Assignment:
Case study 1
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.
Q1a. Discuss 4 signs and symptoms of a Major Depressive Disorder (MDD).
Q1b. How could the behaviours that Bill is showing impact his family / friends?
Q1c. As an enrolled nurse how would you respond to Bill should he become aggressive again?
(Tick the 4 possible answers)
Assess environment to ensure that there are no objects Bill could use in a dangerous manner
Holding full on eye contact with Bill to get his attention
Holding intermittent eye contact and avoiding staring at Bill
Have several people communicating with Bill at once to all try and calm him down
Actively listen to what Bill has to say
Remaining connected to Bill via rapport-so that Bill is made to feel valued and respected
Get close as possible to calm Bill
Q2a. Bill has already demonstrated aggression and continues to be potentially threatening to staff and patients.
Describe 4 common triggers for aggressive behaviour.
Q2b. Describe 5 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 2 communication interventions.
Q2c. To assist you with Bills issues and possible outbursts of aggressive behaviour who can you seek to obtain guidance or support?
Q2d. 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)
Q3. Bill is experiencing oral health issues due to his disorder.
Outline 2 specific nursing strategies you can put in place to assist Bill to improve these issues
Outline 3 possible causes for his oral health issues
Poor oral health Nursing strategies
Possible causes of poor oral health
Q4. "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 history and background, the main focus of risk assessment is what is happening for the client now. 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 be the marker 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
Q5. Discuss 2 of the principles from the domains covered in assessment 1, that you could use for Bills situation when assisting with planning his nursing care
Q6a. Identify 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
Q6b. Discuss 2 people whom you could consult with from within the multidisciplinary team to maximise health outcomes for Bill and why?
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
Q7. 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
a. Discuss which members of the multidisciplinary team would possibly attend,
b. What would your role as the EN be in this meeting? Discuss at least 3 possible roles.
c. Review Bills case study and outline 2 possible community based service providers that you could liaise with and suggest for Bill when he is discharged, and state how these services can help.
d. How could Bill be supported as a valued member of the community that will help him to build on his own strengths and to take as much responsibility as possible for decisions that affects his life.