• Internal Code :
  • Subject Code : NRSG263
  • University : Australian Cathloic University
  • Subject Name : Nursing

Patient: Paul (26 years old)

Ans 1) Risk assessment for Paul includes three columns: static risk factor, external dynamic and internal dynamic.

Static

External Dynamic

Internal Dynamic

The risk factor that cannot be change

The risk factor that can be altered

The risk factor that can be altered

Genetic factor: Person cannot change his or her genetic factors.

Frequent job change: the patient was unhappy from his previous jobs, therefore, he always between job changes and his mood swings

Trauma: he was not happy with the working place and employers that may be the reason for his trauma.

Stress: Higher stress level can reduce prefrontal cortex activity, which led to high impulsivity and low control over behaviour. Chronic stress can damage or alter the HPA axis that in turn hampers the activity of the brain area that is associated with learning, adaption and motivation. one of the risk factor that is responsible for mental disorder and has more likely one of the common neurological connection between mental disorder and substance abuse.

Substance abuse: Bipolar is usually comorbid with substance abuse as substance abuse causes changes at a brain level.

Gender: As male has slightly more tendency to develop bipolar symptoms than female.

Alcohol: increase his hallucinations

Self-isolation

Separating from family for 2 years

Depression

Age: usually onset occurs approximately at 25th. In the present case, Paul was 26 years old.

Hate prior employee

In the present case, Paul was 26 years old male suffering from bipolar disorder. The protective factors were his socioeconomic status and location of his house. As per studies, people of high socioeconomic status living in urban areas have more tendencies to develop the bipolar condition. In the present scenario, Paul was from the middle class and resided in the suburban area. Another protective factor was the patient's own family. His wife was from a medical background therefore she could support him for medical seek. Further, his wife was self-dependent therefore she would not pressurize her husband to take responsibilities of the family.

Ans 2) Most of the people who develop substance abuse are generally suffering from mental disease and vice versa. Further, people who experience a mental disorder during their life span are more likely to have substance use disorder. Moreover, youngsters with substance abuse have more chances of having a mental illness. Data show anxiety disorders such as panic disorder, stress after any trauma and generalized anxiety co-associate with substance abuse. Further, the patient suffering from mental disorders including bipolar disorder and depression, psychotic illness, antisocial personality disorder and attention deficit hyperactivity disorder are more inclined towards substance abuse. Schizophrenia patients have more risk to consume tobacco, drug and alcohol abuse as compare to a normal population.

The human brain develops continuously through adolescence. Brain functioning that is responsible for the decision-making is the last to get mature, which increase the susceptibility to develop substance abuse and drug use. Further, drug abuse in early age is considered to be a strong threat for later to develop substance abuse disorder. The above-stated relation between brain development and substance abuse is not essentially causative. The other risk factors can be associated like genetic vulnerability, environmental influence, and /or psychosocial experiences. For example, if the person had frequent marijuana consumption in adolescent have more risk to develop psychosis as compare to non-user. Moreover, mental illness in childhood leads to substance abuse in the later stage of life. Other factors that are associated with substance abuse are stress, a trauma in childhood and epigenetic factors.

Ans 3) Mental status examination (MSE) is a vital tool which helps the physicians to make a psychiatric diagnosis. MSE consists of various components that help to differentiate between different types of mental illness. The mental status examination should consist question for accessing patients' appearance, motor activity, general activity, speech, mood, thought process, perceptual disturbance, thought content, cognition and sensorium to identify various mental disorders.

Component of MSE and question for Paul are as follow:

1. Appearance/ general behaviour

2. Motor activity

3. Speech

4. Mood and affect: How would you define your mood?

Have you ever experience opposite of unhappiness? How long it lasts.

Have you experienced irritated/ angry?

Have you felt high/energized?

5. Thought process

6. Thought content: Have you felt intrusive?

Do you have excessive fear?

Have you felt that people are talking behind you?

Do you ever fell that you are a bad person?

7. Perceptual disturbances: Do you ever feel/hear/taste/see/things that are not there?

Have you experienced any unusual sensations?

8. Cognition

9. Insight: What is your understanding related to your issue?

10. Judgment: What you do if u will find any purse on the road?

Three questions those are essential to ask are Question 1 “How would you define your mood?”; “Have you ever experience opposite of unhappiness?”; “How long it lasts?”; “Have you experienced irritated/ angry?”, Question 2 is “Have you felt intrusive?”; “Do you have excessive fear?” Followed by Question 3 “Do you ever feel/hear/taste/see/things that are not there?”. Question 1 will help to evaluate the mood of the patient as in bipolar, patients feels sometimes extremely happy followed by depression. Question 2 will help to evaluate the thought content of the patient. Question 3 will aid to assess the perceptual disorders as hallucinations are common in bipolar patients.

Ans 4)

figure shows Paul's bipolar disorder

In the present case, Paul was diagnosed with bipolar disorder. The factors that influenced his alcohol/ drug and mental health disorder are stress due to family separation. Earlier the patient was in the defence force, therefore, was separated from his family. The family separation was the biggest challenge he had faced when he was posted in Afghanistan for two years. After, leaving that job, Paul was continuously finding a stable job. Moreover, he was not happy with the working place and employers that may be the reason for his stress. Stress is one of the risk factors that are responsible for mental disorder and has more likely one of the common neurological connection between mental disorder and substance abuse. Hypothalamic- pituitary- adrenal axis mediates the stress response, which influences the brain portion that is responsible for the control stimulus. Higher stress level can reduce prefrontal cortex activity, which led to high impulsivity and low control over behaviour. Chronic stress can damage or alter the HPA axis that in turn hampers the activity of a brain area that is associated with learning, adaption and motivation. Substance abuse can contribute to mental illness development therefore in the present case the patient was separated from the family. Moreover, the patient got worsens his hallucinations. Drug and/or alcohol can lead to some changes in the brain areas that can be turned into some mental illness or disorder.

Ans 5) Chronic drug and/or alcohol use can lead to mental illness and vice versa. Three pathways contribute to comorbidity between mental illness and substance abuse. The pathways are as follow:

  1. There are mutual factors that add to substance addiction and mental illness.

  2. Mental illness can contribute to addiction or substance use.

  3. Addiction can lead to mental illness development.

Common factors that contribute to substance abuse and mental illness are genetic vulnerabilities, epigenetic influences, environmental influences, brain involvement, trauma and stress. It has been estimated that approximately 60 per cent of the people's genetic contribution to the development of mental illness and substance abuse. During adolescence, frequent marijuana intake can be associated with psychosis development in later life, specifically the person who carries the specific gene variants. Interaction between environmental factors and genes at the molecular state can also lead to both substance abuse and mental illness. Mental disorders may be the risk factors for the development of substance abuse. People with subclinical, mild or severe mental illness may consume drugs as self-medication. However, some of the drugs can help in ease the patients on temporary bases; sometimes the same drug can increase the severity of the symptoms. Drug abuse in early age is considered to be a strong threat for later to develop substance abuse disorder. Substance abuse can lead to alteration in some of the brain areas that can lead to the development of mental disorders including mood swings, anxiety, or schizophrenia.

Ans 6) Delirium tremens (DTs) is considered a severe form of alcohol withdrawal, followed by altered mental position and autonomic hyperactivity that can lead to cardiovascular failure. Minor ethanol withdrawal shows symptoms of anxiety, tremor, vomiting, insomnia and nausea. Further, major alcohol withdrawal is characterized by auditory and visual hallucinations, diaphoresis, hypertension, and body tremor. DTs is the more severe form of alcohol withdrawal, characterized by global confusion, hallucinations, agitation, sympathetic overdrive, disorientation, and diaphoresis. Global confusion is the main symptom associated with DTs. Further, this condition should be considered as a medical emergency as associated with a high death rate. Sometimes DT can be associated with uncontrolled tremors, paranoia and panic attack. Followed by confusion, as the patient is not able to do a simple calculation and form a basic sentence. In this case, diagnosis is based on the sign and symptoms presentations of the patient. It is vital to rule out associated issues like pancreatitis, hepatitis and electrolyte imbalance. Benzodiazepines are the first line of the treatment. In severe condition, the high dose may be needed to prevent patients' death. Further, the dose is equally proportional to the severity of the symptoms. Benzodiazepines include oxazepam, lorazepam, chlordiazepoxide and diazepam. Further, antipsychotics like haloperidol can be used to support the patient. Acamprosate can be used occasionally to reduce relapse-associated risk. Moreover, alcoholic drinks can be prescribed for DT treatment. Thiamine with high dose can be given intravenously.

Patient: Emma

Ans 1) Emma was suffering from anxiety as she had faced adversities in the form of negligence by her stepfather. Moreover, her mother, Julie, had a history of substance abuse. During this stage of time, Emma must be in a lot of stress. Prolonged trauma exposure can have an impact on brain development. Hypothalamic- pituitary- adrenal axis mediates the stress response which impacts brain portion that is accountable for the regulator stimulus. Higher stress level can decrease prefrontal cortex action, which led to high impulsivity and low control over behaviour. Therefore, the nurse must identify the developmental issues include biological and psychological while rendering care to Emma. The nurse needs to consider factors like Emma's family background and genetic influence as her mother was suffering from mental illness along with substance abuse history. Moreover, Emma was just 12 years old girl child therefore she needed her family support for anxiety treatment. Further, her brain or intellectual standard was developed by her age. Although, her mom had told that the girl was more mature than her age. All the above-stated factors should be kept in mind while rendering holistic care to Emma.

Ans 2) In childhood time, it is very common that the child could expose to a traumatic situation. Trauma during early childhood can cause a tremendous impact on the physical and psychological development of the child. Further, trauma can have consequences for self-identity and language development. Early life difficulties for the kid may include alcohol exposure, substance abuse by mother (in utero impact) and negligence by the parents. In the present case, Emma had faced adversities in the form of negligence by her stepfather. Moreover, her mother Julie had a history of substance abuse and one day Emma found that her mother was unconscious. Further, the little girl had heard from one of the paramedics that Julie could have died if she had not called an emergency team on time. During this phase of time, Emma must be in tremendous stress. In various pieces of literature, it has been mentioned that prolonged trauma exposure can have an impact on brain development. Hypothalamic- pituitary- adrenal axis mediates the stress response which impacts brain portion that is accountable for the regulator stimulus. Higher stress level can decrease prefrontal cortex action, which led to high impulsivity and low control over behaviour. Chronic stress can destruct or alter the HPA axis that in turn hinders the activity of a brain area that is associated with learning, adaption and motivation. Therefore, it can be concluded that stress/ trauma can be responsible for the development of mental illness. Moreover, mental illness in childhood leads to substance abuse in a later stage of life.

Ans 3) Emma and her mother need help from the mental health team. Health condition of Emma cannot be ignored, as ignorance to mental health services can have an impact over social and schooling interaction. Trauma exposure leads to biological changes in cascade. Post-traumatic stress can lead to alteration in the functioning of the limbic system, hypothalamic-pituitary-adrenal axis and neurotransmitter system. The changes in the above-stated area can affect the development of the brain and increase the patient's susceptibility to facing social violence. In the present case, Emma with time can also develop a violent nature at social and school level. Moreover, there is a risk to develop physical illness, chronic disease, substance abuse, impaired life activities and mental illness. Emma can lose interest in a school activity that will lead to low performance. Followed by the development of intrusion thoughts and can trigger aggressive behavioural and emotional thoughts. Trauma can influence the thought process of the person, as the person can feel different. Traumatic incidence makes the patient believe that he or she is damaged goods and with time, they stop talking to another person. In the present case, Emma will also develop isolation from her friends and known people. Mental health nurse should make possible efforts to engage Emma and her family while rendering health services. The nurse should communicate with the patient and family to explain the importance of mental health intervention in trauma associate illness. It is important to discuss the traumatic stress associated symptoms and its long term effects on the patient. Further, the nurse should support the patient and his/her family by sending hope linked messages. In the present case, also the nurse should explain to Emma that she is not alone and she should not feel faulty for her present illness.

Ans 4) Trauma-informed approach has "four Rs”. The nursing staff should follow the four Rs to render holistic care to the patient. The four Rs includes realizes, recognizes, responds and resist re-traumatization. The nurse should thoroughly realize the effect of trauma followed by understanding the recovery path. Moreover, the nurse should understand the symptoms and sign of the patient and family. Further, medical staff should respond accordingly as per the policies and help to the resistant incidence of the re-traumatization. In the present case, the nurse should follow the four Rs principle. Further, try to build a relation and trust with Emma and her mother. The nurse should ensure the safety of the patient in a physical setting; further, interpersonal communication should promote the safety sensors. Secondly, organizational decisions and operations should direct with transparency to build trust with family members and patient. In the present case also, the nurse should follow the transparency principle. Further, mental health nurse should take peer support to establish hope and safety, enhance collaboration and building trust. The nurse should encourage Emma to meet children who had experienced traumatic happenings to build self-confidence in her. The nurse should follow mutuality and collaboration principle. Further, all the staff in the organization should work together to demonstrate the healing process. In the present case, the nurse can help Emma and her mother to realize their strengths and should work upon it. Emma and her mother should be the part of decision-making, goal setting and choice to incase healing process.

Ans 5) HEEADSSS is the technique to interview adolescents and children. This method focuses on evaluation of H-environment of Home, E-Education, E-Eating, A-Activities related to peer group, D- Drugs, S-Sexuality, S-depression/Suicide, and S-Safety from violence and injury. In present case, follow assessment must be done and questions should be formulated accordingly.Mental status examination (MSE) is a dynamic tool which aids the physicians to make a psychiatric diagnosis. MSE consist of different modules that help to distinguish between different kinds of mental illness. The mental status examination should consist question for accessing patients' appearance, motor activity, general activity, speech, mood, thought process, perceptual disturbance, thought content, cognition and sensorium to identify various mental disorders.

In the present case, the question could be asked to Emma to engage her in conversation are as follow:

Question a) How are feeling? What is your current mood? Is there anything about school that worried you?

Question b) Do you involve in sports? What is your favourite game? What do you feel about your favourite game?

Ans 6) Risk assessment for Emma includes three columns: static risk factor, external dynamic and internal dynamic.

Static

External Dynamic

Internal Dynamic

The risk factor that cannot be change

The risk factor that can be altered

The risk factor that can be altered

Genetic factor: Anxiety is common in a person who has a familiar history of anxiety disorder. As in the present case, Emma's mother was suffering from substance abuse and anxiety.

Absent parent.

Emma was derived from her father's love

Obsessive memories

Trauma

Emma was in tremendous stress after the incidence of her mother

Gender, females are more prone to develop anxiety as compared to male.

Family issues like alcoholism and violence.

Emma’s stepfather had multiple violence episodes with her mother.

Self-isolation from friends. Isolation can initiate a terrible cycle.

No interest in the favourite game (netball)

Location of her home

In the present case, Emma has three protective factors include good academic performance, good friend circle and involvement in sports. Earlier Emma had secured good scores in school; if she will get proper support from the mental health team then definitely she will come out of her anxiety. Further, she was involved in her netball game; again, involvement in the physical activity will help Emma to cope up with trauma and stress. Moreover, again association with her friends will boast her moral and fill positivity in her.

Ans 7) Children also experience anxiety like adults. In the present case, Emma had a provisional diagnosis of anxiety. By the literature, early interventions should consider while dealing with anxiety in children. Anxiety should be targeted early as ignored anxiety symptoms can lead to low grades and bad school performance. Moreover, anxiety can also affect the interpersonal and social skill. Untreated anxiety disorder can lead to the development of substance abuse and depression. Also, untreated anxiety can be converted into a condition that is more serious and becomes difficult to cure and treat. Untreated anxiety can make the children isolated from everyone. The interventions should be age-specific as small children should be treated by parents under the guidance of registered health care worker through parenting skill. The goal of early intervention is to improve resilience and reduce the associated risk. Further, help kids to face fear. The nursing staff should include both pharmacological and non-pharmacological interventions while treating anxiety. The patient must be very well aware of his/ her anxiety condition. Further, in non-pharmacological intervention, nurses should use touch with permission, demeanour, verbalization and presence to remind the patient that he/she is not alone. Moreover, encourage the patient to communicate effectively without fear. The medical staff should help the patient to familiarize the environment to decrease the risk of a panic attack and help the patient to be comfortable in the environment. In the present case, interaction with Emma in a peaceful manner will be an effective non-pharmacological intervention. Non- pharmacological interventions should be followed by effective pharmacological interventions. Benzodiazepines are the first line of treatment. Beta-blockers are effective in the management of anxiety.

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