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1. Identify two (2) high priority problems /issues for the person and briefly justify why each is a high priority.


2. Outline one (1) nursing intervention for each of the identified problems /issues and briefly explain how each is likely to positively contribute to care of the person with reference to relevant literature. Interventions must be nursing related, detailed, practical and within your scope of practice.

Mental State Examination

The scenario is about Cormac, a 24 years old man who lives with his parents and works in an audio-visual store as a salesman. The client has been diagnosed with schizophrenia which is known as mental disorder associated with hallucination, delusion and other cognitive difficulties (Frith, 2014). At the age of 20 he has been hospitalized for the first time due to psychotic issues and after 4 years he has been hospitalised again as he has become threatening towards his mother.

Mental state examination:

Appearance and behaviour

Cormac, the 24 years old white man has been found to have beared and long, blonde, greasy and mated hair with a washcloth on his head. His clothes were stained and crushed. He has been found to be thin which has led to the demonstration of malnourishment. He was unable to remain on his seat for long time and often went to window to see outside. His agitation, non-productivity and repeated motor activities have indicated feeling of tension. However, he has been found to be cooperative with the nurse.

· Speech form

· Speech content

Poor form of speech has been identified due to his brief replies to the questions and some of his replies were irrelevant to the question asked. He has replied in a monotonous tone.

Mood and affect

· Mood

· Affect

· Congruency

He has been found to be apathetic as he was relating his story with no emotion.

His expressionless attitude and monotonous tone has led to the identification of blunt affect.

He laughed without any reason which has indicated incongruent affect.

Form of thought

His brief and irrelevant reply to the questions has indicated his limited or restricted thoughts.

Content of thought

Persecutory delusion of thought has been identified due to the thought of serving for national spy agency and believes that he can communicate with God through television and radio (Hartley et al., 2015).

Perception

Cormac has reported that he can hear voice of strangers talking about him that he is worthless, which has indicated the perception of experiencing auditory hallucination (Paillère?Martinot et al., 2017).

Sensorium and Cognition

He was fully conscious and well oriented to place and person.

His memory regarding recent incident was intact.

Insight and judgement

Cormac has stopped his medication and also started to smoke marijuana which has indicated his poor understanding regarding his health.

Clinical formulation table:

Presenting factors

The client has been presented with washcloth on his head, crushed and stained clothes and lack of eye contact. He has been found be thin which indicated poor nutrition status. Due to lack of motivation he has been found to show least interest in work. Along such factors the client has been presented with psychotic symptoms like auditory hallucination and delusion and physical symptoms like dry mouth and trouble in passing urine.

Precipitating factors

The workplace of Cormac could be a potential precipitating factor as most of his delusional thoughts were associated with his workplace, such as the thought of boss monitoring him and representing himself to the customers as a member of national spy agency.

Predisposing factors

As mentioned by Steullet et al., (2017) stress can be predisposing factor of psychotic disorder. In case of Cormac the incident of relationship breakdown has led to the development of mental stress which can be considered as the predisposing factor of schizophrenia.

Perpetuating factors

According to Sekar et al., (2016) patients with schizophrenia who abuse cannabis shows poor health outcomes on treatment of the illness. Hence, in case of Cormac, the use of marijuana can be considered as perpetuating factor.

Protective factors

The ability of the client to respond to the questions, cooperate with the nurse, remain oriented to place and person, remember recent events and family support have been identified as protective factor.

Plan for nursing care:

Issue

Intervention

Goal

Evaluation

1. One of the main issues that have been found in case of Cormac is the problem of delusional thoughts and auditory hallucination.

In this case at first a risk assessment is required to identify the factors contributing to the development of psychotic disorder (Coffey et al., 2017). Additionally, the client could be provided favourable surrounding which is free from the triggers of delusion and hallucination. It is important to communicate with the client and induce hope to reduce his agitation (Slade et al., 2014). Further, pharmacological interventions could be provided such as antipsychotic drugs in order to address the symptoms (Meichenbaum, 2017).

To relief the symptoms of psychotic disorder and improve trust relationship and connectedness with the peers and family as well.

Risk assessment would help to identify the contributing factors. Additionally, comfortable environment, communicating with others and inducing hope would help the client to reduce his stress. While providing drugs it is required to evaluate the side effects as Cormac has experienced dry mouth and urination problem due to side effects of drugs.

2. According to (Aggarwal et al., 2016) adequate nutrition is required to maintain both the physical and mental health. Hence, it is important to focus on the nutrition requirements of the patient as he has been found to be thin.

It is important to provide proper diet chart to the patient and maintain proper meal time. It would be helpful to involve the patient to prepare his own food as such kind of occupational therapy could help to increase the connectedness of the patient and build trustworthy relation (Jacob, 2015). Further, he could be encouraged to intake fluid to remain hydrated.

Improve the nutrition status of the patient in order to maintain both the physical and mental well-being.

As opined by Sahoo & Josephs, (2017) dehydration exacerbated through substance abuse could act as the contributing factor to delusional thoughts, hence improved nutrition status and maintaining hydration could help to reduce the trigger of thought disorder due to dehydration.

Cormac is a 24 years old man who lives with his parents and works as a salesman in an audio-visual store. He has been diagnosed with schizophrenia and presented with the symptoms of delusional thoughts and auditory hallucination. The mental state examination has identified lack of eye contact, restricted thoughts, blunt and incongruent affect, apathetic mood and lack of motivation. He has reported that he can hear the voice of strangers. He has ceased medication due to side effects such as dry mouth and urination issue. Further, he has started to smoke marijuana which is another risk factor of psychotic disorder. However, he has been found to be well oriented, intact with recent events and cooperative with the nurse which could be consider as positive factors in this case.  It has been found that nursing interventions for resolving the issue of delusional thoughts and auditory hallucination and focus on the nutritional factor would be helpful for Cormac. 

Establishing therapeutic relationship is one of the most important part of nursing care. According to the standard 2 of NMBA registered nurse standards of practice, it is important to engage in therapeutic relationship with the patient purposefully and build mutual trust and respect in order to facilitate the nursing care process and achieve positive health outcomes (nursingmidwiferyboard.gov.au, 2018). In case of mental health issue it has been found that the clients lack motivation and interest to interact with others, hence, effective therapeutic relationship would be one of the most important aspect in order to manage a mental health patient to motivate him/her to improve connectedness with peers (Gelso, 2014).

In this given scenario, the patient Cormac has been found to have poor friend’s network and trust issue as well. On the other hand he has experienced relation breakdown.  Such incident has led to the development of stress and psychotic disorder such as schizophrenia. The client has been found to be unable to remain on his sit, which has indicated his lack of concentration. Hence it is required to establish therapeutic relationship in this case to encourage the patient in order to concentrate on the treatment process and recover faster. In this regard the nurse could use communication skill and a motivational interview could be introduced in order to build in-depth understanding about the patient (Satre et al., 2016). The nurse needs to speak politely with respect to the dignity of the patient and encourage him to take medication and meal properly without any force. Such effort of the nurse would help to build mutual trust and facilitate the establishment of therapeutic relationship, hence, could enhance the focus of the patient on treatment.

Clinical Formulation

The concept of cultural safety in nursing is associated with the clinical environment which is physically, spiritually, emotionally and socially safe for a person and there would be no assault or denial of one’s identity (Pauly et al., 2015). According to Milne, Creedy & West, (2016) it is important to have self-awareness and acknowledgement of the diverse culture during the interaction with a client who belongs to culture which is different from the culture of the nurse. Hence, I would like to evaluate my cultural position and understand the way in which my cultural perceptions could impact the nursing care. In case of Cormac I would like to utilise the principle of remain culturally aware of one’s own cultural influence in order to provide culturally safe care approaches. At first, I will introduce myself to the patient and use active listening tool to understand the concern of the patient. It could help me to gain the trust of the patient and build effective therapeutic relationship as well (Pauly et al., 2015). Such effective listening to his concern would help me to understand the contents of his thought disorder. However, it may be challenging to change his delusional thoughts as he thought them to be real and he has trust issue from early life, hence, it may be difficult to establish mutual trust with him.

In mental health issue, recovery does not mean complete physical or mental fitness, however, it is associated with the ability of individual to manage their illness and live a meaningful life while maintaining the physical and mental well-being in an effective manner (Jacob, 2015). As mentioned by Slade et al., (2014) recovery in mental health means retaining hope and understand the strength and weakness of individual in order to involve in active and purposeful life with social identity, positive sense of self and personal autonomy. The main purpose of the recovery oriented mental health service is to ensure that adequate care service has been provided to the client in order to support the recovery of the patient Gulliver et al., (2018). In case of Cormac, the five principles of recovery oriented mental health practice has been utilised in order to facilitate the recovery of the patient. The five principles provided by Jacob, (2015) include-

Hope: This is the backbone of the recovery oriented practice and it helps the client to recover from the feeling of helpless. The intervention of involving Cormac in the preparation of his own meal could help him to improve his strength to take care of his basic need like feeding and reduce the delusional thoughts such the voice of strangers to point him as worthless.

Connectedness: The principle of connectedness helps to reintegrate into the wider community. As found in case of Cormac, he lacks proper friend network which has indicated poor connection with society. In this case, the intervention of communicating with the patient, providing favourable environment and connecting him family and support group could increase connectedness with wider community.

Personal responsibility: It allows the patient to take responsibility of own recovery. In case of Cormac, involving in making own food, encouraging him to take medication and his cooperation with the nurse could help to improve personal responsibility.

Plan for Nursing Care

Discovery: The principle of discovery includes the personal learning from the overall treatment process. In this process, it is important to evaluate the care process and listen to Cormac to identify the factors that has helped him to improve his condition. Further, it is required to discover personal goals and encourage the patient to focus on it and live active life.

Active sense of life: this is considered as the final stage of recovery oriented practice which aims to help the client to convert from a service consumer to being able to restore the recovery and maintain personal wellbeing. The above mentioned nursing interventions would help Cormac to develop active sense of life and live meaningful life to achieve the personal goals. 

References:

Aggarwal, A., Rehm, C. D., Monsivais, P., & Drewnowski, A. (2016). Importance of taste, nutrition, cost and convenience in relation to diet quality: Evidence of nutrition resilience among US adults using National Health and Nutrition Examination Survey (NHANES) 2007–2010. Preventive medicine, 90, 184-192.

Coffey, M., Cohen, R., Faulkner, A., Hannigan, B., Simpson, A., & Barlow, S. (2017). Ordinary risks and accepted fictions: how contrasting and competing priorities work in risk assessment and mental health care planning. Health Expectations, 20(3), 471-483.

Frith, C. D. (2014). The cognitive neuropsychology of schizophrenia. Psychology press.

Gelso, C. (2014). A tripartite model of the therapeutic relationship: Theory, research, and practice. Psychotherapy Research, 24(2), 117-131.

Gulliver, A., Morse, A. R., Wilson, N., Sargent, G., & Banfield, M. (2018). An evaluation of a tailored care program for complex and persistent mental health problems: Partners in Recovery program. Evaluation and program planning, 68, 99-107.

Hartley, S., Haddock, G., e Sa, D. V., Emsley, R., & Barrowclough, C. (2015). The influence of thought control on the experience of persecutory delusions and auditory hallucinations in daily life. Behaviour research and therapy, 65, 1-4.

Jacob, K. S. (2015). Recovery model of mental illness: A complementary approach to psychiatric care. Indian journal of psychological medicine, 37(2), 117.

Meichenbaum, D. (2017). Stress Inoculation Training: A preventative and treatment approach. In The Evolution of Cognitive Behavior Therapy (pp. 117-140). Routledge.

Milne, T., Creedy, D. K., & West, R. (2016). Development of the Awareness of Cultural Safety Scale: A pilot study with midwifery and nursing academics. Nurse education today, 44, 20-25.

nursingmidwiferyboard.gov.au (2018). Nursing and Midwifery Board of Australia - Registered nurse standards for practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Paillère?Martinot, M. L., Galinowski, A., Plaze, M., Andoh, J., Bartrés?Faz, D., Bellivier, F., ... & Artiges, E. (2017). Active and placebo transcranial magnetic stimulation effects on external and internal auditory hallucinations of schizophrenia. Acta Psychiatrica Scandinavica, 135(3), 228-238.

Pauly, B. B., McCall, J., Browne, A. J., Parker, J., & Mollison, A. (2015). Toward cultural safety. Advances in Nursing Science, 38(2), 121-135.

Sahoo, A., & Josephs, K. A. (2017). A Neuropsychiatric Analysis of the Cotard Delusion. The Journal of neuropsychiatry and clinical neurosciences, 30(1), 58-65.

Satre, D. D., Leibowitz, A., Sterling, S. A., Lu, Y., Travis, A., & Weisner, C. (2016). A randomized clinical trial of Motivational Interviewing to reduce alcohol and drug use among patients with depression. Journal of consulting and clinical psychology, 84(7), 571.

Sekar, A., Bialas, A. R., de Rivera, H., Davis, A., Hammond, T. R., Kamitaki, N., ... & Genovese, G. (2016). Schizophrenia risk from complex variation of complement component 4. Nature, 530(7589), 177.

Slade, M., Amering, M., Farkas, M., Hamilton, B., O'Hagan, M., Panther, G., ... & Whitley, R. (2014). Uses and abuses of recovery: implementing recovery?oriented practices in mental health systems. World Psychiatry, 13(1), 12-20.

Steullet, P., Cabungcal, J. H., Coyle, J., Didriksen, M., Gill, K., Grace, A. A., ... & Meyer, U. (2017). Oxidative stress-driven parvalbumin interneuron impairment as a common mechanism in models of schizophrenia. Molecular psychiatry, 22(7), 936.

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