Nursing Care for Mental Health - Case Study Example

Mental Health Issues: A Case Study Student’s Name Institution Table of Contents 1. An Overview of Issues in the Case Study and Required Precautions 3 2. Ben’s Mental State Examination 4 3. Potential Risks 7 4. Formulation and Hypothesis Surrounding Ben’s Presenting Issues 8 a) Formulation 8 b) Hypothesis 10 5. Nursing Care Plans for Ben’s Most Presenting Issues 10 6. References 13 Mental Health Issues: Ben’s Case Study 1. An Overview of Issues in the Case Study and Required Precautions Ben’s case is a technical one given that he is illiterate. He has been to the emergency department (ED) several times as a result of threatening his neighbours and physical injuries, which he often causes himself. He seems to be suffering from a mental health problem and the situation is worsened by the fact that he has no one to take care of him. Ben and his extended family live in a small house where they take alcohol and smoke marijuana. As illustrated in the teachers’ report, it seems Ben was good mannered initially, but he became irresponsible and mentally disturbed as a result of the environmental influence and mistreatment from his relatives. Ben is likely to be suffering from traumatic stress disorder following the sexual assault he underwent when he was around 13 years. It is alleged that his step father and a group of friends sexually assaulted him, while they were under the influence of drugs. It is reported that the behaviour of Ben changed and began to worsen after this experience. He started heavily smoking marijuana, probably to keep himself from the stress of paranoia and the depression that he acquired after the sexual assault experience. Ben is now despondent, angry and he tries to avoid other people’s company all the times, as manifested in his move to walk away from his own mother while at the clinic. He has become restless and irritable and can only relax when he is under the influence of marijuana. As a result of Ben’s condition, a lot of precaution should be taken for the sake of his safety and that of the nurse and other staff at the hospital. Ben suffers from symptoms of hyper-arousal depression; this is evident in how he behaves towards his mother and the other people around the ED. There are a number of occasions in which he is reported to have been furious towards his mother without any clear reason. The best ways to manage Ben at the moment is to help him relax. Relaxation provides the most effective technique for anger management for people like Ben who are mentally ill. Ben can be helped to relax by guiding him through a number of physical exercises, such as meditation and taking several deep breaths (Ford, Hartman, Hawke, & Charpman, 2008). Apart from Ben, the nurse taking care of him also needs to take precautions for her safety since the patient is an imminent danger. The nurse should be accompanied by a security guard, who can protect her in case Ben’s condition becomes unbearable. Ben has been quoted to get irritated easily at times. The way he paces in the cubicle and how he stares angrily at whoever passes by also confirm how dangerous he might be. The nurse should also talk to Ben to make him calm down before the treatment is commenced. This may prove difficult as he currently does not want anyone to talk to him. However, the nurse should apply professional skills to pacify him and make him less aggressive. The staffs also need protection as their security is also at stake. The fact that Ben is reported to have threatened the neighbours with a large kitchen knife shows that he can also be a threat to the employees of the hospital. The staff should be adequately informed about his conduct and the possible things he is likely to do. To ensure that the staffs are properly kept out of danger, the guards should be advised to keep a close watch on Ben and accompany him wherever he goes while in the hospital. 2. Ben’s Mental State Examination Appearance Ben is a 17-year-old young adult of Aboriginal descent; at the time of examination, he was poorly groomed as shown by the dirty clothes he wore. He also seems to be unhygienic as shown by the strong odour that emanates from his body. He seems to be restless as he gets up and constantly paces the corridor of the emergency department. He is unable to maintain an eye contact with anyone and he keeps on looking at everyone who passes by him; he also looks depressed. Behaviour Ben is very uncooperative and does not want to talk to anyone. He is aggressive and he wants to keep on pacing the corridor of the ED. He is also suspicious as he does not want to enter the cubicle willingly. He only agrees to enter the cubicle after he is persuaded by his mother. Speech Ben does not articulate himself clearly. He does not answer the questions he is asked clearly. He is not audible in his speeches and seems to talk about things that are not relevant. In most cases, he mumbles incoherently to himself whenever he is asked a question. He also takes a lot of time before he responds to the questions he is asked. Mood Ben appears to be angry with himself and he feels that everyone is against him. He does not trust anyone, including his own mother. He is irritable, depressed, and hyper-aroused. These signs are shown in the way he reacts towards the nurse and other people around him. Affect Ben is agitated and confused; he often smiles to himself and then becomes sad again. He does not recognize that he is in a hospital and keeps on asking the nurse to explain to him why he is there. He keeps on looking around the cubicle, which shows how restless he is. He even shouts at the nurse and begins to make a deafening noise while at the cubicle. Form of Thought Ben’s thought stream seems to be extremely disturbed. He cannot recollect his thought and say something meaningful. He is just confused and cannot make any meaningful statement. His language is also disturbed and, at some point, he runs short of words to express himself and unexpectedly begins to make loud noises. Content of Thought Ben seems to be having suicidal thoughts; he is reported to have subjected his body to physical injuries in many occasions. He also seems to be possessed by delusions as he keeps on thinking that some people are always after him. He tells the nurse that those people are always watching and asks the nurse not to tell them where he is. Ben is also obsessed with a number of issues, such as the fact that he is confined in the cubicle. He seems to looking for a chance to escape from the cubicle. However, he does not seem to have any overvalued ideas, may be as a result of the state of confusion that he is in at the moment. Perceptual Ben exhibits abnormal perception. His behaviour and the way he answers the questions he is asked show elements of misinterpretations, illusions and passivity phenomena in him. He seems to be in his own world and cannot understand what goes on around him. He feels so uneasy being in the cubicle and having the nurse around him. Cognition Ben is neither alert nor is he oriented to time and place. He cannot answer even a single question correctly. He also cannot recall anything that happened to him in the past. All he sees in his mind are people chasing after him. He ends up screaming loudly when the nurse tries to extract information from him. Insight It is hard to question Ben about his present condition. He is either too confused to know about his condition and he finds it difficult to accept the condition he is in at the moment. He does not cooperate with the nurse and is not compliant with anyone in the hospital. 3. Potential Risks It is argued that mentally ill people are at a high risk of being perpetrators and, at the same time, victims of murder. They contribute to a large percentage of the total murders that are reported annually. Most of these mentally ill individuals involve themselves in cases of murder without their awareness. They are driven by the illusions, anger, and depression that they suffer when in this condition. Some of them also commit acts of “violence out of confusion and desperation” (Robinson, 2006, p. 226). Ben’s scenario can be treated as one of the common situations mentally ill people find themselves in. He poses great risks not only to the nurses and the ED staff, but also to himself. The greatest risk that Ben may pose to the ED staff in the next 24 hours is violence and an eventual murder. Ben is reported to have been violent in several occasions in the past. He, in one occasion, threatened his own mother with a knife. He has also been quoted in several occasions to have threatened his neighbours. There is a high probability that he can exhibit the same behaviour at the hospital. He can use any available weapon to attack the nurses around him. This is shown in his lack of cooperation and the demands he makes saying he wants to be left alone. Ben can also be a victim of murder owing to his current condition. It is argued that people with mental illness are at high risk of homicidal death. These people are known to abuse drugs in an attempt to alleviate the stress and anxiety that they suffer. Substance “abuse is normally associated with violence” (Schafer & Najavits, 2007, p. 615). Ben is likely to be murdered by people in the hospital who do not know about his case. He is likely to threaten or cause violence in the hospital as he used to do while at home. There is a possibility that he can attack any other person in the hospital, who in self defence, may fight back aggressively and unintentionally cause his death. Another potential risk that Ben’s condition may pose in the next 24 hours is self injuries. Ben is known for getting desperate and using objects to cut his own body. When he is brought to the emergency department, he has cuts and scratches around his arms. It is reported that he gets very desperate, restless and unbearable when the influence of marijuana subsides in him. This situation is likely to happen in the ED since Ben cannot access marijuana and other substances he normally relies on to make him relax. Unless he is put under close watch, Ben is likely to use any equipment he finds around to injure himself. 4. Formulation and Hypothesis Surrounding Ben’s Presenting Issues a) Formulation From the medical report and records provided by the Department of Child Protection (DCP) and the police, it is evident that Ben lived in a context of danger when he was a child. The danger was presented to him by the members of his extended family, especially his step father. It is alleged that Ben’s step father together with his friends, while under the influence of various substances, sexually abused him. Ben was just slightly above ten years old when this event took place. Ben never informed his mother or any other person about this experience. Apart from the experience involving the sexual assault, Ben also underwent a lot of hardships during his childhood. His needs, both physical and emotional, were never attended to by his parents. His mother and grandmother are drug addicts and could not adequately take care of him. The mother even spent most part of the family earnings to buy alcohol, marijuana and other drugs. They spent very little on basic needs, such as food. It is reported that Ben would be scolded by his mother for eating too much. The mother repeatedly told him that she was not in a position to meet his eating demands. It is possible that Ben, in most cases, concealed his unmet needs and chose to internalize the resulting feelings of depression and anxiety. The two experiences, the sexual assault and unmet needs, seem to have adversely affected Ben’s social functioning and his fundamental sense of reality. The fact that Ben was sexually assaulted by his father, a person he expected to love and protect him, made him develop feelings of loneliness and distrust towards other people (Ullman, Najdowski, & Filipas, 2009). He does not trust people, including his own mother and the nurses in the ED. The report from Ben’s teachers shows that he was a good and quiet boy during his tender age. It implies that the current condition in which Ben is in at the moment was induced by the environmental factors and the mistreatment he underwent in the hands of his family. Lack of good parenting is known to adversely “affect the ability of someone to regulate his own emotions and to relate to others” (Ullman, Najdowski, & Filipas, 200, p. 369). The kind of life that Ben led during his childhood explains the reasons of his involvement in the abuse of marijuana and other hard drugs. Firstly, it is believed that he might have got influenced by his parents, who prefer alcohol and marijuana to their basic needs. Secondly, it is possible that Ben could have chosen to smoke marijuana to help him alleviate his emotional needs and the traumatising memories of the events he suffered in the past, such as the sexual assault case. It is argued that marijuana and other hard drugs are normally used as substitutes for defence mechanisms. Such defences assist people with emotional problems to prevent impulses, subjective experiences, and feelings from reaching conscious awareness. b) Hypothesis There are two hypotheses that can be formulated from Ben’s present issues. Firstly, unmet needs during childhood adversely affect a person’s ability to socialize with other people. Secondly, unmet needs and mistreatment during childhood adversely affect a person’s ability to regulate his emotions. These hypotheses are based on the fact that lack of good parenting and inadequate provision of basic needs seem to have affected Ben’s social function and his ability to regulate his emotions. Lastly, subjective experiences such as sexual assault make a person depressed, anxious and hyper-aroused and cause the consequent desire to use hard drugs to suppress the distressing effects of the traumatic events. 5. Nursing Care Plans for Ben’s Most Presenting Issues A. I. Problem Hyper-arousal symptoms evidenced by irritability, troubled sleep, exaggerated startle response, difficulty in concentrating, and always being alert (Bonnet & Arand, 2010). Ben is reported to stay awake all night and day. He also does not pay attention to anyone and easily gets irritated by all the people around him. He is reported to have been irritated by his mother and threatened her with a knife on several occasions. Ben, while at the emergency response, does not concentrate on the questions he is asked and instead, he chooses to talk about his own things. II. Plan (Interventions) Commence administration and monitoring of anti-anxiety medication such as Klonipin or Xanax (Bonnet & Arand, 2010). Commence administration and monitoring of talk therapy and sleep aids (Dilsaver, 2010). III. Expected Outcome (O) and Criteria for Evaluation (E) (O) (i) Slowing down of the central nervous system as a result of reduction in brain activity (Bonnet & Arand, 2010), (ii) Relief from social phobia and panic disorder (Dilsaver, 2010), (iii) Reduction of stress in the heart by blocking the effects of adrenaline on various organs (Dilsaver, 2010), and (iv) Acquisition of tactics for coping with side effects caused by depression medicine (Foa, Keane, Friedman, & Cohen, 2009), (v) Improved sleep pattern and hygiene (Dilsaver, 2010), (vi) Reduction in substance dependency (Bonnet & Arand, 2010). (E) (i) Client self-reported brain activity level, (ii) Client self-reported phobia level, (iii) Client self-reported stress level, (iv) Evidence of increased level of social interactions, (v) Client self-reported sleep hygiene, and (vi) Evidence of reduced drug dependency. IV. Evidence suggests that commencement of anti-anxiety medicines, sleep aids and talk therapy improve the symptoms of hyper-arousal (Foa, Keane, Friedman, & Cohen, 2009). B. I. Problem Symptoms of depression as evidenced by restlessness, feelings of loneliness, low self-esteem, problems with concentration, and social withdrawal (Ostacher, 2007). II. Plan (Interventions) Commence administration and monitoring of prescribed anti-depressant medicines (Ostacher, 2007). Commence administration and monitoring of psychotherapy programs prescribed by psychologists (Pull, 2009). III. Expected Outcome (O) and Criteria for Evaluation (E) (O) (i) Significance reduction in levels of restlessness (Rey & Birmaher, 2009), (ii) Significance increase in levels of liveliness (Pull, 2009), (iii) Significant increase in levels of self esteem (Ostacher, 2007), (iv) Significance improvement in concentration (Rey & Birmaher, 2009), and (v) Increased levels of social interaction and self motivation (Pull, 2009). (E) (i) Client self-reported level of calmness, (ii) Client self-reported level of companionship, (iii) Evidence of increased levels of self-esteem, (iv) Evidence of increased level of concentration, and (v) Evidence of increased level of social interaction and self motivation. IV. Evidence suggests that commencement of anti-depressant medicines and relevant therapy programs improve symptoms of depression (Ostacher, 2007). 6. References Bonnet, M. H., & Arand, D. L. (2010). Hyperarousal and insomnia: State of the science. Sleep Medicine Reviews, 14(1), 9-15. Dilsaver, S. C. (2010). How to treat PTSD in patients with comorbid mood disorders. Current Psychiatry, 9(4), 48-59. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2009). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies. New York, NY: Guildford Press. Ford, J. D., Hartman, J. K., Hawke, J., & Charpman, J. F. (2008). Traumatic victimization, posttraumatic stress disorder, suicidal ideation, and substance abuse risk among juvenile justice-involved youth. Journal of Child & Adolescent Trauma, 1(1), 75-92. Ostacher, M. J. (2007). Comorbid alcohol and substance abuse dependence in depression: Impact on the outcome of antidepressant treatment. Psychiatric Clinics of North America, 30(1), 69-76. Pull, C. B. (2009). Current empirical status of acceptance and commitment therapy. Current Opinion in Psychiatry, 22(1), 55-60. Rey, J., & Birmaher, B. (2009). Treating child and adolescent depression. Philadelphia, PA: Wolters Kluwer Health. Robinson, L. R. (2006). Trauma rehabilitation. Philadelphia, PA: Lippincott Williams & Wilkins. Schafer, I., & Najavits, L. (2007). Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse. Current Opinion in Psychiatry, 20(6), 614-618. Ullman, S. E., Najdowski, C. J., & Filipas, H. H. (2009). Child sexual abuse, posttraumatic stress disorder, and substance use: Predictors of revictimisation in adult sexual assault survivors. Journal of Sexual Abuse, 18(4), 367-385. Read More