Students are required to prepare a written care plan that addresses the care and recovery needs of the consumer identified in your chosen case study.
The care plan should reflect and align with the findings of your previously completed mental health assessment (Assessment 2).
- Please provide a detailed overview of the consumers' presentation to the health care setting
John is a 20-year-old boy, a university student in his second year, his mother found him at home trying to get on to the roof, appeared in a very confused mental state, very agitated, appeared to want to self-harm by jumping off the roof. The mother called the ambulance and on their assessment, he appeared very agitated and hyped up, appeared to be hearing voices, instructing him to work on a project. The mother stated he was not any medication, didn't have any prior medical condition. John stated that he had not been sleeping well by his choice, he had not been eating well but drinking lots of sugary drinks and energy drinks. He at times appeared extra happy and at other times appeared scared and agitated, also while he was talking with the medical team he was confused and forgetful and at times appeared to zone out and become non-responsive. He seemed scared and resistant to go to the hospital to get more help saying he had to work on a project with X. On examination at the hospital, he also appeared very restless and couldn't sit still. He was not very responsive to the doctor's questions and attempts to examine him. talked about hearing voices telling him to harm others and to jump off the roof to fly like a bird. He was still insisting to his mother that he wanted to continue his project with X.
- Provide a detailed social history and consider any social or psychological factors that may have contributed to the consumers’ presentation
John is a 20-year-old male who presented to the hospital with extreme agitation, symptoms of delusion, and aural hallucinations.
His social history is that he is a 20-year-old male, a second-year university student who is living at home with his single mother. He seems under pressure to finish his university project on time. He hasn't been sleeping well choosing to spend extra hours working on his project rather than sleeping. According to his mother, he hadn't been eating well and only drinking sugary and energy drinks. He used to go to the gym, and go hiking and walking but it seems like he had just been staying at home and working on his study of late.
He had no previous medical conditions or medications, not using any alcohol or drugs. Currently, he is suffering from sleep deprivation and anxiety which may have contributed to his psychological condition.
- Provide a structured mental state examination for the consumer
John's mental state examination:
Appearance: John appeared well presented, physically in a healthy condition and well-groomed. He appeared agitated and showing fidgeting behavior, unable to sit still. He appeared to zone out and seemed to be listening to someone and responding to aural stimuli.
Behavior: John behaved in an agitated manner, seemed unable to make eye contact, easily distracted, very anxious, and worried. Became very confused and resistive to help, good rapport with mother support.
Speech: Sometimes John was speaking very fast and at other times slow. His volume was consistently at a normal level, he had no accent. Most of the time he was incoherent and his responses were inappropriate to what was asked.
Thought-form: His thoughts seemed delusional focusing on an imaginary project and responding to aural hallucinations ( Mr. X talking to him).
Perception: very distracted during examinations with doctors and ambulance staff. seemed to be in a mixed state somewhere between reality and a delusional place.
Insight and Judgement: His judgment and insight were impaired significantly and were not able to make decisions for himself without help from his mother or medical personnel.
Substance use: No previous history of substance use and no medication.
Social factor: living with his mother, used to go to the gym, hiking, walking, a second-year university student.
Risk factor: Risk of self-harm, stated voices saying to harm others, and to jump off from the roof and fly like a bird.
- Summarise a risk assessment for the consumer. What priority risk areas can you identify and why? Are there any other risk factors to consider? (approx 250 words)
John seemed healthy physically but his mental status puts him at risk of self-harm and possibly harming others because he is in a delusional state with hearing voices telling him to jump off from the roof and fly like a bird. On examination by the doctor, he also responded yes when she asked did the voices say to harm others.
Priority risk areas:
His Risk of self-harm - John is hearing aural hallucinations that are telling him he can fly and jump off the roof to make the project a success. Giving him false illusions that he is capable of flying, not identifying with reality, and seeming excited about flying.
Risk of violence: When the doctor questioned him, "did the voices tell you to harm others", he replied "yes". He seems to be disjointed from reality. He was trying to hide whatever instruction he was getting from X and was agitated. This showed his delusional state and the risk of delusion developing further into a more harmful path.
Risk of absconding from the hospital: He was very unsettled and didn't want to stay in the hospital, he was asking his mother to go home because he needs to continue his project with X. He appeared incapable of making safe decisions for himself.
- Provide a structured clinical formulation for the consumer based on the available information (approx 250 words)
Conducting the clinical formulation using the 5 P's model.
Presenting problem - John presented in an agitated state in early psychosis, suffering from delusion and aural hallucinations. Believing he was talking with an imaginary Mr. X over the phone telling him to harm himself and others. he was in a confused place between delusion and reality.
Predisposing factors - John was sleep-deprived, poor diet, stimulated by energy drinks, and under anxiety and stress coping with the university. Possibly socially isolated.
Precipitating factors - He was under extreme stress wanting to complete his university project, deliberately depriving himself of sleep to try and get it done. eating very poorly and consuming highly stimulative drinks. because of these factors, he seemed to be affected neurologically and this led to his psychosis state.
Perpetuating factors - This problem was not resolving because he continued to be sleep-deprived and affected by his mental state. It had reached a point where he was not able to come out of this condition on his own and he required medical intervention.
Protective factors - He has a loving and very supportive mother that is providing positive encouragement, he has goals that he is passionate about in his university studies. When he is well he is active in the gym and getting exercise and generally physically healthy. He is now under mental health care and can seek the treatment he needs.