For this essay we were presented with the following patient care scenario:
Jack Jones is a 42 year old man who has had several psychiatric admissions, his first when he was 18 while he was in his first year at university. Over the past 9 years he has been declining in his ability to live in the community. After a 10-day admission, Jack is almost ready for discharge from the psychiatric unit in which you are working. Prior to Jack’s admissions to hospital he repeats a similar pattern. He often ceases to take his medication, risperidone 4mg BD. He states that he stops the medication because of the extra-pyramidal side-effects, dry mouth and blurred vision that are “sometimes unbearable, and at times, are worse than the psychotic symptoms”. Shortly following this he begins to believe that he is being talked about on the radio (derogatively) and hears voices telling him that the government is monitoring his every move via a tracking device. When Jack is ill, he believes this device was implanted during his first admission. Just before this admission he went to the police to ask them to “find out who put it there and to lock them up in prison”.
Jack lives in a large men only hostel in the community supervised by an unqualified home care assistant. “I like it because it is cheap, I can spend my money on what I want, and they don’t hassle me”. He has recently been unable to keep regular employment as a labourer on building sites, and is hesitant to apply for any job for fear of being rejected or eventually sacked. Jack also believes that he should have a girlfriend but often expresses feelings of intimidation and anxiety when approaching women. He has a highly ambivalent relationship with his family, whom he says “shout and argue all the time”. They live in a remote country town and keep asking me “when am I going to find a nice girl and get married, and have someone to look after me”. A week ago, Jack’s treating team decided to switch his medication from risperidone to paliperidone palmitate (INVEGA® SUSTENNA) monthly. Briefly outline two priority problems for Jack and discuss the role of the community mental health nurse in enabling someone like Jack to live in the community and avoid unnecessary hospitalisations.
We were to state two priority nursing diagnoses, a rationale for each, and answer the question according to the instructions given. I received a High Distinction for this essay. My assessor gave me the following feedback:
“Excellent paper, well organized and evidenced. Excellent synthesis and analysis of ideas, may have been strengthened with the introduction of the wider role of the nurse especially specific therapies aimed at addressing altered mental status, not just medication. 🙂 Great work.”
Please note my writings are published for educational purposes only, all of my works have been submitted to Turnitin so please do not copy and paste or you will be flagged for plagiarism. My reference list is included at the bottom.
Patient Care Essay
This patient care essay examines the case study of Jack, a 42 year old with a psychiatric history of medical nonadherence, repetitive behaviour and family disfunction leading to multiple hospitalisations. Two priority nursing diagnoses are identified and explored to establish nursing interventions and therapies to improve Jack’s mental health and prevent rehospitalisations. The role of the community mental health nurse in Jack’s recovery is discussed and a plan for care implemented, concluding with the importance of evaluating treatment efficacy.
Jack is a 42 year old man with a history of psychiatric admissions spanning 24 years. Jack typically repeats a pattern of behaviour beginning with the cessation of his medication, followed by psychotic symptoms, and resulting in hospital admission. Jack lives in a male only hostel, is unable to maintain employment and experiences anxiety around women. Jack and his family clash often, with many arguments and pressure for Jack to settle into an intimate relationship. The purpose of this essay is to study the patient care scenario presented and identify two priority problems for Jack, give a rationale for this identification and discuss appropriate nursing interventions for Jack to live within the community and avoid being re-hospitalised. NANDA International (NANDA-I) is a professional organisation developed for standardising nursing diagnoses and terminology (NANDA International, Inc, 2020). NANDA-I defines a nursing diagnosis as a clinical judgement about an individual’s, family’s, or community’s responses to present or anticipated health problems and life processes (NANDA International, Inc, 2020). Nursing diagnoses are used to guide the selection of nursing actions that will help the nurse accomplish the outcomes for which they are responsible. The two priority nursing diagnoses identified for Jack are Risk-prone Health Behavior (NANDA Nursing Diagnosis Domain 1. Health Promotion, Class 2. Health management) and Interrupted family processes (NANDA Nursing Diagnosis Domain 7. Role Relationship, Class 2. Family relationships) (NANDA International, Inc, 2020). These diagnoses have been identified as priorities to increase Jack’s potential for successful recovery with improved family support and self-awareness of destructive behaviours. This essay will also discuss the community mental health nurse’s role in helping Jack to prevent readmission to hospital and live in the community, set goals for the desired outcome, explore appropriate nursing interventions to achieve the desired outcome, and project a plan to evaluate the effectiveness of the interventions.
Identification of priority nursing diagnosis 1 and rationale
Risk-prone Health Behavior as evidenced by Jack’s repeated pattern of ceasing his risperidone medication leading to hospital readmission, inability to maintain employment, and social isolation.
Noncompliance as a nursing diagnosis was removed from NANDA-I’s list of approved diagnoses in 2018 after being classed as outdated (Nurselabs, 2018). Past noncompliance, socioeconomic status, a stressful lifestyle and environment, opposing cultural or religious views and values, a lack of social support, a lack of financial means, and an emotional state of mind as previously associated factors of noncompliance (Nurselabs, 2018) can all be corelated to the diagnostic indicators of risk-prone health behavior when applied to Jack’s situation. According to NANDA-I, risk-prone health behavior is defined as an impaired ability to change one’s lifestyle or behaviour in a manner that promotes improved health (Amaya, 2020). Factors related to the nursing diagnosis of risk-prone health behavior that are relevant to this diagnosis for Jack include insufficient social support, lack of understanding, decreased self-efficacy, stressors, and a negative attitude towards health care (Amaya, 2020). The defining characteristics of Risk-prone health behavior are refusal to recognise a change in one’s health status, failure to reach an optimal sense of control, failure to take activities that might prevent new health problems, and diminishment of change in health status (Amaya, 2020). Risk-prone Health Behavior was chosen as the first priority diagnosis due to Jack’s belief that the psychotic symptoms are better or more bearable than the side effects of medication demonstrating indications of all four of these defining characteristics. Consequently, Jack repeats a pattern prior to hospitalisation that begins with him ceasing his medication due to intolerance of the side effects, after which he begins to experience the positive psychotic symptoms of schizophrenia. Jack’s ability to maintain his employment declines and he experiences anxiety about social interaction, particularly with females. Additionally, although Jack does not live alone, his living arrangements of a male only hostel place him at a higher risk of experiencing social disconnection as it limits his opportunity to connect with others socially, emotionally, and physically (Barrenetxea et al., 2021).
Identification of priority nursing diagnosis 2 and rationale
Dysfunctional family processes as evidenced by Jack’s ambivalent relationship with his family, their constant quarrels, family pressure to develop a relationship with a nice girl, the family’s remote location and lack of support.
Nanda defines Dysfunctional family processes as a condition in which the family unit’s psychological, spiritual, and physiological functioning are chronically disorganised, resulting in conflict, denial and inefficient problem solving, a series of self-perpetuating crises and a resistance to change (Amaya, 2020). A diagnosis of Dysfunctional family processes has many defining characteristics that apply to Jack’s relationship with his family and how it impacts upon his health including family that does not respect the individuality and autonomy of its members, chronic family problems, lack of cohesion, impaired communication, criticism, inappropriate expressions of anger, and growing conflicts (Amaya, 2020). Jack’s family lives in a remote country town and it is assumed he lives within a short distance from his family. The Australian Government defines a remote community as that in which the population is less than 5000 with highly restricted accessibility (Australian Institute of Family Studies, 2008). The case study does not state if Jack is indigenous, however if he is there is a higher risk of biological factors associated with a diagnosis of dysfunctional family processes compounded by being economically disadvantaged due to the remote location of the country town he lives in (Amaya, 2020). Dysfunctional family processes was chosen as the second priority diagnosis due to Jack experiencing a problematic relationship with his family whom he says argue and shout constantly and apply pressure for him to settle into a relationship with someone who will look after him. Although it has not been specifically stated in the case study, Jack is likely to have been diagnosed with schizophrenia which historically has been shown to significantly impact upon families of patients diagnosed with the disorder as relatives are often the main support system (Rus-Calafell et al., 2015). Family therapy interventions aimed at psychoeducation and improving social support have been shown to be effective in reducing anxiety and stress levels within family units which can lead to improved quality of life for the patient and their family (Rus-Calafell et al., 2015).
The role of the community mental health nurse and interventions
It is important to remember that mental health nursing involves a recovery-oriented approach (NSW Government Health, 2019). The Australian Government Department of Health (2010) lists the six principles of recovery-oriented health practise as uniqueness of the individual, real choices, attitudes and rights, dignity and respect, partnership and communication, and evaluating recovery. Essentially this means that the mental health nurse must recognise that recovery does not equal cure and each individual is a unique person who should be involved with all aspects of their care plan and feel able to make choices without being judged and instead feeling supported. The nurse needs to create an environment where the individual feels respected, supported and able to communicate comfortably and participate in their recovery plan. Community mental health nurses provide client care in a wide range of settings from residential homes to private residences to provide safe and effective mental health care with collaboration from health care providers, clinicians, support and recovery services, and family (Heslop et al., 2016). The desired outcome for Jack is to have him become interested in taking care of himself, make changes to his lifestyle that will improve his ability to cope with stressful situations, improved communication with his family and to have him adhere to his medication therapy (Amaya, 2020). Nursing interventions to reach this outcome should begin with establishing a therapeutic relationship with Jack and his family to build trust and create an environment in which Jack feels supported (Nurselabs, 2016; Nurselabs, 2018). Therapeutic relationship is the foundation of mental health practice that has long been linked with beneficial outcomes and should be developed by appreciating individuality, establishing clear boundaries, providing support, being available, being real, supporting equality, exhibiting respect, and having self-awareness (Browne et al., 2012). Interventions aimed at maintaining Jack’s medication therapy involve patient education, patient involvement and removing barriers to adherence (Nurselabs, 2018). Jack’s medication has been changed from risperidone to paliperidone palmitate (INVEGA® SUSTENNA) to reduce his experience of the adverse side effects that prompt him to stop taking his medication. While these medications are similar in their effects, paliperidone has a reduced risk of extrapyramidal side effects associated with its use because it does not bind to the D2 receptors as closely as risperidone does (ClinicalTrials.gov, 2011). Paliperidone has the added benefit of being an injected medication (depot injection) administered monthly while risperidone is an oral medication that has to be taken by the patient. Advantages associated with depot injections include improved adherence, fewer side effects, enhanced monitoring of adherence and increased long term stability (Barnes & Curson, 1994). Patient education has the potential to increase cooperation and satisfaction with treatment for mental health as it enables the patient to manage their own health care by obtaining the information, skills, behaviours, and confidence (Lara-Cabrera et al., 2016). Additionally, providing psychoeducation to Jack’s family can improve awareness of the impacts of living with a psychotic disorder, decrease family disfunction and increase coping skills within the whole family unit (McFarlane, 2016). Evaluating the effectiveness of interventions is an important step in obtaining the desired outcome for Jack, thus the mental health nurse needs to maintain regular contact with Jack and periodically reassess him (Jones, 2016).
This essay has introduced Jack and briefly discussed his history. An introduction to NANDA-I as the organisation developed for the standardisation of nursing diagnoses and a definition of nursing diagnosis have been explained and two priority nursing diagnoses have been identified for Jack. Defining characteristics and factors of these nursing diagnoses have been explored to establish and implement nursing interventions with the goal of allowing Jack to live in the community and stay out of hospital. In conclusion, a community mental health nurse must be able to utilise a wide range of skills and evidence-based interventions combined with empathy and an unbiased mindset to provide a care plan that fits each individual person to foster successful recovery.
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