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NCS2102 Mental Health & Illness

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Case study scenario

John is a 47-year-old male who was admitted to the medical ward several days ago following an ‘injury’ on his rural property and issues with ongoing chronic back pain. John was also diagnosed (two (2) weeks ago) by his local general practitioner (GP) with depression, and commenced on antidepressant medication. John is being cared for in a single room, but during shift handover, there are concerns the ‘injury’ is a possible self-harm episode, although attempts to discuss this with John have been unsuccessful so far. John was initially cheerful and chatty when first admitted, however in the last 24 hours it has been documented that John has become withdrawn, he has stated ‘he feels miserable and is in pain’, but he smiles when nursing staff enter the room. He has voiced his frustration at being in hospital and says he does not think he is ‘depressed’. This morning John refused to take his medications and his daily self-care is lacking.

To begin to build the therapeutic relationship with John, the nurse (following handover) sat down with John to discuss his past, present, and future health needs and goals from the biological (physical), psychological (mental health) and social domains.

During the conversation, the nurse discussed John’s ongoing history of a ‘bad back’. John did not report this to the GP who diagnosed his depression, since John did not see it as important but rather ‘just a part of getting old’. John also told the nurse that he has had no previous history of mental illness and was not sure what had triggered his depression, however, he went on to say he was recently retrenched from his job as a horticulturalist. This

occurred soon after John’s boss told him that business had slowed down. John wondered if he was retrenched as a result of his bad back, which had been effecting him more and more with each passing year. With this history in mind, the nurse then explored John’s current situation and found the back pain that John experienced often kept him awake at night. John says he doesn’t sleep, so wakes feeling tired and unmotivated. He states he doesn’t feel like socialising because he feels exhausted.

In gathering additional background information, John tells the nurse “he thinks his dad may have had some sort of mental illness”. John also reports that the antidepressant medication was doing nothing other than putting on weight, so John thought it might be better if he just stopped taking it. However, his wife and adult children, who are supportive, have told him not to and this is the only reason he continues to take it.

The nurse then asked John to think about his future. At first John was unable to see any hope - either for re-employment (because working outdoors was his only skill), or for being able to keep his own farm due to how he was feeling and his ongoing back issues. John did agree (after some discussion) that he was interested in finding out if there was anything that could be done for his back. When the nurse asked John how he sustained his injury (a deep cut on his upper thigh), John was evasive, became upset, and refused to answer any more questions.

Later that afternoon John was seen packing his overnight bag, he had changed out of his hospital gown and when approached by the nurse he said “there is no point, there is nothing wrong with me and I am not depressed, I told everyone that so I am going home”.

  • What are the immediate identifiers of possible signs of deterioration in John’s mental state?
  • Identify how baseline information can be obtained and communicated about John’s current mental state.
  • What aspects of the comprehensive mental health assessment are the most important in this case? Explain your rationale for your choice.
  • In the scenario, what could be contributing to John’s feeling of depression? Discuss in reference to the biopsychosocial model of assessment.
  • Address why this approach is deemed ‘best practice’ in mental health care.
  • How can the nurse ensure accurate risk assessment and management strategies are implemented for John, while maintaining positive relationships with him and his family?
  • Identify and provide rationale as to whether John would be deemed low, moderate or high risk based on predisposing, perpetuating and precipitating factors.
  • Discuss how the nurse might manage these risks.
  • Describe a potential duty of care (legal/law) versus individual rights conflict as an ethical dilemma that may arise concerning John’s mental state.
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