NURS2098: Complex Mental Health, Trauma and Recovery. Complex Mental Health & Recovery 1 NURS2098: Recovery Focused Nursing Care Plan Case Scenario for Cohort B Clinician Role: Case manager: Mental...

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NURS2098: Complex Mental Health, Trauma and Recovery. Complex Mental Health & Recovery 1 NURS2098: Recovery Focused Nursing Care Plan Case Scenario for Cohort B Clinician Role: Case manager: Mental Health Continuing Care Team. Presenting Information: Anjelica (prefers to be called ‘Angie’) is a 23-year-old single female currently admitted as an inpatient on the Hospitals Mental Health Unit where she has been a patient for the past 3/52. Angie was admitted with worsening psychotic symptoms over an 6/52 period in the context of poor compliance with her oral anti-psychotic medication; she states that this was unintentional and puts her increased forgetfulness in this regard down to due to increased stress at home linked to everyone in her family having to self-isolate due to COVID-19; she additionally commented that she wonders if the medication is causing her to lose her memories. She has been re-established on the same oral anti- psychotic medication medication with good effect and you are seeing her today to review her and discuss his discharge plan before she is discharged home in approximately 1-2 weeks’ time. You have been her case manager for the past 9-months; she has been quite well for the first 6-months of that period prior to her becoming non-compliant with her medication. Presenting Mental Health Complaint: Angie reports starting to become increasingly paranoid around 9/52 ago (6/52 prior to her admission); initially she said she started to feel uneasy about the causes of the virus and started to worry that people weren’t be honest about the cause of the virus. She says she withdrew from her family and isolated herself in her room, sleeping during the day and staying up overnight. Whilst awake overnight she started to intercept messages through her iPad from an “Alien Strike Group called the Zysperepeenion” who were spreading COVID-19 an attempt to weaken the human race before a full alien invasion was launched to destroy humanity. She became gradually more preoccupied with this belief until eventually she started to suspect that the ‘Zysperepeenion’ had also infiltrated many governments around the world leading them to participate in spreading the virus in exchange for ‘immunity’ once the invasion started. She stopped eating and drinking (losing 4kg) and taking her medication; and once her family became aware of her relapse they contacted her MH Case Manager (you) and she was subsequently admitted for urgent treatment to stabilise her mental state. NURS2098: Complex Mental Health, Trauma and Recovery. Complex Mental Health & Recovery 2 Mental Health History: Angie reports first being diagnosed with first onset psychosis at the age of 18 when she was undertaking Year 12. She was in the lead up to mid-year exams when she first started to experience hearing voices in the context of Cannabis use [which she reports using to help manage her anxiety due to the stress of Year 12). She had engaged in social use of Cannabis since Year 11 however her use became more regular in Year 12 due to increasing anxiety levels and her being unable to manage these through other more appropriate stress management strategies. At this time, she experienced paranoid ideation, hearing the voices of the Dark Angels who told her she was “The Marked One” and told her that her family were being hunted by Daemons and that she alone could save them. Her mental state deteriorated slowly over a 3-month period as did her performance at school; she became quiet and withdrawn and it wasn’t until later in the year that she started to express floridly psychotic delusional ideas about the Demons that family became concerned and contacted MH Services. She was treated by the local First Onset Psychosis Team and made a good recovery over time in the community. Eventually she was discharged to ongoing treatment via a private psychiatrist and her GP. She was able to return and complete her Year 12 the following Year though she lost many of her friends as a consequence of the episode. Angie remained well for almost 4 years until she experienced a full relapse of symptoms whilst on a trip overseas with her family. On this occasion Angie expressed religious delusions and heard the voice of Jesus commanding her to leave the hotel she was staying in and “tend to the poor”; she left the hotel in the middle of the night and was found the next day lost and wandering the streets of Edinburgh; she was admitted into a Public Inpatient facility there for 8/52 during which she made slow progress. Once well enough she returned to Melbourne, where she was subsequently assigned a Case Manager to oversee her recovery following this episode as she had many residual symptoms that had not fully resolved. She initially made slow but steady progress in the community however this plateaued out after 6 months and whilst she no longer had any positive symptoms her still struggle with motivation, and cognitive functioning. Her compliance with oral medications was reasonable though she had reported a couple of periods where she had forgotten to take her medication “for a couple of days” and had recommenced taking same with encouragement from her parents when they became aware of the NURS2098: Complex Mental Health, Trauma and Recovery. Complex Mental Health & Recovery 3 issue. She had started to engage with a vocational training program through TAFE though she had stopped going after isolation started as she felt that “it was too unsafe; the virus was everywhere and there was no way to avoid it”. Angie reported to avoiding calls and Skype Appointments with her Case Manager (you) as she started to become more unwell; she says “I didn’t know who I could trust: I thought that the Zysperepeenion were everywhere and manipulating everything and I even worried if the MH Team were part of it all”. She also started to worry that one of the effects of the virus was to “wipe out memories to make it easier for them to take us over” and that she started to worry about her own memories. Once admitted Angie was restarted on the same anti-psychotic medication that she had previously been on (as she had responded well to it). She now states that the paranoia has receded over the past fortnight she has experienced ongoing anxiety, feelings of helplessness and worthlessness, as well as feeling overwhelmed by her situation, saying “I’m really worried about going home with the virus getting worse again; I’m not worried about the aliens any more but I am really worried I’ll get it and then who knows what…and what if all this extra stress makes me sick again and I’ll just end up back in here again”. Angie sleeps 8-12 hours per night, and experiences difficulty getting to sleep as she tends to lie in bed worrying about her life and the future of the human race. Her appetite has returned since commencing medication and she reports a weight gain of 2 kilograms in the past 3/52. She eats large meals and usually snacks on top of this. Angie had been contributing to the running of the household prior to her relapse however as she became unwell, she increasingly withdrew into her bedroom. She became increasingly insular and has avoided social contact, tending to avoid those friends and family who have come to call: she states this is for fear of them becoming targeted by the same “Zysperepeenion Hit Squads” who were targeting her. Angie describes few interests or activities outside the home; she had been very social in High School and had been a keen surfer and swimmer before first becoming unwell, however she lost contact with most of the people she knew from these activities once she became unwell. She has been unable to establish a new social circle since then though she is still keen to do so; she has a positive view of herself and states “everyone has some sort of MH issues; mine are a bit more intense but I’ve also got great support to help me out”. NURS2098: Complex Mental Health, Trauma and Recovery. Complex Mental Health & Recovery 4 Mental Status Examination General Appearance: Angie is a 23yo who appears of stated age. She is of medium build, has long blonde hair and is appropriately dressed. She is well presented in appearance [appropriate clothing and makeup] and she presents with reasonable eye contact. Speech: Angie speaks with a normal rate, tone and volume for the most part. Occasionally her responses to questions are delayed however the content of her conversation is well organised goal- directed and appropriate to situation and context. Thought Content: Angie describes themes of uncertainty, anxiety, helplessness and hopelessness. There are some residual paranoia ideas evident regarding the causes of COVID-19 and she reports becoming preoccupied by watching ‘conspiracy theories’ on YouTube though that often spark concerns about the causes of COVID-19 though these are generally fleeting in their nature and are less intrusive when they do occur. Affect and Mood: Angie describes her mood “pretty good” overall; she reports period of increased anxiety and uncertainty for the future though she says this is linked to “the same stuff everyone is worried about anyway, so I reakon it’s pretty normal”. Her affect is mildly restricted, with diminished range and a generally anxious quality though she becomes warmer and more relaxed as the conversation unfolds. Motor Behaviour: Angie’s posture is generally relaxed, though her level of psychomotor activity increases when anxious. Perceptions: Angie describes occasional fleeting paranoid ideas regarding being targeted by “Zysperepeenion Hit Squads” though these are gradually softening and appear much less frequent and intrusive than they were prior to her admission. She describes some emotional response to them [primarily anxiety] though firmly denes any plans to act on same. Orientation: Angie is oriented to person, place and time though she is unclear of the date, or month. Concentration: Angie denies any issues with her attention span and concentration (this is evident in conversation with her) and she reports no issues with TV or reading. Recent and Remote Memory: Angie’s recent memory is intact, with three of three objects recalled after 5 minutes. She is able to describe accurately events from the past. She still worries about memory loss and still feels that there may be something causing her to lose her memories however she states she is able to distract herself from these sorts of thought. Insight and Judgement: Angie has partial insight into her illness; she accepts that she has a psychotic illness though she is unhappy with the diagnosis of schizophrenia as she worries it means she’ll never NURS2098: Complex Mental Health, Trauma and Recovery. Complex Mental Health & Recovery 5 recover. She is