Posted: August 6th, 2015

Intergrated Nursing Concept ASSESSMENT 1 – conclusion

Intergrated Nursing Concept ASSESSMENT 1 – conclusion

Mental Health Presentation
Case study of Mrs S 47 years old

Mrs S is suffering with auditory hallucination; she hears her mother’s voice and other voices to harm herself.   The consumer is non-compliant with her medication because the voices tell her not to take the medication. Due to this, she was admitted several times to Hornsby Acute Mental Health Unit. Mrs S had a referral to Assertive Outreach Residential Support (AORS) for follow up regarding her recovery since 2009.  Mrs S is unemployed; she is on a disability pension. She lives with her partner who has dialysis 3 times a week. However, he is independent with daily activities. Mrs S has a daughter who also suffers from auditory hallucination, her daughter is currently studying.

Medical History
Schizophrenia with negative symptom such as depressive mood, auditory hallucination since 1989
Type 2 Diabetes
Obesity
Hypercholesterolaemia
Hypertension
High risk of falls- last admission from mechanical fall in 21/4/2015

Diagnostic test

Blood test every fortnight for monitoring WCC due to clozapine prescription.  Her recent blood test is on 26/5/2015. It shows that her WCC count is elevated and Neutrophils is also out of normal range.
Currently once every fortnightly Electroconvulsive Therapy (ECT).
Mrs S stated that it relieves her psychotic symptom. This type of therapy is a form of medical treatment for schizophrenia, severe depression, bipolar disorder and other psychotic illnesses. Clinical evidence showed that ECT is effective in relieving depressive and psychotic symptoms.  The common side effect is memory impairment. This procedure needs to have consent and it has to be under supervision of a psychiatrist, an anaesthetist (Sane Australia 2014).

Mental Health Assessment

Appearance – lack of personal hygiene, messy hair and strong odour from the cloth.
Behaviour- pleasant, maintain eye contact during conversation.
Orientation- alert and oriented to place and time.
Moods – withdrawal, lack of motivation.
Affect – Flatten affect, dull tone of voice.
Speech – normal speech.
Perception –appropriate emotional response, continuing of auditory hallucination.

Risk assessment

Mrs S is rated as a high risk due to periodic thought of suicide. Also, depressive symptom appears to be increasing because she neglects her personal hygiene and her physical illness. For example, her blood sugar level monitoring and healthy eating.  The consumer has social vulnerabilities relating to financial difficulty and recently finding a new rental property. These issues potentially impact her mental illness symptom.

Nursing Intervention

Goal: Improving the psychotic and depressive symptoms.

Strategies
•    Supervise self administration of medication by visiting and telephoning a consumer.
•    Ensure consumer follow up with GP and Psychiatrist appointments.
•    Encourage a consumer to discuss about the voices that she has heard and her general health concerns.
•    Promoting distraction technique to reduce the hearing voices symptom such as listening to the music, going out with friend and family.
•    Referral to Recovery Pathway Unit for assisting in moving to a new house.

Goal:  Reducing the risk of fall and improving mobility.

Strategies
•    Educating of side effect of antipsychotic medication such as drowsiness and suitable time to take the medication.
•    Monitoring any changes in mobility after anti psychotic dose adjustment.
•     Referral to physiotherapy for mobility assessment and encourage a consumer to participate in fall prevention program.
•    Once a week regular monitoring of postural blood pressure.

Goal:  Maintaining the appropriate range of blood sugar level.

Strategies
•    Monitoring a consumer for regular blood glucose check at home and record the result before meal and 2 hours after meal with insulin treatment.
•    Educating a consumer and her family of type 2 diabetes treatment in case of emergency due to hypoglycaemia .Also, promoting good preventative foot care.
•    Promoting healthy diet and exercise such as walking. Mrs S has obesity which is a high risk of cardiovascular disease.
•    Encourage a consumer for a blood test every 3-6 months of HbA1C.

Goal:  Increase social activities and promoting independency.

Strategies
•    Involving a consumer in setting up a goal for a care plan such as studying, hobby.
•    Monitoring a consumer to maintain personal hygiene.  Discussing of showering products that a consumer likes to use.
•    Engage a consumer in the recreation activities such as crafting, painting. Mrs S is encouraged to go to knitting class.
•    Referral to Housing Accommodating Support Initiative (HASI) for social activities service. Mrs S likes to go out for with a HASI staff for a milk shake and movie.

Patient Medication

Clozapine 300 mg nocte
The medication is for resistant Schizophrenia. Other antipsychotic drugs have not had any effect on consumer’s condition. This medication can elevate WCC. Therefore, blood test needs to be monitor weekly prior commencing and continuing this treatment.  Therapeutic dose range is between 200-450mg a day with dividing dose. Large doses are recommended taking at night time.

Aripiprazole 30mg daily
It is used for atypical antipsychotic, schizophrenia and bipolar disorder. It is not for dementia and Alzheimer treatment. This medication can cause leucopenia and neutropenia. FBC needs to be monitored. Maintenance dose is between 10-30 mg.

Escitalopram 20mg daily
It is Selective Serotonin Reuptake Inhibitor (SSRI) for treating moderate and severe depression and social anxiety disorder. It is for a person who is assessed with GP and a psychiatrist as part of mental health care plan. The therapeutic dose is between 10-20 mg.

Atorvastatin 40mg nocte
The medication is for hypercholesterolaemia in conjunction with healthy diet. It is recommended reducing risk of stroke in a person with hypertension.  The common side effect of the medication is the elevation of liver function.  Individual dose is between 10-80 mg.

Metformin 1 g twice a day
It is a treatment for uncontrolled type 2 diabetes with diet and exercise. It can be used together with insulin dependent diabetes. Regular blood sugar test is needed as this medication can cause hypoglycaemia. Moreover, lactic acidosis can occur due to accumulation of metformin. The risk factor is renal function impairment in high doses above 2 g per day. Mrs S is on 2 gram with dividing dose at meal time.

Novomix 30 12 unit twice a day
It is a DNA synthesis of human insulin; it is a rapid, onset medication to reduce hyperglycaemia. Individual dose is various. It is administered into subcutaneous tissue such as abdominal wall, thigh, Deltoid and gluteal. It should be injected immediately before meal. The injection site needs to be rotated due to high risk of lidodytrophy and hypersensitivity on the injection site.

According to Mrs S medication adjustment, a neurologist gradually reduced the dose of clozapine from 500 mg to 425mg in 2014 and 300 mg in 2015 due to numerous falls.  After that, sodium              valporate was ceased after medication review in the last admission from mechanical fall in 21/4/2015.  Mrs S stated that she did not have any fall since she stopped taking sodium valporate.

On 16/06/2015, a psychiatrist reviewed her new medication regime. Sodium Valporate was prescribed for mood stability. Therefore, there might be a fluctuation in consumer’s mood in the next few months.  It is essential to monitor any changes in her temperament.

Reflection on the role of registered nurse in Assertive Outreach Service (AORS)

•    Providing medication education and management both oral and injection.
•    Closely observing and assessing any changes holistically.
•     Monitoring both physical and mentally condition in relation to the anti psychotic medication.
•    Assisting consumers to maintain personal hygiene and management of clothing.
•    Offering transport to dependent consumers to health care facilities.
•    Continuing to maintain stability of serious illness consumers in the community as long as possible.
•    Collaborating   with multidisciplinary team to facilitate daily life activities skills such as cleaning and household maintenance.
•    Promoting independency and quality of life to consumers who have serious mental illnesses.

Reflection on multidisciplinary team in Assertive Outreach Service (AORS)

Occupational Therapy

•    Helping consumers to achieve daily life skills such as cooking and household cleaning.
•    Attaining occupational and vocational skills
•    Assessing physical safety environment to consumer with disability.
•    Discuss with consumers to set up goals to improve daily living skills. For example, preparing of shopping list, developing financial and budgeting skills.
•    Associating with other multidisciplinary team in relation to consumer needs.
•    Monitoring and reporting any changes in both physically and mentally to other multidisciplinary team such as registered nurse, social worker.
•    Promoting independency such as bus travelling training.

Social Worker

•    Assessing psychosocial issues that relate to the current mental illness.
•    Provide information and resources regarding to accommodation, financial support and household maintenance in the AORS.
•    Working with consumers and consumers’ families to improve the quality of life and independency.
•    Assessing the  impact of mental illness on consumers and their families in order to
assist them both socially and mentally.
•    Working cooperatively with other multidisciplinary team such as Department of Housing, Occupational therapy and registered nurses.

Integrated Nursing Concepts
Assessment 2 2015

Case Study:
This case study involves an exploration of the impact and associated challenges of chronic illness on a particular patient and their family in the Australian context.  An evaluation of the provision and adequacy of care, the efficacy of management and support, and importantly the emerging role for nurses in chronic disease management will be of particular interest throughout this assessment.

Objective(s): Learning Objective: 1, 2, 3, 5, 7, 9
Graduate Ability: 1.1, 1.2, 5.5, 2.1, 2.2, 5.1, 4.2
ANMC Competency: 1, 2, 4, 5, 6, 7, 8

Weight:             50% (Case study presentation 30%:  Student conclusion 20%)
Due:                 Case presentation:  In class in Sessions 7 and 8
Student conclusion:  9th November 2015
Time allowance:        Case Study:  30 minutes
Student conclusion:        500-600 words

This assessment task will assist students to understand theories and concepts related to the prevention and non-acute management of chronic and complex illness and the role of nursing in this increasingly important arena of care.

In small groups students will prepare a presentation based on an identifiable chronic and complex illness group from the list below in an attempt to capture the lived experience of a person and their family who are on a particular illness journey.  Where a specific disease is not mentioned students may choose a disease commonly experienced by this group as their focal point.

Students are also required to submit an individual written conclusion to this assessment task that connects learning from the case presentation to the present and emerging role of registered nurses in chronic disease management.

The person with a chronic mental illness

Process:
1.    The final aspect of this assessment task is to write a short individual conclusion to this learning experience that connects the understanding gained with present and emerging roles for registered nurses in chronic disease prevention and management.  To be clear the question to be answered is:  Is there an emerging role for registered nurses in chronic disease prevention and management in Australia?  Relate this discussion to the general literature in this area and your case study learning.

This question is to be answered in the same way as the short answers in assessment 1.  Students will be provided with all references required apart from one which students must locate either individually or as a group.

The following marking criteria will be used to grade the presentation:
Criteria and weighting    Fail:
Below expected level    Pass:
At expected level    Credit:
Above expected level
Distinction and High Distinction:  Exceptional

Development of topic:  research, understanding and knowledge demonstrated (15%)
Limited understanding of topic shown. Some links and connections made between ideas but largely superficial. Points are usually developed with minimum detail. Information is at times irrelevant and lacks analysis and critique    Good understanding of topic shown. Links and connections between ideas made clear. Information was relevant and expressed in own words. Points were developed with sufficient and appropriate detail.  Some evidence of critique and analysis    A very good understanding of the topic shown. Links and connections between ideas made clear. Information was relevant and well expressed in own words. Points were well-organised and developed with sufficient and appropriate details.  Aspects of critique and analysis noted    An exceptional understanding of the topic shown.  Links and connections between ideas have clarity, ideas were integrated, synthesised and critically delivered. Information was relevant and well expressed in own words. Points were well-organised and developed with sufficient and appropriate details
Ability to engage and involve audience (5%)    Topic not introduced with any clarity
Some eye contact was made.
Techniques used to engage audience were minimal and mainly ineffective
Choice of case study is poor for purpose
Topic introduced clearly, and purpose of presentation was made clear
An interesting approach taken to topic. Some eye contact was made.  Presentation used techniques such as visual aids and props, anecdote, surprising facts, direct audience participation

Case study is authentic, appropriate and of interest. The case study is connected to discussion    Topic introduced clearly and in an interesting way. Purpose of talk was made clear. Outline of focus was provided
Speakers monitored audience and adapted presentation accordingly. An interesting or original approach taken to the topic. Speaker used techniques such as visual aids and props, anecdote, humour, surprising facts, direct audience participation

Engaging, authentic and well utilised case study
Introduction was particularly engaging.  Purpose of talk was made clear. Outline of focus was provided
Outstanding creativity was demonstrated.
Class engagement was maintained throughout the presentation.  Speakers monitored audience and adapted presentation accordingly. An interesting or original approach taken to the topic. Speaker used techniques such as visual aids and props, anecdote, humour, surprising facts, direct audience participation

Engaging, authentic  and well utilised case study

Use of visual aids (5%)    No visual aids were used; OR
Visual aids were inappropriate or poorly related to the spoken message    Visual aids were often appropriate and related to the spoken message    Visual aids supported the presentation effectively. They clarified and reinforced the spoken message    Visual aids were carefully prepared and supported the presentation effectively. They clarified and reinforced the spoken message. The aids added impact and interest to the presentation
Conclusion of topic and presentation of concept map (5%)    A poor attempt was made to conclude the presentation.
Concept map demonstrated a poor understanding of chronic and complex illness and was not informed by this assessment    An attempt was made to conclude the presentation.
Concept map was informative and contained sufficient detail.  Group could express some connection between the map and this assessment    The presentation was summed up clearly.
Concept map was informative and detailed.  Group conveyed a sense of understanding how this assessment informed their understanding and the development of the concept map    The presentation was summed up clearly and effectively, with key points emphasised.
Concept map was informative and detailed.  Group conveyed at a high level how this assessment informed their understanding of chronic and complex illness

The following criteria will be used to grade the individual student conclusion
High Distinction    Distinction    Credit    Pass    Fail
Ideas, theory and information sources are well integrated to provide a sound argument and position on the question    Ideas, theory and information sources are sufficiently integrated to support the general position
reached    Conclusions are not always supported by evidence (e.g. use of generalisations).  Position on the question is supported and clear     Some attempt to integrate ideas and information sources in a meaningful way to support the answer    Little or no attempt to integrate ideas and information sources to support the answer
Information or evidence is critically evaluated (e.g. in terms of significance, relevance, contradictions, linkage to theory)    Most of the key information/evidence is scrutinised in some depth    Some important aspects of the information/evidence are scrutinised. Answer is not superficial    Little attempt to evaluate the information/evide-nce in a critical way.  Answer is largely descriptive with some evidence of critical thinking    Answer lacks a critical approach
Ideas flow clearly and coherently, with appropriate use of paragraphs

Referencing is appropriate and according UTS Harvard    Ideas in the main flow logically in a suitable paragraph structure

Referencing is appropriate and according UTS Harvard    Ideas in the main flow logically in a suitable paragraph structure

Some referencing errors are noted but largely referencing is appropriate and according to UTS standards     Flow of ideas not always clear or logical.  Some difficulty with paragraph formation and written expression

Some referencing errors are noted but largely referencing is appropriate and according to UTS standards    Overall lines of logic are not clear and written expression is difficult to understand

Referencing is absent or not appropriate and does not meet Faculty standards