Case Study, Mohr

CHAPTER 1, Introduction to Psychiatric–Mental Health Nursing In completing the case study, students will be addressing the following learning objectives: Explain elements that contribute to mental health.

Review trends, problems, and goals related to the delivery of mental health care and treatment of mental illness.

1. Karen is a 25-year-old white woman who lives alone in an apartment with her dog. Karen has been divorced for 2 years and is taking Prozac prescribed by her psychiatrist for depression.  Karen and her boyfriend had been discussing marriage until he told her that he wanted to end their relationship.  Karen became even more depressed and could not work for a week.  Karen returned to work, refusing to discuss her issues with family, friends, or coworkers. She did, however, make an appointment to see a psychiatric nurse practitioner.  Karen told the nurse that she was making some changes in her life.  Karen said that she and a girlfriend were joining a gym program for workouts and a social group for young men and women.  Karen stated that she realizes that her former boyfriend had not been committed to her, and she anticipates meeting and dating other young men from the adult social group.  Karen also said that she thinks that the gym exercise will be beneficial to her mentally and physically.

Learning Objectives: 1, 4)

• How will the psychiatric nurse assess if Karen has made progress toward self-realization? 
•  
• Identify strengths that Karen has for progress in personal growth.
•  

Karen has been seeking treatment for her depression. Analyze the factors that might contribute to Karen’s reluctance to discuss her depression with others.

Case Study, Mohr:  CHAPTER 2, Neuroscience: Biology and Behavior

In completing the case study, students will be addressing the following learning objectives:

Discuss neuroplasticity and how this concept relates to mental health and mental illness.

Briefly explain the importance of interaction between genes and environment, the role of endophenotypes, and the stress-diathesis model of psychiatric illness.

1. Michael is a 22-year-old college senior whose GPA has declined with this semester’s grades.  Michael plans to apply to medical school and thinks that the lower GPA may prevent his acceptance to medical school.  For the last 2 weeks, Michael has skipped most classes because he has insomnia and fatigue.  Michael is now very depressed and has been thinking of suicide.  He took a loaded gun from his father’s gun cabinet and then wrote a suicide note to his family.  At the last moment, he telephoned 911 and told them of his suicide plan.  The police came, took the gun away, and then took Michael to the city hospital to be admitted for psychiatric treatment.   In the admission interview with the psychiatric nurse, Michael said that his pastor thought that only weak-willed people experienced depression and that it was a punishment for personal sins and the sins of one’s ancestors.  Michael told the nurse that he must be weak-willed and will never be able to accomplish anything.  The psychiatric nurse explained that multiple factors are the cause of depression.  The nurse told Michael that one theory holds that an imbalance of neurotransmitters, or chemical messengers of the brain, occurs in depression.  Neurotransmitters influence the individual’s emotions, thoughts, and subsequent behavior.  Recent research implies that neurobiology, heredity, as well as Psychological and environmental factors may be involved in the development and progression of depression. 

(Learning Objectives: 5, 6)

a. Will Michael think that the psychiatric nurse’s explanation for the cause of depression is more correct than that of his pastor?

b. Michael asks the nurse why he has to have psychotherapy. He states that he only needs to take a couple of pills to get better. How should the nurse respond to Michael’s question and comment?

c. Develop an assessment question for each of the following possible causes of Michael’s    development of depression:

              Genetic, Environment and Stress.

Case Study, Mohr

CHAPTER 3, Conceptual Frameworks and Theories:

In completing the case study, students will be addressing the following learning objective:

Give examples of behavioral and cognitive-behavioral interventions.

The student nurse has been assigned a 37-year-old woman admitted to the psychiatric hospital with an anxiety disorder.  This morning, the student notices that the client has a tense facial expression and is walking constantly around the group room.   The student walked over to the client and used reflective communication by stating, “I see that you have a tense expression and are walking around almost all of the time.  Is there something that we could discuss?”  The client replied that she has talked on the telephone to her mother who was keeping her children while she was in the hospital.  The client said that her mother had told her that she was not a good mother, and then said, “I guess I am a bad mother, but I could never measure up to my mother’s expectations.”  The student has learned that negative self-talk can greatly aggravate anxiety and lead to depression.  The student decided to use a behavioral intervention with the client and asked the client who is a good artist and why the client liked the artist’s works. The student and the client then made a list of activities that the client liked. The student taught the client to engage in one of these activities when an unpleasant experience evoked negative thoughts.  The following day, the student decided that the client needed some cognitive restructuring for her relationship with her mother.  The student taught the client that during discussions with her mother, feelings of incompetence might be experienced when the mother made negative comments.  The client was instructed that if her mother made negative comments about parenting, she was to immediately tell her mother that she was a good parent to her children and terminate the conversation at the first opportunity.

(Learning Objective: 3)

a. Will the client be able to learn cognitive restructuring in her relationship with her mother?

  b.    How will engaging in activities help the client with her anxiety?

Case Study, Mohr

CHAPTER 4, Evidence-Based Practice

 In completing the case study, students will be addressing the following learning objective:

Define evidence-based care.

1. Jessica, a 17-year-old girl who came with her family from Romania to the United States 10 years ago, is brought to the mental health clinic by her mother.  At the admission psychiatric interview, the mother stated that Jessica has been saying for 6 months that aliens have been conducting experiments on her and will soon take her in a spaceship to their planet.  Jessica is often awake at night and roams the house with a hammer and sharp knife, searching for aliens. Jessica’s mother says that she fears that some night Jessica will harm a family member whom she believes to be an alien.  The mother then said that she did not bring Jessica for psychiatric care earlier because she had heard that much of mental health treatment was quackery and a waste of money. The psychiatric nurse explains to Jessica’s mother that all mental health treatment is based on scientific principles. 

(Learning Objective: 3)

a. How would the nurse best explain that the care Jessica will receive at the psychiatric   facility is based on evidence? Give two examples of psychiatric evidence-based care, and explain the scientific evidence that supports your examples.

Case Study, Mohr

CHAPTER 5, Legal and Ethical Aspects: In completing the case study, students will be addressing the following learning objectives:  Identify the basic rights of people with mental illness. Describe the different types of commitments and states of competency.

1. Gerald, a 22-year-old black man, has a diagnosis of schizoaffective disorder.  Gerald has been living at home, but this afternoon he had a physical fight with the neighbors and set a fire in their garage to burn their house.  His father took him to the local psychiatric hospital and said that he wants an involuntary commitment for Gerald since he will not agree to the hospitalization.  The father expressed concern over Gerald’s legal rights.  The psychiatric nurse practitioner recommends to the father that he commit Gerald on involuntarily for emergency care for a period of 72 hours since he is clearly a danger to others. The nurse explains that Gerald will be evaluated to determine if he needs involuntary detention for observation and treatment for a longer period of time.  The nurse explains that Gerald will be periodically evaluated, and that when it is determined that he is no longer a danger to others or himself, Gerald will be released from the hospital.

(Learning Objectives: 4, 5)

a. What basic legal rights does Gerald have at the time of this illness?

b. Why can Gerald not make the decision for himself about being an involuntary emergency commitment to the hospital?

Case Study, Mohr

CHAPTER 6, Culture

In completing the case study, students will be addressing the following learning objective:

Describe skills essential to the implementation of culturally competent care.

1. Mrs. Maria Gonzalez is a Mexican National, age 58, who was brought to a health clinic by her adult son. She is complaining that she has had aches and pains all over her body for 2 days. Mrs. Gonzalez states that her neighbor is a witch who gave her the mal do ojo (evil eye) and cast a spell on her to cause her death. The clinic nurse takes an oral temperature and it is 101º F.  The clinic nurse refers Mrs. Gonzales to the clinic physician because she believes that the client has influenza.  Mrs. Gonzales is reluctant to see the doctor and states that the doctor cannot prevent her death. 

(Learning Objective: 8)

a. How can the nurse provide culturally competent care to Mrs. Gonzalez and convince her to see the clinic doctor? 

b. Can Mrs. Gonzalez be convinced that there is no spell cast on her to cause her death? Explain your answer.

Case Study, Mohr

CHAPTER 7, Spirituality in Psychiatric Care

In completing the case study, students will be addressing the following learning objective: Explore reasons for the resurgence of interest in the spiritual aspects of healthcare.

• Marta, a 16-year-old high school teenager, has been depressed over a recent break-up with her boyfriend.  Marta, accompanied by her mother, is seen in the community mental health clinic.  A mild antidepressant is prescribed for Marta with weekly counseling sessions.  Marta and her mother ask if it would be beneficial for Marta to attend a 1-week church camp to begin in 2 months.  Marta would like to reconnect with her religion and voices a belief that the camp experience will help her. The psychiatric nurse practitioner informs them that research reveals that involvement in religious activities has been helpful in social support and in coping with depression.  Marta appears relieved and said that she will register for the church camp.

(Learning Objective: 2)

a. Why might Marta want to reconnect with her religion, and how will attendance at the church camp benefit Marta?

b. If Marta attends the church camp, will this pose a problem to counseling sessions?

Case Study, Mohr

CHAPTER 8,- Nursing Values, Attitudes, and Self-Awareness

In completing the case study, students will be addressing the following learning objective:

Discuss how situational factors can potentially influence the behavior of healthcare professionals toward clients with mental illness.

1. Joe, a 26-year-old Caucasian man, is a client in a state prison system.  Joe is admitted to the prison clinic after being involved in a fight in which he sustained a stab wound to the chest that did not penetrate the lungs or major blood vessels.  The clinic doctor on duty was an employee of several years at the prison.  The doctor showed little compassion for Joe, stating, “He is a convicted criminal, and he is just getting back some of what he deserves.”  The new graduate nurse who was being oriented to the clinic thought that the doctor did not exhibit professional behavior toward Joe.  The clinic nursing supervisor later explained that the doctor was influenced by situational factors.

(Learning Objective: 3)

• What is a situational factor, and how can this influence the behavior of healthcare workers? Provide an example where a situational factor impacted on your behavior while in a healthcare setting.

Case Study, Mohr

CHAPTER 9, the Nursing Process in Psychiatric–Mental Health Care

In completing the case study, students will be addressing the following learning objective:

Apply the nursing process to psychiatric–mental health nursing.

1. The student nurse is assigned to assist the psychiatric nurse with the admission interview of a client at the psychiatric hospital.  The nurse explains to the student that the interview is very important in obtaining a total health history of the client.  The nurse should be courteous and respectful of the client to obtain as much information from the client as possible.  Assessment information should include the subjective information from the client with the reason for needing treatment, the cause of the present problem(s), and the client’s expectation of the outcome of treatment regimen.  The nurse alerts the student to the need to be sensitive to both verbal and nonverbal behavior of the client and to focus on topics that seem important to the client.

(Learning Objective: 1)

a. How can attention to the client’s nonverbal cues be of value in an interview?

b. Why is the interview the most important aspect of the nursing process?

Case Study, Mohr

CHAPTER 10, the Interview and Assessment Process

In completing the case study, students will be addressing the following learning objective:

Describe essential elements to include in psychiatric interviews and the assessment process.

• The student nurse is accompanying the psychiatric nurse during the nursing interview and assessment of a newly admitted patient.  The psychiatric nurse told the student that preparation with subjective and objective data collection is an important part of the process.  The nurse explains that assessment has reference to the interviewer’s interpretation and prioritization of all data for the client.  The nurse must have self-awareness and self-knowledge to be objective and avoid influencing the responses of the client.  Anxiety on the part of the nurse may limit the ability for thorough data collection and interpretation.  Anxiety in the nurse may evoke anxiety on the part of the client. The psychiatric nurse stressed that a process recording, or written analysis of the interaction between the client and nurse, is essential for nurses to recognize the effects of their communication style in the assessment process.  A review of the client’s history is important, and a private setting for the interview is necessary.  The content of the nursing assessment should include the ability and reliability of the client’s response to questions of the interviewer and the skill of the nurse in identification of relevant facts.  The nurse should discuss with the client prior health history, any present illness, and the reason for seeking healthcare at this time.  Medication history with compliance and allergies of the client require investigation.   Substance use by the client, past illnesses, and family history need exploration.

(Learning Objective: 2)

a   The student nurse asked the clinical psychiatric nurse practitioner to explain what she considered the most essential part of the assessment process. How should the psychiatric nurse respond to the student’s question? Explain your answer.