Problem
Case I: Denise
Denise, a 19-year-old woman, has been admitted informally to an acute mental health ward; this is Denise's first admission. Denise was being treated for depression by her GP; prior to her admission Denise attempted to kill herself by cutting her wrists. Subsequently a short admission was arranged with the aim of devising a comprehensive care package.
After speaking about the circumstances leading up to her suicide attempt Denise became increasingly tearful and distressed, and started demanding to see a doctor. After being told that the doctor was on their way and would arrive in about 10 minutes, Denise became angry demanding medication to calm her down; she then proceeded to run towards the ward's doors shouting that she wanted to go home. At that moment the doctor arrived on the ward and Denise also immediately calmed down.
During the assessment process Denise disclosed that being angry if she did not get her way was not unusual for her. She also mentioned that she felt awful after these bouts of anger. She described herself as a "terrible person who was out of control" and she just wanted to die. After assessing Denise the nurse started to formulate a plan of care.
i. What type of psychological interventions would the nurse consider implementing?
ii. Currently Denise has been admitted informally to the ward. Due to Denise's impulse control difficulties this may change. On this basis what does the nurse professionally need to know when managing Denise's legal status?
iii. Denise is subsequently diagnosed with a "borderline personality disorder". What other types of personality disorders are there?
iv. What specific psychological interventions would the nurse deliver?
v. How could the nurse learn from their experiences of working with Denise?
Denise has now been on the ward for over 6 months. Each time discharge has been arranged Denise self-harms or threatens suicide. Denise has now agreed to go to a therapeutic community, a place has been secured and Denise is now engaging in pre-therapy work.
i. What other treatments besides a therapeutic community are recommended for individuals diagnosed with a borderline personality disorder
ii. While working with Denise the primary nurse has found the relationship at times to be quite stressful. What are the signs of stress?
iii. What strategies could the nurse use to manage their stress?
iv. What process should be utilized as a way to support the primary nurse to improve their practice?
Case II: Ellie
Ellie is a 21-year-old woman who lives at home with her parents. Recently Ellie was assessed by the mental health crisis services after being referred by her GP. It was noted that since dropping out of university a year ago Ellie had become more withdrawn, preferring to spend most of her time in her room. When engaging with her parents Ellie would frequently become angry, accusing them of spying on her and on occasion she would threaten them with violence. On assessment Ellie admitted hearing voices; at times these voices were comforting and at other times quite threatening. Ellie also described feeling special, stating she could predict the future; she was also not sure that her parents were her real parents.
i. How would the mental health nurse collect the required assessment information
ii. When assessing risk what factors should the nurse consider and how would they positively manage any identified risks?
iii. Clinical risk management can at times lead to over-defensive practice. To ensure a positive approach is taken the nurse would:
iv. Ellie is diagnosed with schizophrenia. How is schizophrenia diagnosed?
v. When devising a care plan for Ellie, what types of psychological intervention should be considered?
vi. Ellie is prescribed antipsychotic medication. On this basis what physical health issues might arise?
Initially Ellie agreed to take her antipsychotic medication and has been well for over a year. Over the last 6 weeks it has been noted that Ellie has become increasingly unwell exhibiting symptoms that were first highlighted on admission to the mental health service. Ellie has also stopped taking her medication.
Subsequently Ellie attacked her mother, and a decision was taken to admit Ellie to an acute mental health ward. Ellie was admitted informally to the ward but since refusing to take any medication and refusing to stay on the ward Ellie is now on a section 3 of the Mental Health.
i. The ward organises care through a primary nursing approach. What other ways of organising nursing care could be used?
ii. A key issue in deciding that Ellie needed to be placed on a section relates to the judgement that Ellie did not have capacity. How does capacity relate to an individual making their own decisions?
iii. During Ellie's admission there was an incident where Ellie was physically restrained and then placed on supportive observations - level 4. What are supportive observations?