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Mental Health Nursing Practice

Tina presented to the hospital after retiring from the Army following 15 years of service. Tina reports ongoing nightmares and periods of disassociation. Tina has been drinking four bottles of red wine a night “to manage the nightmares and flash backs”. She is currently monitored and her observations ae being recorded on an Alcohol Withdrawal Scale. Tina’s scores on this scale have averaged 15 since admission three days ago. Tina is a quietly spoken woman who stays in her room for long periods and only briefly attends the programs provided by the unit. She does not engage with other patients or staff. Staff have reported that Tina is “brittle and sharp” at times when they interact with her. Other patients have also complained about ‘the rude lady’. Tina lives alone in her own home and received a veteran’s pension. She attends a specialist PTSD treatment program for returned service members. During her stay on the unit, Tina starts to refuse to attend the programs stating, “I don’t have the same problems as these people and I already go to the veteran’s program”. Tina is a smoker but is currently trying to quit and is taking nicotine replacement therapy (NRT) to assist. Staff often notice she smells of cigarette smoke, but Tina has denied she is still smoking. Staff have reported that Tina is often awake on the night shift rounds and is a “light sleeper”. She is often up first thing in the morning and keeps her room very tidy. She does not like the nursing staff coming into her room often asking staff to “leave my room please” and only tolerating brief interactions with the staff. She has no family and very few friends – none that come to visit or that she wishes to contact. Tina does have a service dog who remains with her on the unit for support. Her service dog is aging, and Tina has expressed concern about him dying. Tina has experienced much loss in her life. When she was five years old her father was killed in the line of duty on deployment and her mother and brother died in a car accident when she was ten. Tina reports she “tried grief counselling but it didn’t help – its best to ignore feelings”. Tina was raised by her elderly grandparents who she states, “weren’t very caring so I left as soon as I could”. Tina recalls “my grandmother often drank sherry all day, so I used to take sips when she wasn’t looking”. When in the services she reports “we all drank to numb the stuff we see and do” Tina reports craving alcohol especially in the evenings as that is when she would usually drink to then fall asleep. Tina is currently prescribed the following medications: • Thiamine100mg TDS, Diazepam 10mg, Latuda 40mg Nocte and Prazosin 4mg nocte. PRN Temazepam 20mg, Diazepam 10 mg, Seroquel 25mg

The biopsychosocial factors directly affects the mental well-being of a person. The identification of these factors play key role in treatment of problems which cause mental disorder. The problem may rise due to emergency situations including natural or industrial disaster, armed war (Tol, et. al., 2011) and any other tragic event. The rate of mental disorders like post-traumatic stress disorder (PTSD) has been identified that are caused in humanitarian settings. However, other mental disorder including psychotic disorder, non-specific form of psychological problems, and psychosocial distress mostly in young people are important. There are evidences explaining the effect of deteriorated environmental condition on mental health and well-being such as financial stress, demoralised social support and respect for human rights (Tol, et. al., 2011).

The patient, Tina is 38 year old retired women who served in the army for 15 years. She faced many traumatic events that affected her mental condition. Following are the brief assessment of her mental health and the biopsychosocial factors affecting her well-being.

Impact of Biopsychosocial Factors

The three main factors that impacted on the presenting problem of the client are:

Post-War Stress

The armed war often leave the veteran with substance use disorder and post-traumatic stress disorder (Back et. al., 2014). The research shows almost 94.3% veteran suffering from substance use disorder shows PTSD symptoms. The individuals may consume alcohol and drugs in order to lessen distressing symptoms like intrusive flashback memories and nightmares. Remarkably, only 11.4% of the user shows positive effect on PTSD by decreasing substance use. Most of the time, the PTSD problem increases while decreasing substance use (Back et. al., 2014). The horrific war scenes produces lifelong effect on the victims. The trauma is extremely difficult to cope with. The PTSD also proved to be having adverse effect on economic wellbeing, social connectedness, aggression, suicidal thoughts, physical health and criminality (Ramchand et. al., 2015). Tina’s experience was horrific. She seldom have nightmares and flash backs, hence, she is facing sleeping problem. To sleep peacefully, she drink heavily at night.

Trauma from Loss of Family

Tina loss her father when she was 5 years old and her mother and brother in a car accident when she was 10 years old. Sudden and violent death of loved ones sometimes creates mental distress followed by a difficult mourning course (Kristensen et. al., 2012). The occurrence of mental disorders such as prolonged grief disorder (PGD), post-traumatic stress disorder (PTSD), and major depressive disorder (MDD) is more probable in after such loss. The chances of mental health disorder are more elevated after sudden and violent death of loved ones and the recovery trajectory seems to be slow down (Kristensen et. al., 2012). This makes the mental state of the sufferer more fragile. The duration of bereavement followed after is sudden death is longer than that in the case of loss due to natural death. Therefore, any type of distress or disaster may make the person more vulnerable to mental illness and it may become very challenging for them to overcome.

Lack of Affection from Grandparents

Tina was looked after by her grandparents, who were not very caring. She starts drinking liquor at a young age as her grandmother was a frequent drinker and she use to take sip from her drink when she was not looking. A child who receive maltreatment and harsh behaviour from their guardian have difficulty in expressing emotions, lack of empathy, and less active social interactions (Young & Widom, 2014). The victim have trouble in recognising emotions and show appropriate emotional behaviour. The consequence of childhood neglect often seems to be continued till middle adulthood, where the person finds struggle in emotional processing. Tina went through grief counselling, but it leave no effect on her. She have hard time interacting with others including nurses. She is not able to comprehend her emotions and understand the requirement which may create positive impact on her well-being.

Nursing Intervention

The following are the nursing intervention for the client for the above mentioned condition:

Involving in Group Activities

Tina is not well involved in social interaction. She try to keep as less human interaction as possible. Even the nursing staff face problem in looking after her, because of her reserved nature. This behaviour is the result of neglecting and unaffectionate behaviour shown by her grandparents. She developed introvert behaviour and unable to convey her emotions and feelings. She must be involved in group activities by involving her in a support group therapy. She lives in her house alone and that is making her situation even more susceptible to substance abuse. The primary responsibility of a nurse is to ensure care and safety of the patient. With a support group and social involvement, her declining health due to substance abuse can be recovered up to some extent. Although, it might be difficult to involve her in group activities at first. To resolve this problem, she must be interacting with some of her friends in the beginning of this therapy.

Involving in Physical Activities

Tina is an army veteran. During her military service, she must have involved in immense physical activities. This can be used to provide her better coping strategy for PTSD and allowing her to adopt healthier lifestyle. Many researchers suggest that sports and physical activities enhance well-being of mental health in veterans, including reduced PTSD symptoms, outdoor activities, positive experience and life style (Caddick & Smith, 2014). The psychological well-being is also affected in a positive way, which includes sense of achievement, social well-being, emphasis on capability, determination, inner strength, and self-awareness (Caddick & Smith, 2014). Participating in sport and/or physical activity can also enhance motivation for living.

Using Psychiatric Service Dog Therapy

Tina loves her dog and is afraid of losing it. A study was conducted by Kloep et. al., 2017 which shows that using psychiatric service dog can decrease the symptoms of PTSD and related disorder in military veteran (Kloep et. al., 2017). In this therapy, Tina will be involved in dog care training. She will be taught skills for handling and proper caring of dog, accompanying her dog to various public places and event, utilizing her dog skill sets and involved in an intense resilience, skill development and psychoeducation program (Kloep et. al., 2017). Her dog could be used for this treatment method along with a trained psychiatric service dog.

Ethical or Legal Implication

Nurses needs to follow proper code of conduct and ethics in order to provide quality treatment and care to the patient. The violation of any of these codes may cause harm to patient, oneself, colleague or the organization. If the violation is severe, there could be legal action against nurse or penalties could imposed. Therefore, a nurse must be very careful regarding the code of conduct and approach the patient in an ethical manner. Some of the code of conduct followed by the nurses while taking care of the patient are as below (ICN Code of Ethics for Nurses, 2012; Registered Nurses Standard for Practice, 2016) :

  1. To provide care valuing the culture, customs and belief of the patient.
  2. To ask for consent of patient or their family before providing any treatment.
  3. To inform the patient about the treatment procedure, medical aid and health statistics.
  4. To ensure the confidentiality of the patient and protect their valuables.
  5. To provide care while keeping in mind the helplessness and physical and mental weakness of the patient.
  6. To ensure quality treatment without any differentiation made on the basis of race, gender, religion or ethnicity.
  7. To develop practice based on experience.

From the above mentioned guidelines, it can be understood that Tina cannot be forced to anything against her will as this could result into legal charges against nurse. Tina’s mental state is extremely vulnerable. The first thing a nurse need to ensure is that Tina takes her medicine according to prescribed schedule and quantity. Then, she must be motivated to join the other therapy method, with patience and great care. The nurse must think critically to make decisions regarding treatment.

From the assessment, it can be concluded that Tina’s condition is affected by her PTSD caused during her service, death of her father, the mother and brother, and neglecting and unaffectionate behaviour of her grandparents toward her. The coping strategy adopted by her was particularly unhealthy and created an adverse influence on her health. It becomes difficult for nursing staff to provide her proper medication and care due to her social avoidance. Therefore, her interests can be used to treat her. She is fond of dogs and love her dog. Also, being a military veteran, she must be interested in physical activities. Using these both area of interest of her, she could be made more socially amiable. This will create a positive impact on her physical health, lifestyle, self-confidence, social life, psychological and emotional health and give her a better vision towards life. After this, her problem of substance abuse and smoking can be dealt, which will then have high chances of success.

References for Substance Use Disorders and PTSD

Back, S. E., Killeen, T. K., Teer, A. P., Hartwell, E. E., Federline, A., Beylotte, F., & Cox, E. (2014). Substance use disorders and PTSD: An exploratory study of treatment preferences among military veterans. Addictive Behaviors, 39(2), 369–373.doi:10.1016/j.addbeh.2013.09.017

Caddick, N., & Smith, B. (2014). The impact of sport and physical activity on the well-being of combat veterans: A systematic review. Psychology of Sport and Exercise, 15(1), 9–18.doi:10.1016/j.psychsport.2013.09.011

ICN Code of Ethics for Nurses. (2012). International Council of Nurses. Retrieved from https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf

Kloep, M. L., Hunter, R. H., & Kertz, S. J. (2017). Examining the effects of a novel training program and use of psychiatric service dogs for military-related PTSD and associated symptoms. American Journal of Orthopsychiatry, 87(4), 425.

Kristensen, P., Weisæth, L., & Heir, T. (2012). Bereavement and Mental Health after Sudden and Violent Losses: A Review. Psychiatry: Interpersonal and Biological Processes, 75(1), 76–97.doi:10.1521/psyc.2012.75.1.76 

Ramchand, R., Rudavsky, R., Grant, S., Tanielian, T., & Jaycox, L. (2015). Prevalence of, Risk Factors for, and Consequences of Posttraumatic Stress Disorder and Other Mental Health Problems in Military Populations Deployed to Iraq and Afghanistan. Current Psychiatry Reports, 17(5). Doi:10.1007/s11920-015-0575-z 

Registered Nurses Standard for Practice. (2016). Nursing and Midwifery Board of Australia. Retrieved on 1 June, 2016 from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Tol, W. A., Barbui, C., Galappatti, A., Silove, D., Betancourt, T. S., Souza, R., & Van Ommeren, M. (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. The Lancet, 378(9802), 1581-1591.

Young, J. C., & Widom, C. S. (2014). Long-term effects of child abuse and neglect on emotion processing in adulthood. Child Abuse & Neglect, 38(8), 1369–1381.doi:10.1016/j.chiabu.2014.03.008 

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