Four short-essay questions
1600 words (i.e. 4 short essays of 400 words each)
You will find four questions below relating to an evolving clinical scenario. Respond to each question in chronological order. Each response must use correctly structured paragraphs in response to the task (400 words maximum per question).
You are a new graduate nurse and part of a small multidisciplinary team in a large 24-hour medical clinic. A young woman has just presented. She is dishevelled, appears nervous, constantly moving about the waiting room looking closely at different objects. She responds warily to any interaction with other patients. She has asked reception several times if a doctor can see her now. The duty doctor asks you to sit in and assist him with the interview.
1. Describe the key communication skills you will use in order to engage with her in the interview. (400 words)
The young woman gives her name as Sarah. In response to asking why she has attended, she gives a clearly articulated story about a school teacher using radiation to control her thoughts. She describes difficulty getting onto the train to attend school as she feels other passengers can find out what she is thinking. When you ask her how she feels about her situation she says it is very confusing and frightening. In response to the doctor asking if he can help, she says she wants him to “make it all stop”.
2. There are a number of clinical signs and symptoms in the scenario so far. Identify three significant signs or symptoms and support your clinical opinion with evidence from the scenario. (400 words)
Following a basic physical and presenting history the doctor acknowledged the confusion and distress, explaining she is experiencing psychotic symptoms. He seeks Sarah’s permission to ring her mother. He also makes an appointment for the next day to see her again. Before leaving she is provided with a script for 5mg olanzapine nocte.
3. Discuss the education you will need to provide to Sarah about her medication. (400 words)
Sarah briefly acknowledges the education you provided to her. However, you notice that her responses are monosyllabic with a flat tone, and she did not ask any questions.
4. Her response may suggest that she did not fully grasp the information you were providing. Discuss your clinical plan to address compliance issues that might arise for Sarah. (400 words)
Your assessment submission will be marked using the following criteria. Each criteria has equal weighting. The marking rubric is available for your reference here Rubric.pdf.
· Utilises evidence for practice.
· Interprets the scenario.
· Demonstrates critical thinking.
· Academic literacy.
· Academic integrity.
All marking and feedback will be returned via My Grades.
Read to assignment question carefully. Check the marking Rubric so that you understand how your essay will be marked.
The essay length includes in-text citations, but excludes the reference list.
- Communication Skills with an Anxious Patient
As a nurse, it is imperative to remember that effective communication is an essential part of the process of patient care. “Essentially, communication skills encompass observing, listening, and explaining” (Webb, 2011). In this particular case, the patient in question is profoundly distressed and cannot seem to settle down before seeing a doctor. There is a set of communication skills advisable in this context.
The first thing to do as a nurse is to assess the patient’s feelings in that precise moment. In this regard, I will ask the patient how she feels about being at the clinic and the purpose for the visit. Additionally, I will use the communication skill of being an engaged listener whereby I will encourage the patient to explain herself without any interruptions on my part (Morrissey, & Callaghan, 2011). I will listen to the situation, whether relevant to the current scenario or not as this will put the patient at ease by knowing that she has an attentive audience for her plight.
Moreover, I will also pay attention to the nonverbal cues while the doctor examines the patient (Webb, 2011). Commonly, patients are often in habit of concealing some important matters from their physicians, usually for a diversity of reasons. By being attentive to the nonverbal cues I will be able to observe the patient’s reaction to some of the questions asked by the physician regardless of the answer provided. Some of nonverbal cues I will watch out for include: fidgeting, clenched fists, wandering eyes, and rapid breath among others.
Furthermore, it is important to reassure the patient of the significance of the decision to seek help at that particular clinic. On many occasions patients are anxious because they need reassurance that their problem can be solved by the doctors in the clinic. By providing friendly reassurance I can put the patient at ease.
In addition, it is important to keep the questions open rather than closed. This ensures that the patients answers the questions from a wide-ranging perspective to enable the doctor get a clearer perspective of the entire situation and not merely the filtered version. Open-ended questions enable the patient to talk more which gives the doctor an opportunity to conduct a more thorough examination.
Lastly, I will communicate to the patient in a friendly manner as opposed to an interrogative manner. It is important to ensure that the patient relaxes and feels that she has a friend in such an unfamiliar and perhaps scary place, for many people.
- Clinical Signs and Symptoms
The first sign that Sarah may be mentally ill is the fact that she seems to have chronic anxiety (First, & Tasman, 2011). It is clearly mentioned in the scenario that Sarah is seemingly anxious. Evidently she is unsettled as is manifest in her behaviour of asking for the doctor multiple times even after being asked to wait. Additionally, her apparent anxiety is visible in the ways she responds to the question asked concerning how she feels about her situation; in response she states that she is very confused and frightened. Chronic anxiety as portrayed by Sarah is one of the most prevalent signs and symptoms used to identify patients with a likelihood of developing mental illnesses among other mental problems. Sarah is afraid of everything, including her surroundings. She mentions to the doctor that all she wants is for him to ‘make it stop’.
Secondly, Sarah portrays the symptom of erratic thinking (Compton, & Kotwicki, 2007). This is usually considered to be a sign of mental problems as the patient’s thoughts are often characterized by illogical ideas (Hicks, 2006). When Sarah talks to the doctor about her condition, she is utterly convinced that her schoolteacher has been using radiation to control her thoughts. The idea that this could even be a possibility seems completely unreasonable. Additionally, she emphasizes her anxiety concerning the illogical prospect of other people being able to read her thoughts. In fact this notion frightens her so much that she is constantly afraid to board the train to school. The erratic thinking of Sarah’s mind is one of the most commonly used signs and symptoms to denote mental illness among patients.
Thirdly, Sarah shows the sign of feeling disconnected. Clinically, this is a symptom of mental illness whereby a patient has a sense of unreality and feelings of detachment from one’s surroundings (Davidson, 2012). In Sarah’s case, she is evidently detached from her surroundings. This is manifested in the ways she studies objects around the waiting room unusually closely. Moreover, it can be concluded that Sarah is disconnected from the people around her based on her wary interaction with the other patients. She is not in the least bit interested in the people around her. Rather she is fascinated by the objects she sees and examines them in a manner likely to suggest that she does not feel connected to her surroundings.
- 5mg Olanzapine Nocte
Olanzapine is an atypical antipsychotic. It is commonly used for the treatment of bipolar disorder and schizophrenia as approved by the FDA (Victor, 2010). The main side effect of the drug is commonly weight gain. Some of the rarer side effects from the drug include muscle rigidity and tremors. The risk of being affected by the drug’s side effects is extremely high for most patients and therefore Sarah needs to be prepared for that. For patients with diabetes mellitus, it is possible for them to endure hyperglycemia (In Stringer, In Hurn, & In Burnside, 2016). In general, the drug may disrupt the natural thermoregulatory systems of the body thereby allowing excursions to alarming heights when faced with certain situations as strenuous exercise and exposure to heat. Additionally, there is a small chance that the drug may instigate major paradoxical responses such as alterations in personality, behaviour or thoughts; extreme thought contemplating suicide, and hallucinations (Zhang, 2013). Moreover, in severe cases it is possible for the drug to cause or worsen diabetes. This information will help Sarah in the event that she has a history of diabetes in her family.
Furthermore, Sarah, being a female, needs to be informed that the drug is generally safe during cases of pregnancy although this inference is not fully backed by concrete evidence. However, it may not be advisable for Sarah to get pregnant while under medication as this may affect the health of the offspring. With regards to withdrawal, a gradual process is recommended in order to avoid rapid relapse or acute withdrawal syndrome. The doctor will provide her with the necessary direction when it is recommended that she terminates her medication. Otherwise, the withdrawal symptoms she might experience include: light-headedness, nervousness, dizziness, extreme relentless crying, headache, anxiety, diaphoresis, and dyskinesia. The withdrawal process is generally very unpleasant for patients and needs to be handled with certain guidelines from the doctor. Additional symptoms may include hypersensitivity and acute psychosis.
The symptoms of an overdose encompass agitation, dysarthria, agitation, coma, and decreased consciousness. The drug is basically considered moderately toxic on overdose and therefore Sarah should be advised not to attempt it as it will be highly disagreeable for her.
In general, the information that Sarah needs to have about the drug includes: the usage, side effects, overdose, and the process of withdrawal. Such information will help her and her mother to avoid certain risk factors as pertains to the drug’s usage.
- Clinical Plan for Compliance Issues
In the event that Sarah does not comply with the medication given to her, there needs to be a clinical plan to ensure that such a situation is averted from causing severe problems in her general treatment. Firstly, once in a while Sarah will be required to return to the clinic for the hospital to take a measurement of the drug concentration in her blood among other bodily fluids. Such a procedure can give adequate information on the issue of adherence and also the patient’s variability in metabolism and absorption (Joint Commission Resources, Inc., 2004). Regardless however, this measure can only convey certain indications on compliance. Additional measures will be required if the clinician hopes to get the complete story for instance an observation of ingestion and pharmacokinetic study to denote the specified blood level in the case that the patient is completely adherent to medication. Normally, these approaches are perceived to be costly and burdensome to patients and clinicians alike. The second plan involves monitoring Sarah’s blood level (Tampi, Muralee, Weder, & Wilkins, 2010). This measure is actually imperative especially considering the fact that the medication has high risks of toxicity if not strictly adhered to.
Moreover, my plan involves the indirect method of simply asking the patient. In this way I can measure the physiologic responses involved in this specific drug or use clinical therapeutic responses as a form of proxy for compliance. Furthermore, pill counts method is also another measure I could use. Considering the fact that it would be quite easy for Sarah to discard the pills from her medication, I would enforce this method through making unannounced home visits to her place of residence (Boyd, 2007).
All in all, the most optimal way to ensure that Sarah complies with her medication is through consistent monitoring. In the event that I cannot be around her throughout her medication period then her mother will be required to assist in this process. The side effects of consuming the medication Sarah was prescribed for by the doctor are highly conspicuous. The existing data on the medication can be easily linked to adherence patterns to pertinent behavioural and physiologic measures like activity and sleep, and weight gain.
The most important part of my clinical plan involves regular check-ups with Sarah. By forming a close relationship with the patient, it would be easier for her to confide in me about certain matters as non-compliance with her medication among other factors associated with her medication.
Conclusively, Sarah’s condition is prevalent among several patients presenting symptoms of mental illness. However, it is important that she sought treatment. As a nurse such matters as effective communication skills with such a patient determine the level of trust that may exist between the nurse and the patient.
Boyd, M. (2007). Psychiatric nursing. Philadelphia, Pa: Lippincott Williams & Wilkins.
Compton, M. T., & Kotwicki, R. J. (2007). Responding to individuals with mental illness. Boston: Jones & Bartlett Publishers.
cPsychiatry: breaking the ICE: Introductions, Common tasks and Emergencies for trainees. Chichester, West Sussex ; Hoboken, NJ : Wiley Blackwell
Davidson, M. R. (2012). A nurse's guide to women's mental health. New York, NY : Springer Pub. Co.
First, M. B., & Tasman, A. (2011). Clinical Guide to the Diagnosis and Treatment of Mental Disorders. Hoboken: John Wiley & Sons.
Hicks, J. W. (2006). 50 signs of mental illness: A guide to understanding mental health. New Haven, Conn: Yale University Press.
Joint Commission Resources, Inc. (2004). Issues in provision of care, treatment, and services for behavioral health care. Oakbrook Terrace, Il: Joint Commission Resources.]
Morrissey, J., & Callaghan, P. (2011). Communication skills for mental health nurses. Maidenhead: Open University Press.
Tampi, R. R., Muralee, S., Weder, N. D., & Wilkins, K. M. (2010). Clinical assessments in psychiatry: Mastering skills and passing exams. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Victor, P. A. T. S. S. (2010). End of Life Care in Dementia. Oxford: Oxford University Press.
Webb, L. (2011). Nursing: Communication skills in practice. Oxford: Oxford University Press.
Zhang, M. W. (2013). Mastering psychiatry: A core textbook for undergraduates. Place of publication not identified: Lulu Com.