Prioritisation and Competent Nursing Practice - Essay Example

Comprehensive Mental Health Prioritisation and Competent Nursing Practice A. Nursing Diagnoses Based on Assignment Diagnosis Risk for Injury related to hopelessness and impaired problem solving indicated by poor judgment, indecisiveness, impaired problem solving, poor concentration including suicide risk due to depression manifested by suicide attempt in the current admission and sadness, suicidal thoughts, dejection, or episodes of weeping on assessment and feeling of rejection, despondence, self-reproach, and hopelessness indicated by expressions of feelings of discouragement, despair, pessimism about future, which cannot be dispelled. Also, current serious attempts of suicide and helplessness and worthlessness indicated by patient's statement on interrogation. Diagnosis 2: Hopelessness related to depressive thought process manifested by sadness, dejection, weeping episodes, worthlessness, guilt, anhedonia, low spirits, disturbed sleep pattern, all indicating depression and manifested by despondency, gloom and despair reflected in speech, facial expression, and posture and observed sleep pattern in the hospital. Diagnosis 3: Risk of serious malnutrition and existing malnutrition indicated by greater than 1 lb weight loss in a week, which is probably related to this current illness. The patient's feeling of heaviness of limbs, back, head, and aches in the same areas; loss of energy and fatigability, difficulty eating without the staff urging poses risks for further malnutrition. Gastrointestinal symptoms of dry mouth and somatic psychic gastrointestinal symptoms of depression manifested by wind, indigestion, diarrhoea, cramps, belching may aggravate the decreased appetite. Slight retardation at interview may indicate lassitude, and irritability may further aggravate loss of appetite, since it may represent inner tension representing feelings of ill-defined discomfort, edginess, inner turmoil, mental tension mounting to panic, dread or anguish that may lead to further loss of desire for food. Prioritization Priority 1: Diagnosis 1: Risk for Injury related to hopelessness and impaired problem solving indicated by poor judgment, indecisiveness, impaired problem solving, poor concentration including suicide risk due to depression manifested by suicide attempt in the current admission and sadness, suicidal thoughts, dejection, or episodes of weeping on assessment and feeling of rejection, despondence, self-reproach, and hopelessness indicated by expressions of feelings of discouragement, despair, pessimism about future, which cannot be dispelled. Also, current serious attempts of suicide and helplessness and worthlessness indicated by patient's statement on interrogation. Rationale of the Priority 1: Depressed individuals have negative evaluation of their worth, which often is unrealistic. They are known to have guilty preoccupations or ruminations about minor past failings, where always they blame themselves. It is very common for these individuals to misinterpret neutral or trivial everyday events as due to failure of his or her person. Their exaggerated sense of responsibility for untoward events makes them very commonly feel hopeless, helpless, worthless and powerless. Due to her previous history of paranoid schizophrenia, it would be natural to expect possibility of disorganized thought processes, such as circumstantial or tangential thinking. Although there is no evidence of such in examination or history, there is a high possibility of hallucinations and delusions. Any assessment of depression requires that the risk of self-harm or suicide be assessed. This is the first priority since patient safety if the first nursing priority. In this patient, due to attempted suicide and related admission, this becomes a greater priority. In depressed patients, self-harm and suicide are very prevalent. Anyone showing symptoms of severe depression, especially psychomotor retardation and/or psychotic symptoms should be regarded as at high risk of suicide, as should anyone who has previously attempted suicide or self-harm (Ginsberg, 2003). She is 2 months in the hospital and recovering. Evidence indicates that depressed people are at highest risk of suicide when they begin to recover. This happens due to the fact that their mood begins to lift, psychomotor retardation decreases and motivation increases, the individual may become more able and motivated to carry out a suicidal act, because they may still feel profoundly depressed. Moreover, she has all the risk factors for an increased risk of suicide or self-harm attempts. Her mood and related negative thoughts are still very prominent. She has very less social support; since at home, she thinks she is the worst of the siblings. Although she does not use substances nor has any symptoms related to psychosis, her previous attempts indicate that on the face of inadequate social support, she had been unable to control the suicide impulsiveness and have a past history (Keller et al., 2006). She does not have thoughts of death passively or active suicidal ideation at present, but all the predisposing factors are still present, and she might as well start thinking that other in her family will be better off of she is dead. She has undeniable impaired ability to think, concentrate, and make decisions. She complained of memory difficulties and could be easily distracted. So she has decisional conflict, spiritual distress, ineffective individual coping, dysfunctional grieving, all related to her hopelessness and low self-esteem which may promote a wrong situational interpretation leading to further attempt at suicide and/or self-harm if she has a plan, intent, and accessibility of means. This is the first priority since nursing management and interventions can be designed to prevent this as soon as possible (Oquendo et al., 2004) Priority 2: Diagnosis 3: Risk of serious malnutrition and existing malnutrition indicated by greater than 1 lb weight loss in a week, which is probably related to this current illness. The patient's feeling of heaviness of limbs, back, head, and aches in the same areas; loss of energy and fatigability, difficulty eating without the staff urging poses risks for further malnutrition. Gastrointestinal symptoms of dry mouth and somatic psychic gastrointestinal symptoms of depression manifested by wind, indigestion, diarrhoea, cramps, belching may aggravate the decreased appetite. Slight retardation at interview may indicate lassitude, and irritability may further aggravate loss of appetite, since it may represent inner tension representing feelings of ill-defined discomfort, edginess, inner turmoil, mental tension mounting to panic, dread or anguish that may lead to further loss of desire for food. Rationale: This patient is in risk of future malnutrition due to her loss of appetite. She has demonstrable loss of weight in the unit, and she hardly makes an attempt to feed herself. Over and above that she has gastrointestinal somatic symptoms of depression. The fullness of stomach, constipation, belching, all are contributing to her loss of appetite. The malnutrition, if not intervened, would eventually lead to anaemia and deficiency states resulting in fatigue, lassitude to further compound the baseline abdominal pain; low energy level; fatigue and listlessness of depression. A general slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention; anorexia; and weight loss are very common in depression. Imbalanced nutrition leading to less than body requirements of food and nutrients related to depressed mood, loss of appetite, lack of interest in food have started to manifest itself through loss of weight. This if not abated would soon lead to poor muscle tone, pale conjunctivae and mucous membrane, poor skin turgor, and weakness. This would aggravate the self-care deficits further, aggravating her clinical condition. Physically, there is evidence of weakness and fatigue. She has very little energy to carry on activities of daily living. She has heightened sensitivity to her physical problems of dry mouth, wind, indigestion, diarrhoea, cramps, belching. In response to a general slowdown of the body, digestion is often sluggish. This is the second priority since nursing intervention and management is possible to prevent further deterioration and improve her nutrition (Stuart & Laraia, 2005). Priority 3: Diagnosis 2: Hopelessness related to depressive thought process manifested by sadness, dejection, weeping episodes, worthlessness, guilt, anhedonia, low spirits, disturbed sleep pattern, all indicating depression and manifested by despondency, gloom and despair reflected in speech, facial expression, and posture and observed sleep pattern in the hospital. This is the third priority since these are related to her primary alterations in mood, and this would need ongoing treatment. In a major depressive episode, either a depressed mood or a loss of interest or pleasure in nearly all activities must be present for at least 2 weeks. She is continuing with these for at least the last 2 months. She is on medications, and hopefully, gradually she will improve. The nursing intervention or management in this area are mainly providing support and monitoring of her condition repeatedly to document progress. Many of the feelings and thoughts engendered by depression are intensely personal and difficult to discuss. Nursing staff need to be aware of this and should take time to build a relationship with depressed people and enable them to discuss their problems. However, monitoring is very important, and this was done through mental status examination, which is an effective clinical tool to evaluate the psychological aspects of major depression because the focus is on disturbances of mood, affect, thought processes and content, cognition, memory, and attention. She was like any person with depression with sustained period of feeling depressed, sad, or hopeless with anhedonia. Therefore in congruence with that fact, she was sad, dejected with feelings of hopelessness and helplessness. Her outlook was gloomy and pessimistic with the sense of worthlessness prevailing. This was consistent with her slow thoughts with difficulty concentrating. She was perhaps having obsessive ideas and rumination of negative thoughts. She could also be misinterpreting her environment. She had limited verbalization, although she was cooperative. When she would speak, she would express ruminations regarding her own life regrets. Her social participation was almost nil, and she would spend time with sole concentration on self with evident discouragement of others in pursuing a discussion with her, and this would further aggravate her feelings of worthlessness and look out for isolation. She was showing a general slowdown. Her energy levels were apparently depleted; her movements were lethargic, and she would perform her daily activities with insistence from the nursing staff. To support the idea that she is still depressed, her alterations of sleep rhythm also conformed to this pattern (Oquendo et al., 2004). Reflection: It has been already noted in the first assignment that I gained consent from Ms. G. about assessing her while she was in the hospital, where she permitted me to interview her, to record her information, and to analyse her health records in order to complete this assignment. She has been hospitalised into this mental health unit 2 months ago, is being treated, and she is communicable. Ms. G. consented to this process immediately and was very cooperative. From this prioritization of the diagnosis, it was very apparent that I needed to intervene directly on the issue of her suicidal intent with the goal that she would not harm herself, since her safety was my priority. Since the risk of suicide is greatly increased if she has developed a plan. Although at the present situation in the hospital she does not have any means for to execute the plan, it was important to ask her directly due to her depressed mood, feelings of worthlessness, anger turned inward on the self, misinterpretations of reality that whether she had thought about harming herself in any way. She declined, but it was difficult to trust her on this issue since had still evidence of depression, and she might think that openly disclosing a plan may lead to organized resistance from me. Therefore, I asked her again what was her plan, and if she had a plan, how she is planning to execute it (Carpenito, 2002). I remember, at the same time taking all measures to create a safe environment for her in the unit. I requested and personally supervised removal of all potentially harmful objects from her access, such as sharps, straps, and glass items. I also arranged close supervision during meals and medication administration. It is to be mentioned that she would not ask for meals, and most of the times, a meal would always be forced to her. I took keen interest about her fluid intake since fluid imbalance can be acute if she did not take it. I remember conducting room searches whenever possible. I decided to formulate a short-term verbal contract with her that she would not harm herself. In this way every 3 days, I would renew the contract with her. She agreed to inform me whenever she feels anger and feels any suicidal intent. She agreed. In my absence, if such thoughts came, she agreed that she will inform staff. In my view, this was important since this would confer some degree of responsibility for her safety to herself. This, as I felt, increased her feelings of self-worth since I made sure that she feels accepted unconditionally regardless of her thoughts or behaviour. She was placed under closed supervision and observation in a room near the nursing station, and whenever I would be there I would make one-to-one contact with her, and as requested, both regular checks at 15-minute intervals and irregular checks specially during the night. I arranged a company to the toilet and bathroom, and I remember accompanying her to the labs for investigations. Moreover, whenever I would have a chance to talk to her, I encouraged her to express honest feelings including anger and provide for release of hostility. This was important since depression and suicidal behaviours may be viewed as anger turned inward on the self (Elder, Evans, and Nizette, (Eds). 2005). This was a hopeful venture since if this anger can be verbalized in a nonthreatening environment; the client may be able to eventually resolve these feelings. I accepted her and spent time with her with a focus on her strengths and accomplishments, and that would eventually minimize failures. This resulted in the boosting of her feelings of self worth. I encouraged her to be as independent as possible, since rates of success and independence would promote a feeling of self worth. I discussed on several occasions with her what could be her areas of change, and I helped her to identify areas of assistance where she needs it. All these would have increased her self esteem (Akiskal, 2005). Conclusion: It was not possible to attend her all the time, since my time with her was during my shift hours only; it was not possible to monitor her food and fluid intake. Although not included in this assignment, I also opened discussion to make her understanding clear about her family and support system. Her depression will take time to resolve, she is improving, and hopefully, her sense of worth will be restored, her sleep rhythm will come back to normal, and she would not harm herself. Sometimes the patience necessary for such nursing activity would be missing, and I would be curt and professional, and I must admit that I was wrong. The success of nursing management would depend on establishment of a therapeutic relationship with the patient. This activity in the ward gave me a lot of opportunity to manage the care of a patient with depression with suicidal intent. Reference List Akiskal HS., (2005). Mood disorders: Historical introduction and conceptual overview. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 1. Baltimore: Lippincott Williams & Wilkins; 2005:1559. Carpenito, L. J. (2002). Handbook of nursing diagnosis (9th ed.). Philadelphia: Lippincott Williams & Wilkins. Elder, K., Evans, K., Nizette, D.(Eds).(2005). Psychiatric and mental health nursing. Marrickville:Elsevier/Mosby Ginsberg, DL., (2003). Anticonvulsants may reduce suicidality in bipolar disorder. Primary Psychiatry. 2003;10:19. Keller J, Gomez RG, Kenna HA, Poesner J, DeBattista C, Flores B, Schatzberg AF., (2006). Detecting psychotic major depression using psychiatric rating scales. J Psychiar Res.;40:22-29 Oquendo MA, Galfalvy H, Russo S, Ellis SP, Grunebaum MF, Burke A, Mann JJ., (2004). Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry;161:1433-1441 Oquendo MA, Barrera A, Ellis SP, Li S, Burke AK, Grunebaum M, Endicott J, Mann JJ., (2004). Instability of symptoms in recurrent major depression: A prospective study. Am J Psychiatry;161:255-261 Stuart, G.W., & Laraia, M.T. (2005). Principles and practice of psychiatric nursing (7th ed.). St. Louis: Mosby Read More