NRSG262: Clinical Integration: Mental Health Practice

NRSG262: Clinical Integration: Mental Health Practice

Case Studies
You need to choose from one of the two (2) following case studies and provide an 800 word
medication management plan for the chosen individual.
You will need to reference according to APA referencing.
A marking grid has been made available on the unit outline to support your response.
Please include the following areas in your management plan:
?  The physical health considerations associated with the administration of the drug
?  Provide a rationale for the use of the drug for the individual
?  Management of side effects / adverse effects
?  Consider recovery oriented practices in medication management

CASE STUDY: JOSEPH
Joseph is a 39 year old man who currently lives in a community care residential
unit (CCU). Joseph has a long history of schizophrenia with diagnosis at the age
of 24. On his first presentation Joseph was acutely unwell and had a traumatic
first admission to mental health services and was bought into the inpatient
ward via police. On admission he was displaying positive signs of
schizophrenia, he was responding to auditory hallucinations and had paranoid
delusions that his parents were not his parents but imposters, who were trying
to ‘kill him’. He was agitated and distressed on admission. Since this admission,
Joseph has had numerous admissions (10 in total) to acute mental health
services, as a compulsory client and was usually discharged home to the care
of his elderly parents. Joseph has been trialled on various antipsychotic and
mood stabilisers to help manage his symptoms over the years, with limited
improvement, in fact deemed treatment resistive.
On his last admission (11
th
) to acute mental health services, the Consultant
Psychiatrist and the treating team made a collaborative decision to commence
Joseph on Clozapine, given the chronicity of his illness. He commenced this
medication on the ward; commenced on a titrating dose of 12.5 mg and was
discharged to the care of the CCU on 500mg daily (200 mg mane and 300 mg
nocte), two months ago.

NRSG262: Clinical Integration: Mental Health Practice

Family History:
Joseph has elderly parents, who are now aged in their 70’s; they still live in the
family home and usually have Joseph stay at home on the weekends when he
is well enough to do this.
His has only one sibling, a sister who is 41, married and has three children.
Joseph only sees his sister when he visits the family home on the weekends.
Medical History:
Joseph has been diagnosed with schizophrenia and is currently being managed
on an antipsychotic medication – CLOZAPINE – 500mg daily
Current Mental State Examination
Observation
Appearance & Behaviour:
–  Greek descent
–  Overweight in appearance, height 190cm
–  No distinguishing features ( e.g. no scars)
–  Dishevelled in appearance
–  Needs encouragement to attend to ADL’s
–  Suspicious and paranoid
–  Irritable at times
–  Unusual gesturing of his arms ( waves in the air)
–  Difficult to engage in conversation and difficult to establish rapport
–  Fixed eye contact when irritable
Cognition:
–  Orientated to  time, place and person
–  Some deficits noted in recall memory only
Mood:
–  Euthymic mood
–  Describes himself as reasonably happy
Affect:
–  Blunted affect
Speech:
–  Disorganised speech
–  Poverty of speech – at times
–  Rate and flow of speech often slow
NRSG262: Clinical Integration: Mental Health Practice

Form of thought:
–  Loosening of associations
–  Neologisms
–  Thought blocking
Content of thought:
–  Disordered thinking
–  Paranoid thinking at times
–  Continually expresses thoughts about his parents, challenges whether they are really his
parents
–  Denies any suicidal and homicidal thoughts
Perception:
–  Experiences auditory hallucinations of a derogatory nature
–  Describes hearing one male voice
–  Often seen responding to internal stimuli
Insight:
–  Limited insight into his illness.
–  Constantly questions the need to take his medication
Judgement:
–  Poor judgement

CASE STUDY: Melinda
Melinda is a 30 year old married woman who has a 10 year history of bipolar
disorder. She has a history of non adherence to her prescribed medication.
Melinda was admitted after her husband rang the triage team expressing
concern that Melinda was relapsing, he reported that Melinda had not been
sleeping, was spending money excessively and had quit her job after an
altercation with a co-worker. Melinda’s husband reports their relationship is
under strain.
Family History
Melinda is the youngest child of three siblings with two older brothers aged 39
and 36 years old; her parents are very supportive and have a good relationship
with Melinda and her husband. Melinda’s maternal grandmother and her aunt
have a diagnosis of bipolar disorder. Melinda and Paul live in the same suburb
NRSG262: Clinical Integration: Mental Health Practice

as her parents. Melinda’s parents are active members of the carer’s group run
by the local Mental Health service. Melinda will be discharged next week, and
requires education on her discharge medications.
Medical History
Ectopic pregnancy 2 years ago.
She has a long history of bipolar disorder, first diagnosed at the age of 19,
several acute admissions over a 10 year period.
Melinda has been diagnosed with bipolar disorder and is currently being
managed on a mood stabiliser – Lithium – 600mg BD.
Current Mental State Examination
Observation
Appearance & Behaviour:
–  Looks stated age of 30
–  Average height and weight
–  Black hair, styled and kempt
–  Dressed appropriate to weather
–  Wearing heavy makeup/multiple bracelets, rings, necklaces.
–  No distinguishing features ( e.g. no scars)
–  Very friendly in manner, overfamiliar in conversation and gestures
Cognition:
–  Orientated to  time, place and person
–  Able to maintain concentration through interview.
Mood:
–  Mood appears slightly elevated,
–  Describes herself as  happy, “never been better”,
Affect:
–  Bright and reactive. Incongruent at times when discussing events leading to admission
Speech:
–  Pressured at times, but able to be interrupted
–  Expansive in conversation
–  Loud at times
Form of thought:
–  Logical and sequential , occasionally tangential
–  Not grossly thought disordered
NRSG262: Clinical Integration: Mental Health Practice

Content of thought:
–  Some grandiosity in theme around wanting to set up new business with co-client.
–  Believes that her marriage is sound and that her and her husband will not separate. Is willing
to attend relationship counselling.
Perception:
–  No perceptual disturbances elicited
Insight:
–  Moderate insight into illness, states she knows she has Bipolar and will take medication but
hates the flat feeling it gives her.
–   Has a realistic concern about medication and any future pregnancy.
Judgement:
–  Judgement is currently good, is willing to take medication, and wants to stay well.
–   Is accepting of need for case-management, has agreed to attend counselling with her
husband.

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