Analysis of Service-User Diagnosed with Ongoing Mental Illness - Case Study Example

Introduction This essay is a case study of a service-user diagnosed with ongoing mental illness and his journey to recovery. It will examine his progress and the care plan designed for him. The service-user shall be known as Mr. X to protect his identity and maintain the confidentiality of his case. Mr. X is a 37 year old man diagnosed with Schizo-Affective disorder concurrent with substance abuse of illegal drugs and alcohol. He was admitted into an acute care ward and was later on discharged into the community but still receives continued treatment from a Community Psychiatric Nurse (CPN) assigned to him. He has been in treatment for the past 10 months, and provided pharmacological therapy as well as monitoring of his Activities of Daily Living (ADL’s) . He is also provided with therapeutic talk sessions to allow him opportunities to express his thoughts and feelings, especially because he has a history of suicidal episodes and self-harming. It was actually these self-injurious events and suicidal ideations that prompted him to call for help way before he was admitted to the acute ward. He voluntarily called the police to declare his desire to kill himself and reported cuts to his left arm with a razor blade. He was detained in his home under Section 136 MHA’83. Because of his will to get better, he has been cooperative with his treatment and has shown great improvement in his well-being over time. As a student nurse in placement, I chose to work with this service-user when I met him six weeks after he was discharged from the ward and came back for a 7-day follow up. Although his case may seem complicated due to all the co-morbid conditions he has, I felt challenged to help him since he seemed to be a real good person but has been stigmatized by society as a bad one. I know both of us will benefit from working together because his ongoing recovery process shall be monitored by me as his Community Psychiatric Nurse and I believe I will learn so much from my experience in working with him and his complex mental illness and multiple conditions. Main body of assignment Mr. X’s condition is diagnosed under 2015 ICD-10-CM Diagnosis Code F25.9. Clinical Information (http://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F25-/F25.9) A disorder in which the individual suffers from both symptoms that qualify as schizophrenia and symptoms that qualify as a mood disorder (e.g., depression or bipolar disorder) for a substantial portion (but not all) of the active period of the illness; for the remainder of the active period of the illness, the individual suffers from delusions or hallucinations in the absence of prominent mood symptoms. Mental disorder characterized by the presence of both affective disorder and schizophrenia-like symptoms. Under the DSM-IV-TR (text revision of 2002), Mr. X’s substance abuse/dependence is analyzed with a multiaxial evaluation. Axis I: Substance Abuse/ Dependence Mr. X’s manifested symptoms may be diagnosed as Substance Abuse/Dependence. Under Following are the usual behaviours exhibited by substance abusers/ dependents: SUBSTANCE ABUSE:             Manifests one or more of the following behaviour:  Failure to fulfil major obligations: At 37, Mr. X is expected to be a mature, responsible adult, but he can be negligent even in duties to his own self that he needs someone to remind him or help him in simple tasks. Use when physically hazardous: He resorts to substance abuse when he feels like cutting himself. Recurrent legal problems: The rate at which he used several illegal drugs could have sent him to be incarcerated but instead, he was put in rehab Recurrent social or interpersonal problems: He prefers to be alone in his flat rather than be in the company of family or friends. He has not made new friends for several years now except for acquaintances whom he does not develop further relationships after the first or second encounters.   SUBSTANCE DEPENDENCE (ADDICTION/ALCOHOLISM)             Manifests three or more of the following behaviour:  Tolerance: He drinks between 2 and 8 cans of krononberg lager daily with whisky or vodka and still cravesfor more. Withdrawal: when he stops drinking, he loses his appetite and unable to sleep well. Large amounts over a long period: He started drinking from the age of 16 and continued up to the present. Unsuccessful efforts to cut down: He has attempted to cut down many times but easily falls back into the habit especially because he lives alone in his flat and there is no one to stop him or to remind him of the ill consequences of his vices. Time spent in obtaining the substance replaces social, occupational or recreational activities: He has been unable to find work for years due to his addiction. Continued use despite adverse consequences: Having developed suicidal ideations, he drinks and takes drugs to cope with it. He also engages in the illegal behaviours to silence the “voices” he hears that threaten him.l Axis II:  Developmental Disorders/ Personality Disorders: Mr. X has been diagnosed with the mental disorder, Schizo-Affective disorder. He suffers from paranoia and schizophrenia. Axis III: Physical Conditions: Apart from his mental illness, Mr. X is in good physical condition. Axis IV: Severity of Psychosocial Stressors: Although Mr. X lives alone, he feels stressed once he steps out and meets people. The stigma of being a crazy addict has stuck to him and he feels paranoid at the slightest insinuated glance from others. Axis V: Highest Level of Functioning: When he is sober or relaxed from his mental illness, Mr. X is capable of maintaining an intelligent conversation. making informed decisions and caring for himself and functioning like a normal person. He takes his dogs on walks, pays his bills, shops for his needs, does chores at home. Assessment Following The Roper, Logan, Tierney (RLT) Model of Activities of Daily Living (ADL), Mr. X is assessed on the following areas (Holland et al., 2008): 1. Maintaining a safe environment: Mr. X lives alone and regularly comes to the community care centre for treatment. He used to pose as a threat to his own safety when he would indulge in illegal drugs and consume large amounts of alcohol and even cut his wrists. Being on medication for his mental illness and guided by a CPN, he has developed more self-control and keeps his environment clean and safe for himself by regularly engaging in chores. 2. Communicating: Mr. X has no problems in communicating his thoughts and feelings to others. He also speaks clearly and can comprehend well and follow instructions. 3. Breathing: Mr. X has no problems with his breathing except when he has paranoid attacks when he reports hearing voices and seeing spirits that haunt him. However, such episodes have now been controlled. 4. Eating and drinking: Mr. X has not been eating well because he does not know how to cook healthy dishes. He survives on convenient foods such as TV dinners, cup noodles and other junk food. With regards to his drinking, he has reduced his drinking from 8 cans a day to two cans of beer. He has learned to drink water again which he did not drink since he was a teenager. 5. Eliminating: He has no with elimination of wastes as he is very regular with his urination and bowel movement. 6. Personal cleansing and dressing: He is now better in his personal hygiene and grooming except when he is under the influence of drugs or alcohol. At those times, he can go unshaven and without a bath for days. He also needs help in doing the laundry, as he does not wash his clothes very efficiently, often leaving stains after washing. 7. Controlling body temperature: Mr. X has no problems in controlling his body temperature. He knows how to dress himself according to the weather and keeps himself comfortable with good ventilation in his home. 8. Mobilising: Mr. X is very agile and can travel to places on his own. 9. Working and playing: Mr. X is not currently preoccupied with work and has no hobbies or sport that he is engaged in. 10. Expressing sexuality: Mr. X is not romantically linked with anyone because he refuses to initiate social interactions with people and would rather keep to himself. His previous relationships did not last long and he has been celibate for more almost 5 years now. He does not seem to be interested in dating or in sex now. 11. Sleeping: Mr. X has difficulty sleeping through the night. He wakes up every so often so during the day, he takes naps to make up for his lack of sleep. He expressed his need for a regular sleep schedule. 12. Dying: Mr. X’s suicidal ideations have decreased, although he admits he still thinks of killing himself to relieve him of his mental disorders and difficulty of living with the stigma of being crazy, an addict and an alcoholic. Upon the assessment of his health needs, a care plan to ensure his biopsychosocial health and well-being while he is recovering in the community under the supervision of his CPN must be created and implemented. This care plan should incorporate all the identified needs of the service-user after assessment. Goals should be set for Mr.X to meet such needs as well as the actions and outcomes expected when the care plan is implemented. This plan should be collaborated upon by the CPN and the service user (Barrett et al., 2009). Based on the assessment of ADL’s, the following care plan is to be implemented. Identified Service-User’s Need Action(s) to Achieve Need Expected Outcomes 1. Mr. X needs to continue taking his medications in order to maintain his progress. He needs to regularly take Clopixol depot, an injection which is an antipsychotic which has proven to be very effective for Mr. X, as he has been able to control his psychotic symptoms. Continued progress in his behaviour so he can manage to be more functional and take in more responsibilities like finding employment to support himself. 2. Mr. X needs to regularly see his CPN to help him set up a workable routine for him in taking in more independent and responsible adult tasks. CPN’s regular home visits to help Mr. X organize his things and routines including chores, self-help activities, etc. Regular visits to the community care centre for follow-up assessment and reporting of progress. CPN needs to accompany him on some days to observe his activities, like monitoring what a typical day for Mr. X is. This may include the simple errands of paying bills, going shopping, getting a haircut, walking the dog. This way, the CPN gets to assess the progress of Mr. X in terms of his independent living skills. With the help of the CPN, Mr. X needs to evaluate what kind of work he wants to do so based on his skills and personality so he can find a suitable job for himself. Eventually, Mr. X will function as a normal person maintaining a lifestyle fit for a responsible adult. He will be employed in a job where he can make use of his skills, such as clerical work. He will more responsible and accountable for his actions. When he has achieved the goal of being independent, he will be weaned from the services of his CPN and just report to the community centre on a regular basis. 3. Need for continued collaboration of CPN, the Approved mental health professional (AMPH) and community services for Mr. X’s further assessment, medication review and progressive interventions Mr. X will be regularly assessed by his CPN and the AMPH as to the implementation of the most appropriate intervention for him. Apart from pharmacological treatment from the community centre and life skills training from the CPN, the AMPH may recommend psychotherapy for him. Mr. X will gain more confidence and improve his self-esteem as he is assured of continued support for his ongoing recovery. Mr. X becomes more self-aware so he would know what he feels and thinks of at certain times and can address his needs accordingly. This facilitates his self-management. 4. Mr. X needs to be more conscious of his health by eating healthy foods, significantly, reducing, if not totally eliminating drug use and alcohol consumption, getting enough sleep and regularly exercising. CPN can help Mr.X shop for healthier food alternatives and cook healthy dishes. Mr. X needs to have the initiative to reduce his vices. So far, he has already done so, and is honest enough to admit if he took drugs or the number of cans of beer he had before coming to meet with his CPN. CPN and Mr. X can jointly plan his daily schedule including the time he should sleep and wake up and Mr. X should adhere to the schedule if he is to get enough sleep and balance it with his activities for the day. Mr. X needs to engage in regular exercise or sports. He mentioned that he used to play tennis. He can take that up again or include the routine of running everyday in his daily schedule. It would also be good if he becomes engaged in a new sport like basketball or go the gym so that the goals for his social skill development will also be met as he interacts with different people. Mr. X will be much healthier physically, trim down due to eating healthy foods instead of nutrient-deficient junk foods and being more physically active because of his exercise regimen. Because he will be free from the influence of illegal drugs and alcohol, his mind will be clearer and his medication will work better, leading to better cognitive functioning. His better health will lead him to maintain a positive disposition and well-being. He will be more organized when he follows his routines. He will develop more friendships with the people he would regularly encounter in his exercise/sport routines. 5. Continue with regular risk assessment to ensure that he will not harm himself by cutting his arm or wrist. He should be able to use tools such as knives, blades, scissors or anything with sharp edges in appropriate ways. His drug and alcohol use should also be well-monitored with the objective of eradicating it in the long run. Mr. X should be instructed to contact the duty team anytime he feels the tendency to harm himself or to indulge in his drug/alcohol use so he is able supported by the team. Removal of access to illegal drugs and alcohol Removal of potentially harmful tools such as guns, sharp tools, poisonous substances, etc. from his home and surroundings in the centre. Mr. X will lose interest in self-harming behaviours and learn to value his life more by engaging in more responsible behaviours. 6. Mr. X needs to join a Maintaining Adherence Programme (MAP) which would involve his participation in the psycho-education module for Schizophrenia. Mr. X is expected to regularly attend meetings for MAP. Mr. X should have an app on his mobile devise that provides SMS reminders for groups and/or medication. He will participate in wellness activities prescribed by the MAP such as ‘coffee & culture’ groups, dance classes, enrolment in short courses on his area of interest. Mr. X will become a well-rounded individual who adheres to compromised arrangements. He will develop a wider range of interests and meet more people who share the same interests. Reflection: Following Johns Model of Reflection, let me share my insights on taking on this assignment with Mr. X. Description of the experience For me, it was challenging as well as overwhelming dealing with the service- user, considering he had a complicated condition. For a student who has very limited work experience, having a case like Mr. X’s, a grown man with Schizophrenia, Paranoia, Drug Addiction and Alcoholism can be intimidating. The stigma given such people is very negative, so it was not surprising that I was scared. However, the people at the community centre were very supportive and they reassured me that he was harmless and was willing to cooperate with me or anyone interested in his complete recovery. Reflection Taking on a positive disposition, I conditioned myself that this challenge was actually a blessing in disguise because I would get to learn so much from the experience. In getting to know Mr. X, I found him endearing despite his mental condition that I wanted to really help him and see him recover from his illness. I envision him to be a respectable, responsible and very productive citizen who can contribute much to society. This vision motivated me to do my job well. I know that in being successful in helping him, I would be enabled to help others who may have similar or even less serious conditions as his and be effective at it. Influencing factors The primary factor that influenced me is the vision of Mr. X successfully recovering from his mental illness. I know I will derive much fulfilment in the experience because of the knowledge and skills I will gain. I know it would be a lot of work doing research, and much effort is necessary in motivating him to change, but in the end, I know it will all be worth it. Could I have dealt with it better? My only regret is that I did not have an opportunity to meet his family and interview them about Mr. X. Had I been given that chance, I would take advantage of the situation and ask for his history and the onset of his symptoms, then I would be able to get a clearer picture of Mr. X’s profile. I also could have done better if I had more time to spend with Mr. X, however, my studies and other personal responsibilities constrained me to meeting him for just a few sessions. In those sessions, I made the most out of really getting to know him and was reflective of my actions to check which ones worked with him and which ones did not. Learning This experience immersed me in the world of the Community Psychiatric Nurse. I realized just how difficult the job is and the huge responsibility a CPN has not only to the service user, his family but to the whole community itself. I also learned how much damage stigma can create in a person, as I saw it first-hand how it affected Mr. X in a very negative way. Now, I am more aware of how I think about other people who may suffer from stigma or stereotyped labels and am more sensitive in helping them instead of judging them. I also learned that I need to be more professional in my demeanour and disposition and provide high quality in my service to others. References Barrett D, Wilson B, Woollands A (2009) Care Planning: a guide for nurses, Dorchester, Pearson Education Holland K, Jenkins J, Solomon J, Whittam S (Eds) (2008) Applying the Roper Logan Tierney Model in Practice, 2nd Edition, London, Churchill Livingstone Read More