns. What are the impacts on the family are common when a member has an ED;
IV. Investigate longer term issues that may impact recovery from an Eating Disorder.
V. Develop three questions you would ask Erin during an interview to complete an MSE. They could be from any MSE area.
VI. Develop a nursing care plan.