All 11 questions, the risk assessment, case study and nursing care plan in this workbook must be answered correctly to receive a satisfactory grade for this assessment. You must achieve a satisfactory result for each question in the workbook and include referencing as per STA requirements to achieve a satisfactory result for this assessment.
All answers must contain core mandatory information to achieve a satisfactory result. A satisfactory result will achieve the minimum grade required. All additional correct information will increase the grade up to the maximum for that question.
For example:
|
This workbook is to be completed in your own time using available reliable sources such as the course text books provided to you at orientation, credible internet sources such as the department of health and other text and online journals available to you through the online library service offered to all students and discussed at orientation.
It is important that you reference all sources of information that you use to obtain information used in your answers. Referencing must be included and failure to adhere to this requirement will result in a not satisfactory outcome for the assessment.
In the event of a not satisfactory outcome for this assessment task, the student will be awarded further opportunity to submit work to the Trainer/Assessor. Where the student has not been able to attain a competent mark following resubmission, a meeting will be held with the student to re-assess the individual’s learning style and the assessment method. This will be conducted between the Trainer/Assessor, the student and where appropriate, the Programs/Training Manager.
Flexibility in assessment will be considered where the integrity of the assessment and learning outcome is maintained. For example, a written assessment may be administered as a verbal assessment and recorded by a STA staff member where a student has sustained an injury preventing them from writing. Any agreement for an adjustment to assessment must be documented in writing to the program manager and placed in your student file.
|
What is the difference between a Voluntary client and a client on a Compulsory treatment order? |
|
An individual can either receive treatment as a voluntary client or a client on a compulsory treatment order. A voluntary client can also admitted to a hospital however he or she has the freedom to leave when they want do. While a compulsory treatment order, the hospital or the mental institution will provide treatment on order. Here an individual may lose his or her rights and freedoms and is entitled to stay in the hospital for specific time duration. A compulsory patient is an individual who has undergone assessment by a psychiatric and is prescribed compulsory treatment. They receive treatment against their will either in a community setting or as an inpatient in a hospital ("Compulsory treatment orders | Victoria Legal Aid", 2017). |
|
A request may be made for a client upon admission to a mental health unit to provide a urine specimen for the detection of illicit substances (like amphetamines or marijuana). A client that you are admitting asks why you need a urine sample. What is your responsibility and response as an Enrolled Nurse in this situation? |
|
As an enrolled nurse in this situation it is essential to clarify the purpose of the meeting of the patient so that the nurse can fully be aware of the patients/clients problem and then take steps to determine the best possible care. A nursing interview comprises of three phases the beginning phase, the middle phase and the terminating phase. As a nurse it my responsibility to make a complete evaluation of the mental status of the patient prior to sharing any information with the client. This allows the nurse to devise the best plan possible to explain the client the need for a urine sample. In case of detection of illicit substances it is imperative for the client to be provided all the information pertaining to the test. |
|
What are the characteristics of case management in the mental health environment and how does this differ to other patterns of nursing care? |
|
Patients that have a history of mental ailments have a vast variety of needs that need to be taken into consideration prior to the commencement of a treatment plan. Case management is one of the most intrinsic kinds of aftercare which is used for the management of illnesses that reoccur or are of a chronic nature. Those who have been hospitalized repeatedly for mental illnesses need active case management where all the needs of the client are kept in mind. As each case is different from the other no standard treatment will work like it does in other patterns of nursing care. If the nature of the mental illness is very chronic and disabling in nature it calls for a more active case management. Effective case managers need to deliver services than referring for different services to the clients. They need to work in accordance to the needs of the patients. In other patterns of nursing there are several nurses assigned to one patient while in case management one manager has the main responsibility of the client’s services ("Department of Health | The role of case management", 2017). The time for case management is usually unlimited unlike other nursing care. As mentally unstable clients need to have access to a person who is familiar to them all the time. |
|
In your role as an Enrolled Nurse and in line with the Code of Professional Conduct for Nurses in Australia, how would you define your role in protecting the cultural values and beliefs of an individual in the mental health setting? |
|
As an enrolled nurse and in line with the code of Professional Conduct for Nurses in Australia it is my duty and responsibility towards the patient to protect their cultural values and beliefs while in a mental health setting. Due to the fact that nurses need to appreciate the different cultural backgrounds that patients come from and this appreciation can only come when I as a nurse can acknowledge my own cultural differences and similarities as well. This will help me to identify the thoughts, beliefs and the perceptions of my clients. So that each person can be treated as an individual and as a nurse it’s imperative to develop cultural knowledge and awareness to that I can have a better understanding with the patient and respond to their needs accordingly ("Department of Health | People from culturally and linguistically diverse backgrounds", 2017). |
|
A client you are looking after tells you that his having a mental illness is considered shameful in his culture and that he believes he must take his own life in order to unburden his family from this shame. Bearing in mind your responsibility to be non- judgmental and not impose your own values and beliefs on this client and his culture. How might you support this client? |
|
As a nurse caring for those patients who have a suicidal tendency is one of the most challenging aspects of a mental health nurse. Suicide prevention is an imperative part of mental health services while dealing with a client that is suicidal a suicide risk assessment needs to be carried out. This risk assessment should not only be based upon the standard risk factor but should also include the warning signs for instance here the patient is telling the nurse that due to his mental illness he should take his own life to unburden his family is the most notable sign. As a nurse it is imperative that I conduct a mental health assessment each time I visit the patient that comprises of a series of informal questions to gauge the mental status of the patient (Hagen, Knizek & Hjelmeland, 2017). Further I would help the patient to understand that his mental illness is not a cultural taboo and by taking his own life his family would only get upset rather than getting free from the burden. I would also discuss the scenario with the client’s family members and help them to explain the patient. |
|
What considerations need to be made in the mental health setting when admitting a CALD client? |
|
As Nurses while admitting a CALD patient an approach that understands the diverging values, cultures and beliefs is assessed. This helps to act as a foundation for giving meaning to concepts in different cultures. For such patients it is imperative that test results are interpreted in a culturally sensitive manner. The translated text should be used with caution. Non standard methods need to be employed that allow nurses to get an insight into the cultural differences and the values of the patient while interviewing them. Culture specific instruments can also be used that have been made specific for certain cultures. Nurses need to enhance their credibility by understanding about various cultures rather than known the technicalities of specific cultures as these broadly based principles are more helpful ("OPA: Your Rights in a Psychiatric Facility", 2017). The health care system of Australia is founded on the Anglo Celtic cultural beliefs that surround health and their behaviors. However when patients who have a different belief need health care services then these barriers can prevent them to gaining the appropriate care. The health care staff should thus be aware of the patient’s needs and their cultural perspectives as well. Having effective communication between the patient and the health care provider is essential can cultural differences tend to impede communication. |
|
Stigma continues to be an issue for those who have mental health disorders. What is stigma and as an enrolled nurse how can you aid to reduce this stigma? |
|
Stigma is a degrading attitude of the society towards a person or a group due to a specific attribute. This could either be on the basis of an illness, a deformity, colour or even religion. Stigma is one of the most prevalent issues for those individuals who have been suffering from mental health disorders as the society does not accept them with their flaws. As an enrolled nurse it is vital To make a positive influence on the patients and make use of their roles as a nurse so that the world can become aware of the need to put an end to stigma in the society and the way it is perceived. Thus for nurses it essential to focus completely on enhancing their knowledge pertaining to mental disorders as stigma acts as a barrier for providing adequate intervention for patients ("Understanding mental health and reducing stigma | Health and wellbeing | Queensland Government", 2017). Educational training programs, interviews and awareness drives should be conducted on a regular basis so that this stigma pertaining to mental illness can be reduced. |
|
A patient who is “voluntary” and extremely unwell wants to leave hospital. What actions might need to be considered to maintain a duty of care to this client? |
|
While dealing with a voluntary patient who is extremely unwell and wants to leave the hospital actions need to be taken to maintain a duty of care to the client. Firstly the patient must be made aware of the situation and the risks associated with it that it is unsafe for them to leave the hospital ("Compulsory treatment orders | Victoria Legal Aid", 2017). If they fail to understand the associated implications with leaving the hospital I will let them leave the hospital. If the patient is mentally unstable and is incapable of making decisions in his good will as he leaves I will contact the police department to ensure the safety of the client for his best interests as being a nurse the law does not allow me to hold a voluntary patient in hospital against his or her will despite understanding the severity of the situation. |
|
Explain why extra-pyramidal side effects occur with the use of antipsychotic medication? Include in your answer a description of what extra-pyramidal side effects are and how they present. |
|
Antipsychotic medications are also called as neuroleptics that are commonly prescribe for schizophrenia. The side effects that these antipsychotic medications creation as known as extra pyramidal side effects. This comprises of physical symptoms that consists of paranoia, tremors and slurring of speech (Nanayakkara & profile, 2017). The pyramidal tract consists of the nerve and muscle pathway that is involved in the process of voluntary muscle movements and the extra pyramidal system is the nerves and the muscles that lay outside this pyramidal tract. These side effects are mainly due to the drug reaction that takes place because of interactions with the extra pyramidal system in the body. Antipsychotic drugs give rise of these side effects as they have dopamine blocking properties in them. |
|
Explain the development of a therapeutic relationship. |
|
Development of a therapeutic relationship needs reflective practices this comprises of self awareness, knowledge, empathy and boundations as a nurse. It is imperative as a nurse to understand the process of a therapeutic relationship with the client as it is central for all practices of nursing ("Establishing Therapeutic Relationships | Registered Nurses' Association of Ontario", 2017). For instance in mental health the therapeutic relationship is the primary and most essential intervention that is used for the promotion of awareness and growth. |
|
Mental health clients are very vulnerable. What would you do if you heard a colleague and a client talking and it was clear from their conversation they were involved in a sexual relationship? Ensure you link your actions to the Nurses Board standards for therapeutic relationships and professional boundaries |
|
According to the Nurses Board Standards for therapeutic relationships and professional boundaries a nurse needs to maintain strict decorum at all given times. In a nurse client relationship the nurse has more power rather than the client and has influence, access to information and skills. As a nurse it is vital to establish only a therapeutic relationship with the client and not misuse their power and establish sexual relations with the patient even if they consent as a mental health client is incapable of making informed decisions. A sexual relationship for a nurse with a client according to the board standards is a serious misconduct in the health care services and is an abuse of the therapeutic relationship as it puts the needs of the nurse first than the client ("Boundaries in the Nurse-Client Relationship", 2017). |
|
You are working in a mental health intensive care unit and notice two clients arguing. It is clear from your observation of their interaction that the situation is escalating and it may become physical. List the observations that make you think the situation is escalating. What would you do in this circumstance? |
|
If two clients were arguing and the situation is escalating rapidly and could become physical the observations that I would make as a nurse would be to check for the factors that could have triggered off the aggressive behaviour in the first place amongst the two clients. After that I would check for the 5 impending signs of aggressive behaviour. Yelling and arguing is one of most common trigger points for a situation to escalate for mentally unstable patients. In this scenario I would make certain that I maintain a safe distance from the clients and accommodate their space as intruding in personal space can further aggravate the situation. Maintaining an open posture with open hands and feet apart. Using a confident approach is essential, using calming strategies in a low soothing voice and alerting the security of the hospital should be done so that the clients and can removed and restrained to prevent further damage. |
|
Read the case study below and develop a nursing care plan using the table provided on the following pages. A 20 year old male (Peter) has been brought into the Accident and Emergency department by the Police. He was found wandering through Bourke Street Mall in the City wrapped in a sheet and proclaiming that he was the Son of God. On presentation he was found to be dishevelled with poor personal hygiene. He appeared to be muttering to himself although denies hearing voices and firmly holds the view that he is the “Messiah that has come to take away the sins of the world.” Blood and urine screens are taken and those test positive to THC (marijuana). When Peter’s mother is contacted she indicated that her son has been progressively withdrawing from the family. Conversation had become more difficult with Peter as he appeared to be talking with someone not in the room. Peter’s mother stated that he had one other previous admission for the same presentation when he was 16 years of age. At that time he was violent and aggressive, stating that the family was the anti-Christ and they were all going to hell. Peter’s mother explained that Peter was always a sensitive child, artistic and empathic to others. His behaviour had changed over the past five years to the extent that he was now angry and aggressive with the family most of the time and he was much more isolative and withdrawn lying on his bed for hours on end. Peter was diagnosed with Schizophrenia and detained under the Mental Health Act. He was commenced on Olanzapine (Zyprexa) 10mg twice a day. He was also written up for PRN Lorazepam 1.25mg – 2.5mg for agitation up to a maximum of 7.5mg a day. You are the enrolled nurse who is responsible for Peter’s admission. You work in an open unit. You have been given the responsibility of his care and notice a decline in his mental state with increased isolation and potential aggression. At interview you notice that Peter is preoccupied and responding to non-apparent stimuli. He is fidgeting and evasive in his answers. Peter denies that he has an illness and states that he is being victimised for his religious beliefs. Peter takes his medication but crushes the cup and appears to hold it in his mouth. On one occasion you catch Peter putting his fingers down his throat in the male toilet to make himself vomit. He is not eating or drinking and is 60kg yet 185cm in height. His hygiene needs have been neglected. Peter sleeps 3 hours per night spending a lot of time giggling or talking to himself. On one occasion Peter becomes aggressive when another client challenges his beliefs. Peter needed to be restrained and is given intramuscular Olanzapine 10mg with Lorazepam 2mg. This has the desired effect and Peter appears calmer and more relaxed. You notice however that Peter has developed a very unsteady gate. He is over sedated and he appears to be hyper salivating.
Develop a nursing care plan using the table provided for the following nursing diagnosis:
Make sure you remember to reference as needed. |
|
The patient appears to be dishelleved, dirty, not had a bath in days, he has poor personal hygiene and has lost a lot of weight. |
|
The patient shows aggressive behaviour when his religious views are challenged. He appears to be calm when he is sedated. His behaviour has become more angry and aggressive in the past 5 years. He likes to be isolated and withdrawn in his own room. |
|
The patient has speech impairment and is seen muttering and talking to him.
|
|
Mood of the patient appears to be depressed, euphoric, suspicious, labile - (alternating between extremes) he seen to be calm at one point and very aggressive the next moment when his religious beliefs are questioned. |
|
The patient appears to be lack of any emotional expression. |
|
Amount of thought and rate of production eg hesitant thinking, vague, flight of ideas. He is constantly talking to him and |
|
He is obsessed about being the messiah of god and considers him to be a messenger of god. |
|
The patient is having severe hallucinations as he is talking to him even though there is no body in the room with him often. |
|
Patient is over sedated, is hyper salivating and has clouding of conciseness |
|
Has poor judgement and does not accept his condition at all. |
|
1. Appearance and behaviour Appearance eg grooming, hygiene, clothing, hair, nails, other significant features Attitude to situation and examiner eg hostile, withdrawn, seductive Motor behaviour eg slowed down, restless, tremors, bizarre ( include description) 2. Speech Rate eg slow, pressured (very rapid), monotonous Volume eg loud, quiet, slurred Quantity of information eg restricted amount of spontaneous speech 3. Mood and affect Mood eg depressed, euphoric, suspicious, labile - (alternating between extremes) Affect eg restricted, flattened (absence of emotional expression) inappropriate 4. Form of thought Amount of thought and rate of production eg hestitant thinking, vague, flight of ideas Continuity of ideas - refers to logical order of the flow of ideas Disturbance in language or meaning eg uses words that don't exist or word salad 5. Content of thought Delusions (particular problems arise from delusions of persecution, poisoning) Suicidal thoughts, plans or intent Other - eg obsessions, compulsions, hypochondriacal preoccupations 6. Perception Hallucinations relating to sounds heard, visions, smells, tastes, tactile or somatic sensations. Note in particular any command hallucinations. Does the patient think that he or she may act upon these? Other perceptual disturbances (derealisation, depersonalisation, heightened/dulled perception) 7. Sensorium and cognition Level of consciousness eg abnormal drowsiness, delirium, clouding of consciousness Memory: immediate, recent, remote Orientation: time, place, person Concentration: ask the individual to subtract serial 7s from 100 Abstract thinking 8. Insight Extent of individual's awareness of problem. Compliance with treatment. |
|
[MENTAL HEALTH SERVICE] BRIEF RISK ASSESSMENT |
SURNAME: |
UMRN: |
SEX: MALE |
BRIEF RISK ASSESSMENT |
|||||||||||||
|
FORENAMES: PETER |
BIRTHDATE: |
||||||||||||||||
|
PATIENT’S ADDRESS: |
|||||||||||||||||
|
SOURCE OF INFORMATION |
q The consumer YES |
q Immediate carer (parent, spouse, child) |
|||||||||||||||
|
q Other informants (family, friends) |
q Previous clinical records |
q Assessing clinician’s knowledge of consumer’s past behaviour/current clinical presentation |
|||||||||||||||
|
q Police/ambulance/other agencies |
q Other (please specify) ___________________________________ |
||||||||||||||||
|
SUICIDALITY Static (historical) factors |
Yes (1) |
No (0) |
Not Known |
Dynamic (current) risk factor |
Yes (2) |
No (0) |
Not Known |
||||||||||
|
Previous attempt(s) on own life |
NOT KNOWN |
Expressing suicidal ideas |
|||||||||||||||
|
Previous serious attempt |
Has plan/intent |
||||||||||||||||
|
Family history of suicide |
Expresses high level of distress |
||||||||||||||||
|
Major psychiatric diagnosis |
Hopelessness/perceived loss of coping or control over life |
||||||||||||||||
|
Major physical disability/illness |
Recent significant life event |
||||||||||||||||
|
Separated/Widowed/Divorced |
Reduced ability to control self |
||||||||||||||||
|
Loss of job/retired |
Current misuse of drugs/alcohol |
||||||||||||||||
|
PROTECTIVE FACTORS (describe) : The patient is at severe risk of self harm as he is losing control over his own life. Is on a overdose of marijuana and is a drug addict. |
|||||||||||||||||
|
LEVEL OF SUICIDE RISK (total score): LOW (<7) MODERATE (7-14) HIGH (>14) high |
|||||||||||||||||
|
AGGRESSION/VIOLENCE Static (historical) factors |
Yes (1) |
No (0) |
Not Known |
Dynamic (current) risk factor |
Yes (1) |
No (0) |
Not Known |
||||||||||
|
Recent incidents of violence |
Expressing intent to harm others |
||||||||||||||||
|
Previous use of weapons |
Access to available means |
||||||||||||||||
|
Male |
Paranoid ideation about others |
||||||||||||||||
|
Under 35 years old |
Violent command hallucinations |
||||||||||||||||
|
Criminal history |
Anger, frustration or agitation |
||||||||||||||||
|
Previous dangerous acts |
Preoccupation with violent ideas |
||||||||||||||||
|
Childhood abuse |
Inappropriate sexual behaviour |
||||||||||||||||
|
Role instability |
Reduced ability to control self |
||||||||||||||||
|
History of drug/alcohol misuse |
Current misuse of drugs/alcohol |
||||||||||||||||
|
PROTECTIVE FACTORS (describe) : patient is paranoid, violent, has hallucinations, shows signs of anger, frustration and has a current misue of drugs. |
|||||||||||||||||
|
LEVEL OF VIOLENCE RISK (total score): LOW (<7) MODERATE (7-14) HIGH yes (>14) |
|||||||||||||||||
|
OTHER RISKS IDENTIFIED (AND RISK FACTORS) Patient is at a risk of harming others who question his religious beliefs. He can get violent as well. |
|||||||||||||||||
|
RISK MANAGEMENT ISSUES (please ensure alerts are noted here) The patient does not like to be put in restraints and controlling his agressiion is a problem. |
|||||||||||||||||
|
(To be completed by assessing clinician) PRINT NAME: DESIGNATION: SIGNATURE: DATE: |
|||||||||||||||||
|
(Where appropriate, management plan to be acknowledged by requesting medical practitioner) PRINT NAME: DESIGNATION: SIGNATURE: DATE: |
|||||||||||||||||
|
Nursing Diagnosis |
Related to |
Nursing Interventions |
Rationale |
|
Altered thought processes |
Schizophrenia |
Assessment of incoherence in speech is of chronic nature or not (Brinn, 2000). |
Having a baseline helps in establishing goals that are realistic in nature and help in effective care planning. |
|
Altered perceptions |
Identification of the duration of the psychotic medication |
The therapeutic levels of antipsychotic medication helps in clear thinking and reduces the looseness of association. |
|
|
Biochemical alteration of certain neurotransmitters Psychological barriers Side effect of medication |
Keep environment calm and free from any kind of stimuli |
Helps in reducing the anxiety and increasing hallucinations. |
|
|
Medication Compliance issues . |
Due to paranoia Delusions and hallucinations Cognitive impairment |
Adherence coping education or (ACE) for early treatment of schizophrenia. Cognitive-behavioural therapy (CBT) ("care plan for client with schizophrenia", 2017) |
Leads to having adherence to the medication regime (Tham et al., 2016). |
|
Impaired sleep patterns |
Due to anxiety and hallucinations. |
Assessment of sleeping pattern to devise a sleeping plan. Provide the patient with a dark and comfortable environment.
Educate the patient on how to fall asleep and when to take sleep aid and its associated side effects.
|
Helps in calming the patient down and helps to relax (Fortinash & Holoday-Worret, 2007).
Educates the patient about the ill effects of taking sleep aids in the long run. |
|
Poor nutrition / hydration |
Inability to trust Panic level of anxiety Low self-esteem Inadequate support systems |
Nurse should work with client as much as possible. Make use of a creative approach to encourage the intake of food. Use food cans or tins (Quee et al., 2014). |
Helps in establishing a relationship of trust. Some suspicious patients may not eat from individual trays suspecting poisoning. |
|
Self-care deficit |
Related to depression Cognitive impairment Environmental factors Fatigue, weakness Neuromuscular impairment Perceptual impairment Severe anxiety |
Determine the cause of each deficit.
Evaluation of the gag reflex or inability to chew. Establishment of short goals. |
Etiological factors need more specific interventions to initiate self care. Absence of a gag reflex can cause choking (Quee et al., 2014). Setting realistic goals lowers frustration levels of the patient. |
|
Social isolation |
Due to recurring hallucinations. Anxiety Depression Stress
|
Engage the patient in reality-oriented activities that involve human contact (e.g., workshops, inpatient social skills training) (Short, 2014).
|
|
|
|
Promote social skills. Provide support in assisting the patient to learn social skills. Deal with the hallucinations. Do not argue over their occurrence. |
Helps the patient to get out of his shell and learn new skills. Occurrence of hallucinations will gradually decrease if you assure the patients that they are not real (Townsend, 2015). |
References
