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Restrictive Practice in Healthcare

  1. Australia’s legal system requires health care clinicians to operate within a ‘least restrictive’ framework. Discuss where this approach is evident in the legislation in your state. You will need to name the legislation you refer to in your answer.

Answer- 'Restrictive practice' means procedure or action that effect on limiting a person with a disability's rights or freedom of movement.' (NDIS Quality and Safeguards Commission) NSW is striving towards minimizing and removing the use of restrictive practices. Supporting behavioural needs discourage the use of restrictive behaviours and this should be the priority. Restrictive measures are required only to be used under specific situations, only as a last option. A minimum restrictive response is used to so as to ensure the protection of the individual or others. It is only used to ensure the safety of the person or others for as short a time as possible. It is used only when underpinned by a support framework for positive behaviour. It should not be used as a first response to nervous behaviours or as a substitute for appropriate supervision (NSW Government, 2020).

In 2013, Australia’s appearance before the UN Committee on the Rights of Persons with Disabilities (UNCRPD), was conducted. There the Australian Civil Society Response raised their concern for the disabled individuals, especially those having psychosocial disability, and cognitive impairment. These individuals were frequently subjected to uncontrolled and un-regulated behavioural modifications or restrictive responses. These practices now have to be used as a last option under the legislation (Australian Law Reform Commission, 2020).

  1. Steve is a 22-year-old man who has attended an appointment with his case manager. Steve is looking gaunt and dishevelled. His clothes are crumpled, and he is malodourous. He is barefoot and the mental health nurse notices his feet are bleeding. Steve is worried about the ‘people’ who are following him. He is certain that they want to harm him if he doesn’t agree to work for them to bring about the downfall of Great Britain. He finds it difficult to maintain eye contact, is restless and appears distracted at times. List the parts of an MSE and complete any sections you can with the data from the above case study.

Answer- Mental Status Examination

Appearance- Gaunt and dishevelled, clothes are crumpled, malodourous, barefoot bleeding feet.

Behaviour-Good, cooperative

Orientation- Not proper

Perception-Hallucinations

Thought content – Delusions

Mood- Anxious, restless

Effect-

Speech-

Thought process-

  1. While anorexia nervosa and bulimia nervosa are both eating disorders, how do their symptoms differ? Males are increasingly being diagnosed with eating disorders; however, it is understood that this number is likely underrepresented. What are some of the possible reasons for this? Males are increasingly being diagnosed with eating disorders; however, it is understood that this number is likely underrepresented.

Answer- Most individuals with an eating disorder often show unhappiness about their physical appearance (Sharan et al., 2015). Other symptoms are often individual-specific. Both anorexia and bulimia represent eating disorders. Both of the disorders have common symptoms of distorted body image resulting from food habits. They are however marked by difference in food-related behaviour. Both shows similar symptoms but anorexia causes behavioural changes also People who have anorexia, greatly decrease their dietary intake to reduce weight. Individuals with bulimia consume, in a short time, an excessive amount of food, then detox or use other methods to prevent weight gain. Although eating disorders are not specific to age or gender, they do affect women disproportionately (Sharan et al., 2015).

Males suffering from eating disorders and struggles with body image have a major stigma to conquer, and as a result, both diagnosis and care have been greatly overlooked. Assumptions of eating disorder hamper the delivery of evidence-based male treatment and fall short of successful control of gender-specific issues. Clinicians who treat males with anorexia nervosa are likely to find themselves in great trouble. Resources are limited as the treatment paradigms were aimed at women. Although this trend is beginning to break, more research is still needed on males and their gender-specific problems to better understand and treat them effectively (Strother et al., 2012).

  1. A student peer asks you to explain the main principles of trauma-informed practice to them. Outline your answer.

Answer- Trauma could be caused by single or repetitive adverse outcomes which endanger to overpower an individual's ability to cope up with a situation. When it is frequent and severe, and happens over a long period of time or is committed by caregivers in childhood, it is called complex trauma (Center for Substance Abuse Treatment, 2014). Amongst the hospitalized and the outpatients, two-thirds of people presenting for mental health treatment, have a direct history of child abuse or sexual assault. The main reasons for complex trauma include psychological abuse, domestic violence, drug abuse, war and migrant trauma, separation, and loss of a mentally ill parent. In Australia, millions of people have been affected by childhood trauma.

Trauma-informed practices is a help-based approach focused on five core values – protection, trust, choice, teamwork and empowerment, and appreciation for diversity (Trauma-Informed Care in Behavioural Health Services, 2014). Trauma awareness programs do not harm anyone, i.e. they make sure the individual is not re-traumaticise or blamed for efforts to resolve bad experiences of their life, and also provide a message of positivity and determination which makes healing possible. The survivors of trauma are treated as exceptional people who encountered highly traumatic circumstances and have dealt with the best they could. Practice educated about trauma means incorporating a. Understanding past and current traumas and mental distress overall service delivery aspects. Trauma-informed programs are targeted at preventing re-traumatization. Individuals and advocates health, choice, and control to facilitate healing (Trauma-Informed Care in Behavioural Health Services, 2014).

  1. John is a 75-year-old man experiencing an episode of depression and he is currently being treated on fluoxetine 40 mg by his local GP. John lost his spouse to cancer six months ago and is finding it difficult to cope with this loss. Explain the difference between grief and depression. What drug classification does fluoxetine belong to, and what are the common side effects associated with this drug.

Answer- The difference between grief and depression is that grief appears to fade with time and occurs in intervals caused by reminders or thoughts of its origin. The person may feel comparatively better in some situations, in the situations when family and friends are there to help them (Patoine, 2018). Yet causes like the memories of a deceased loved one or birthdays or going to a celebration party after finalizing a divorce may cause the feelings to resurface more strongly. Instead, it seems that depression is more severe and persistent. The exception to this situation is depression, where good experiences can help change the mood. An individual with atypical depression appears to have signs and symptoms that are really the reverse of all those usually associated with sorrow, such as sleep deprivation, increased appetite, and weight gain ( Schimelpfening, 2020).

Fluoxetine is a member of the antidepressant selective serotonin reuptake inhibitor (SSRI). This drug is given to patients with depressive disorder, OCD patients, nervous bulimia, panic disorder, and premenstrual dysphoric disorder. Common side effects include sexual dysfunction, appetite loss, dry mouth, indigestion, rash, sleep disturbance, and odd dreams. There can be some severe side effects include depression of serotonin, epilepsy, mania, suicidal tendency increased risk in individuals under the age of 25. A withdrawal syndrome can occur when interrupted unexpectedly with anxiety, dizziness, and feeling changes (Airagnes et al., 2018).

  1. A young consumer’s parent asks you about the difference between self-injury and suicide. How would you explain the difference to them and include some of the reasons people engage in self-injurious behaviour?

Answer- Self-injury is the intentional action of self-inflicted physical injury by an individual on self. Self-injury is a bad sign of emotional distress. According to the Fifth Edition of the Statistical and Diagnostic Manual of Mental Disorders (DSM-5), self-injury is officially defined as a Non-Suicidal Self-Injury Disorder (NSSID), because such self-destructive actions are committed without suicide intent. Teenagers are at the greatest risk of self-harm damage, as several reports show that about 15 percent of adolescents and 17-35 percent of college students have caused self-harmful behaviours (Grandclerc et al., 2016). Females and males show similar rates of self-harming behaviour. Examples of self-injurious acts involve cutting, skin rasping, extreme scratching or burning yourself, as well as punching or hitting walls to inflict pain. The ingestion of toxic chemicals, excessive scalp picking, pulling hair, and intentional wound healing interference are some examples. The victim experiences a temporary sense of mental and emotional relief after the harmful act is complete, accompanied by feelings of remorse or shame resulting in even more negative feelings before this process begins (Hooley et al., 2020).

  1. What education should the mental health nurse provide to a consumer who has been prescribed benzodiazepine for the treatment of their anxiety disorder?

Answer- Benzodiazepines are frequently recommended for anxiety and insomnia. In particular, in general practice, the recommended treatment of these conditions is nonpharmacological treatments, especially behavioural and psychological ones. Due to symptoms of tolerance and withdrawal, longer use of benzodiazepines may contribute to a dose increase and worsening of the underlying illness. Any person who has chosen to take benzodiazepine for longer time that is around 3–4 weeks will certainly have symptoms of withdrawal if the medication is suddenly discontinued. By issuing prescriptions limited to supply for 1–2 weeks, the risk of inducing dependence may be decreased. (Bystritsky et al., 2013).

The nurses can also educate patients in handling the anxiety. They can teach for the regulated respiration. One of the best way’s nurses can help patients alleviate anxiety is controlled respiration. Breathing exercises help relax the mind, body, and heart, countering the side effects of the stress. Guided visualization is another method that can be taught and based on the notion of a brain-body relation in which brain attention relieves the anxiety symptoms, rising blood pressure, respiration, and heart rate. The fact that hospitals and offices do not need much space to do so is one of the best things about adding natural elements. Although an attached garden is fantastic at hospitals and homes to bring down the anxiety level of the patient.

  1. Fred has described increasing his alcohol consumption over the past six months. This is not an uncommon co-occurring factor for people experiencing depression. What actions should the registered nurse undertake if they are concerned about possible alcohol withdrawal for a consumer admitted to an inpatient unit?

Answer- Withdrawal of alcohol is a problematic situation usually seen in general hospital settings. A patient shows symptoms like anxiety, headaches, seizures and nausea. A care- centered nursing examination is important in determining the potential of alcohol withdrawal symptoms (AWS) in all units of the hospital. The nurses have to be very much aware that the other health conditions such as post-operative delirium, septicemia, pancreatitis, pneumonia, uremia, and adverse drug reactions, as the ill patients may have signs similar to withdrawal from alcohol. It is important to measure the normal amount of alcohol intake when AWS is suspected by coordinating with friends or family members and reviewing the test results. The results of the medical exam and biochemical parameters markers such as carbohydrate-deficient transferrin, electrolytes, levels of alcohol in blood, mean corpuscular volume, and tests to check the function of the liver. It is also necessary to note that many AWS patients suffer from comorbid psychological conditions such as depression, anxiety, post-traumatic disorders, and personality disorders that may need intervention by health care professionals (Elliott et al., 2019).

Nurses must ask trustworthy people how much was eaten and what type of alcohol was consumed when the patient had their last drink. Figure out how long, and any history of treatment or drug use, they drank heavily. Individuals who have had time for more than 2 days since their last drink are far more likely to suffer serious complications with the symptoms than those who experience in a shorter period of time. Individuals with a long history of addiction and withdrawal will likely experience more extreme recurrence. A history of depression and a high heart rate raises the likelihood of more serious symptoms of withdrawal (Kattimani, 2013).

  1. Hypomania is a common symptom in bipolar disorders. How does hypomania differ from mania? How would you help a consumer prevent relapse of mania?

Answer- Mania and hypomania are potential signs of bipolar disorder. It can also occur in people who have no bipolar disorder. Mania is more than just getting extra burning muscle. It's a mood disturbance that renders physically as well as mentally abnormally energized. Disorder may be too serious to require hospitalisation. In people with bipolar I disorder, mania exists. Manic episodes overlap with cycles of depression in many cases of bipolar I. it is not always people who have depressive episodes in bipolar though. Hypomania is a more mellow form of mania. When hypomania occurs, the level of energy is higher than average but not as intense as in mania. If a person has hypomania, the individual may not need hospitalization for it (Pietrangelo, 2018).

Individuals with bipolar II disorder can experience depression-alternating hypomania. The important difference between the two bipolar disorders that is mania and hypomania is the symptom severity. Mania individuals’ symptoms are much more severe than hypomania symptoms. The mechanism for preventing bipolar disorder is not known. It is particularly necessary to know its symptoms and seek early intervention as its exact cause has not yet been identified. The mania relapse can be prevented by being positive, reducing stress, sticking to treatment plan and by exercising daily (Pontin, 2009).

  1. Can a health care practitioner ‘coerce or mandate’ someone to engage or be admitted into an alcohol and other drugs (AOD) service or mental health facility or program? If so, under what circumstance? And If not, why?

Answer- The Mental Healthcare Act (MHCA), explicitly discusses the protections of mental illness patients (PWMI) and sets out the legal and ethical obligations of mental health professionals and the government. The rights of PWMI are in line with universal human rights and therefore need to be addressed specifically because they relate to a disadvantaged community from assessment, care, and analysis perspectives (Bipeta, 2019). These privileges translate into the principles of autonomy-related medical care; the concept of non-malice, beneficence, and justice; confidentiality (and disclosure); boundary breaches; informed consent (and compulsory treatment). The health professionals can mandate to the mental health facility and rehab centers only if the patient is having the capability to harm himself or can be a threat to other people. In that situation, the health care professional recommends a patient to get admitted if the patient does not show the will.

References for Restrictive Practice in Healthcare

Airagnes, G., Ducoutumany, G., Laffy-Beaufils, B., Le Faou, A. L. & Limosin, F. (2019). Alcohol withdrawal syndrome management: Is there anything new?. La Revue De Medecine Interne40(6), 373–379. https://doi.org/10.1016/j.revmed.2019.02.001

Australian Law Reform Commission. (2020). The use of restrictive practices in Australia. Retrieved from https://www.alrc.gov.au/publication/equality-capacity-and-disability-in-commonwealth-laws-alrc-report-124/8-restrictive-practices-2/the-use-of-restrictive-practices-in-australia/

Bipeta R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Bystritsky, A., Khalsa, S. S., Cameron, M. E. & Schiffman, J. (2013). Current diagnosis and treatment of anxiety disorders. P & T : A Peer-Reviewed Journal for Formulary Management38(1), 30–57.

Centre for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 3, Understanding the Impact of Trauma. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/

Centre for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 2, Trauma Awareness. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207203/

Elliott, A. P. A. & Dolores, Y. (2019). Caring for hospitalized patients with alcohol withdrawal syndrome. Nursing Critical Care. 14(5). 18-30. doi: 10.1097/01.CCN.0000578828.37034.c2

Grandclerc, S., De Labrouhe, D., Spodenkiewicz, M., Lachal, J. & Moro, M. R. (2016). Relations between nonsuicidal self-injury and suicidal behaviour in adolescence: A Systematic Review. PloS One11(4), e0153760. https://doi.org/10.1371/journal.pone.0153760

Hooley, J. M., Fox, K. R. & Boccagno, C. (2020). Nonsuicidal self-injury: Diagnostic challenges and current perspectives. Neuropsychiatric disease and treatment16, 101–112. https://doi.org/10.2147/NDT.S198806

Kattimani, S. & Bharadwaj, B. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal22(2), 100–108. https://doi.org/10.4103/0972-6748.132914

NSW Government. (2020). What are restrictive practices in the NDIS? Retrieved from https://www.health.nsw.gov.au/mentalhealth/psychosocial/principles/Pages/restrictive.aspx

Patoine, B. (2018). Grief vs. Depression. Retrieved from: https://www.dana.org/article/grief-vs-depression/

Pietrangelo, A. (2018). What you should know about mania vs. hypomania. Retrieved from: https://www.healthline.com/health/mania-vs-hypomania#symptoms

Pontin, E., Peters, S., Lobban, F., Rogers, A. & Morriss, R. K. (2009). Enhanced relapse prevention for bipolar disorder: A qualitative investigation of value perceived for service users and care coordinators. Implementation Science: IS4, 4. https://doi.org/10.1186/1748-5908-4-4

Schimelpfening, N. (2020). Grief vs. Depression: Which Is It? Retrieved from: https://www.verywellmind.com/grief-and-depression-1067237

Sharan, P. & Sundar, A. S. (2015). Eating disorders in women. Indian Journal of Psychiatry57(Suppl 2), S286–S295. https://doi.org/10.4103/0019-5545.161493

Strother, E., Lemberg, R., Stanford, S. C. & Turberville, D. (2012). Eating disorders in men: Underdiagnosed, undertreated, and misunderstood. Eating Disorders20(5), 346–355. https://doi.org/10.1080/10640266.2012.715512

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