Reflections on Patient Care - Case Study Example

Shirley Bongbong Dimitri Psychology 101 February 18, 2007 Reflections on patient care The patient. David is a highly paranoid antisocial patient who is dependent on his wheelchair-bound mother for everything. She finds it increasingly difficult to manage his care as her health is seriously deteriorating. Their relationship shows a very strong implication of getting strained. A brother who also lives with them works full time and sports a very active social life. He made no effort to offer time availability to help provide the high level of supervision David requires. David was admitted to acute ward under Section 3 due to non compliance with medication, developing paranoia with high tendency to induce self harm. He is waiting for his endoscopy test. His laboratory test on his clozapine evaluates an alarming low level of concentrations indicative to noncompliance of medication instructions. The patient’s illness and behavior display. David suffers from schizophrenia with chronic positive symptoms and secondary depressive illness to uncontrolled psychotic state that needs high level care and treatment. It was recorded that he had a number of hospital admissions in a period of 20 years. He also attempted suicide in 1980’s. Few years ago he managed to be an outpatient directly under his mother’s care. His new medication, clozapine, was able to sustain him then. Lately, David believes someone is waiting to murder him due to tax he thinks he owes so he leaves his house only to collect medication and benefits scheduled twice a week. He is very sensitive to strong smells and fragrances such as aftershave, alcohol, and soap powder. He eats maximum of twice a day only because he believes someone is trying to poison his food that leads him to settle lesser food intake for mobility’s sake which resulted to detrimental weight loss. Sometimes he throws his food away of same reason. His mother observes his deteriorating mental and physical health for the past three months and requested minimal viewing of television as this contributes negative effects on him. He is getting disturbed by messages and scenes on television. Aggravated by the absence of social life or zero communications with neighbors and friends, his paranoia continues to lead him to believe death will get him any moment and complains of persistent abdominal pains and nausea which the doctor is currently trying to perform diagnosis. It maybe related to his mood. However there is no presence of illegal substance or alcohol misuse. Healthcare. David has access to services of a Consultant Psychiatrist arranged by his psychiatric Social Worker. He is entitled to free sessions of Cognitive Behavioral Psychotherapy (CBT) and consultations at the Clozarill Clinic where they monitor his mental state and compliance with medication. His Social Worker coordinates his assistance with housing, food, clothing and medical expenses. He was also in the patients list under the care of a Crisis Resolution Team to provide intensive home treatment instead of admission. He is also listed to a Mobile Crisis Team that has a 24/7 operations center with police backup when necessary to stabilize a crisis. He was really secured with both medical and crisis support care by the government. What the Social Worker fails to acknowledge is the importance of social intervention as a part of the crisis resolution. The worker also is helping the person get to live an ordinary life as possible and aims to help search for employment opportunities that can be adapted with this type of illness. He is a member of the MDF The Bipolar Organisation, a charitable organization design to enable people with manic depression take control of their lives which can be accessed online too. Bipolar provides an access to self help groups nearer to the patient’s home to be able to gain mutual support with others of similar situation to manager or learn better mood swings. (MDF Home) It also gives information on National health care (NHS) which promotes healthcare base on need regardless of the ability to pay. Understanding the illness. Schizophrenia is a biological brain disease that causes affected people to show highly irrational behavior sometimes leading to suicide. (McKenna 219) This ultimately interferes with normal brain functions that cause an affected individual to think simple task like hygiene and eating seems unmanageable and often neglected1. An obvious feature is psychosis where an individual loses the ability to ascertain real from imagined experiences. Common symptoms are hallucinations or phantom sensations, and fixed mistaken ideas of delusions. They are kind of trap into virtual reality that leads from hallucinations to delusions. This is a very terrifying feeling for the affected person who understands vaguely their inner senseless perpetual confusion2. This is a clear out of proportion distinction of form and content that affects the individual’s cognitive process, perception and behavior. (Gamble & Brennan 42-43). The person finds it difficult to tell real from unreal experiences. He logically has no appropriate emotional and behavior responses in a given social situation. It has the most devastating effect on the patient and their family and friends because of its severity and failure of the brain’s chemical or neurotransmitter electrical system to function properly. Schizophrenia is a rare condition but shall not be taken as a split or multiple personality. One study shows that adverse childhood events classified as physical or sexual abuse, witnessing domestic violence, or foster or kinship care can be a probable cause for the illness. (Cicchetti 4). It is a known fact that this illness cannot be cured but can be treated to make them able to live a sociable life where the known causes are believe to be genetic, family and individual environment. (Robbins 116). Prognosis. Unfortunately there is no known cure for schizophrenia but only several interventions that can reduce symptoms that will eliminate further forms of psychosis and will let them live a satisfying and productive life. 3 Family history is a contributing factor. The earlier it can be diagnosed the greater are the chances for recovery if treated quickly and consistently then they can live reasonably normal lives. A cognitive therapy for behavior might be admissible to alleviate unpleasant feelings that also go with the interpretation of the relationship of their thoughts and emotions. (Nelson 1-2). It is a fact that medication management and stability vary from patient to patient directly related to the varying degrees of symptoms they are manifesting. (Hogarty 220-221). The only treatments available are hospitalization, psychotherapy, and medical drugs treatment. Behavioral techniques a patient learns from the family at home and from the therapy counseling is used to manage social acceptance in a normal setting. Treatment options. It is more advantageous for a person suffering of schizophrenia illness to be in an outpatient care most probably at home if his family will take him. Family support and social interaction will do him well. (Corcoran 487). It will be damaging to let him be in hospital admission where his social interaction revolves around doctors and patients like him and monitoring of conversations is most unlikely to get 100% viability. The patient is most likely to speed his recovery to home treatments provided there is enough family or group support. Partial hospitalization is used to help them stay on medications if the symptom is real severe. Hospitalization is required to provide the basic needs of hygiene and rest when food is already provided at home. In this case he has to be partially hospitalized because food intake is very limited. This will aid the mother in giving high level care to his son meanwhile psychotherapy sessions and doctors visits are already being taken cared of. (Strauss 168). This is often used as transition steps out of inpatient hospitals but for this particular situation this will suffice more as an option. Part of his day spent in the hospital at least to train him getting out of the house all by himself, having his medications cared for at the hospital, and the mother is given sufficient time to rest with this headache and manage her personal life and disability. This process will help the patient remain oriented while progress on therapeutic routines is promptly monitored. Care management. The patient of such behavior manifestations needs to be admitted in the hospital and treated immediately otherwise he will have a hard time recovering. His hallucinations are increasing and it will do him more harm willingly putting his self in home prison and watching television the whole day. (Costelo 56-120). First, his delusion that somebody wants to murder him is so fixed his mother cannot subdue the train of thoughts anymore that resulted to his being anti social and taking little food intake. Influence and communication is very important to his social psychological needs and I doubt they have one since he is uncontrollable watching television giving him more images to base his delusions on. (Schaub 14-15). Second, television shall be minimized if not eliminated in his list of day to day activities since it promotes a kind of lifestyle that is only virtually feasible. The programs are put together and arranged in an array of images by which the viewer has lost control of it. He has difficulty understanding relationship between reality and controlled images in television. His mind shift cannot tackle transforming virtual images to actual scenes. It is thereby increasing the patient’s passivity and stupor. (Allen & Hill 494-497). It is at this point that delusions will tend to intensify where the flow of images is controlled by the sender and not the viewer. An over dose of television in the form of rapid transmission and frequency eliminates response from the viewer let alone the kind of response and emotions that the sender is trying to control or extract from you. It can be treated as a form of sleep methodology or hypnotism where the patient’s mind and body do not react and cannot react. I can only suggest the taste of yoga or meditation to make his mind calmer and more focus. (Kingdon & Turkington 123). Overcoming stress, tiredness, impatience and unhappiness can be attained by cultivating constructive thoughts found in this spiritual practice. As we meditate to calm our bodies and mind and transform energies into positive energies that will make our experience obtain purer and purer form of happiness, systematically the patient will be able to eradicate from their minds the delusions that they are constantly suffering at the moment. This turn of events will guide him improve his ability to develop confidence and self composure and appease his mind to experiencing inner peace. When you are at peace with yourself and the world, you are happy and everyday stress is literally manageable. We can start each day with thinking that God loves us. Somehow in the life of a person it helps to do the most forgotten and supernatural thing, experiencing God’s love in prayer. It is at this stage that we get to realize no matter how intense the personal and hospital care that we have it is only up to God’s will that we play the roles we are playing now to be understood that everything happens for a reason and that it is always for the common good of all. Think of it and maybe teach our patients to pray a little as part of their daily task. I know science and religion does not come hand in hand but when we are in the verge of giving up there is always someone up there to turn to. Maybe in particular this is the very reason Science cannot unfold the mystery of the unknown as to why some people is getting cured living in close alliance with prayer and God. With Science it can be adequate program for Social Skills Training (SST) to help develop social competence to those who are suffering cognitive deficits in social perception where receiving and processing of information is not efficient. (Bellack 46-76). Interventions made in the form of being in the patient’s list of the Crisis Resolution Team (CRT) not only helps the hospital and the government save on cost but serves to promote closer family ties and bonding between the family and the patient. The only thing that is left for consideration is the situation of the caring mother whose health is deteriorating and who is also plastered on her wheelchair and thus resulting to her inability to give the proper care and attention the patient needs. Since delusions are quite fixed and it is very difficult to convince them to what is their reality, the patient will be giving the mother a very strong edge of not following medications and throwing food away. One thing that can get a patient of psychotic symptoms to his road of recovery is his ability to understand that he needs help and that he is willing in his existing delusional state to try to capture what was once his reality and push himself to change to try to develop and find ways that will lead to at least a manageable situation then further to a more stabilize one. Mobile Crisis Team (MRT) and CRT are two giant big leaps to Europe and America’s cost reduction in bed spaces but do not warrant safety to both patient and family. If the patient is violent he should not be allowed to mingle with the normal population otherwise it will put both under a lot of stress understanding and cooperating for each other’s needs and moods. A kind of private homes like the homes for the aged must be develop and establish for these kind of illness where the individual putting up the business has an inner commitment either by religion or by community to help give these people the high level care they need. It is a fact that nursing professions no matter how good and intelligent you are in class, if you lack the appropriate dose of care and empathy that is naturally innate then you fail to substantiate practice which will be displayed as automatic and for remuneration purposes only. It is like placing the wrong person in the wrong profession. Conscience, empathy, and care must be present to be able to exercise patience and flexibility to attend to this crisis and not just theory and the healthy body for capability. Since housing and environmental factors is very important for the rapid recuperation of the patient I suggest he be admitted in the hospital institution first then maybe afterwards move to one of those private housing care establish for this kind of illness right after he is ready to be treated as an outpatient. Looking into the walls of America and how increasingly these kind of illnesses are growing, maybe we ought to look at our social psychological relationships within the family and of our friends maybe something in our practice and in our strive for greater independence that we miss some strings to get tied to in our ideas of relationship? Social Workers are efficient and professional on their healthcare and monitoring task but I guess that it is about time they look into the need of the mother as well as the need of the patient in their separate individual perspective. The mother needs an individual care this time and shall not be bound to the headaches and stress related activity slump on her shoulder by taking care of the needs of her son. If I may suggest, maybe we can expand globally the hospice care these people need. A change of scene, view, people and culture might help. Is it possible that they be place under the high level care of Aseans? The other option is maybe put some Asean culture in the private business practice of level care for these illnesses, Asean setting and maybe traits of independence could be narrowed to sense of belongingness and the initiative to exert effort to stabilized situation. It is just one observation and suggestion that was not taken into study yet and I challenge culture change in high level care for this type of illness. It is worth spending the research. We have varied cultures why not try the Asean culture of caring? Set up a system and see the outcome. With this kind of emergency and intermediate care, we need to look into the availability and fast access of the clinical information of these patients by their doctors, hospitals, CRT and MRT teams or to the housing care. A computer program made available in their framework that is user friendly with the purpose of collecting individual health issues information to a national centralized database system is an effective means of studying behavior development of the patient without doing any interviews to the concern families for past history. Hospitals and related health care can then be authorized at a certain level to add info electronically. This is needed to accelerate adoption and development of changing technology towards reliable and complete information of an electronic health record. This is a drive for access to complete information and the application and methodology that was used and that shall be implemented relating to the patient’s health care practices and ongoing health care programs. At present practice we are dealing with non interconnected and non interrelated methods of accessing files of patients and it will promote diversities in the application of their high level care issues. Confidentiality of files may not be relevant in this matter where violence could erupt like a volcano if patient’s mood warrants it. The only safe level authorizations are restrictions limited to passwords for people who are allowed to access the files given by the national database central file records custodian. Care delivery. The patient who has difficulty comprehending reality needs to belong to a group that will support him in his ideas and of his moods. Accessible information of the illness shall be provided on the carers which is very essential in the treatment and management of the disease. Clinical language must be kept to a minimum and reading materials shall be adequately provided to educate carers. Choice of treatments shall be developed and documented to all of their care programs. Antipsychotic therapy shall be clinically administered to address the patients emotional and clinical needs. Therapeutic progress and drugs tolerability shall be closely monitored especially if a change in the therapy was just implemented. Checking on his moods to pursue little talks is an attempt to try to dissipate his mood. Tensions can arise at first meeting but it is an important opportunity for a face-to-face communication. What was instituted was an informal and flexible improve communication pattern. The three situations in nursing practice where sensitive interactions are important is communication to patients and to doctors in terms of feedback, keen eye to details on side effects of the drugs instituted such as chlorpromazine which has an easily preventable side effect of potential photosensitive skin response, preliminary assessment from familiarization on signs and symptoms for evidences of potential relapse on withdrawals from antipsychotic medications. Nurses have more exposure on the patient’s needs and behavioral characteristics than the doctors. It will help much if they are also sensitive to issues as enumerated to be able to give appropriate feedbacks to doctors as copartners in their management of the patient’s illness. Behaviors accorded to doctors are rather played role for whatever reasons the patient sometimes want the doctor to think but manifestations of psychotic disorders that are real and which the patient is not conscious is often audible and visual when they are waiting at their chairs at the lounge or at their beds. This is the most powerful observation and feedback a psychiatrist needs to help assessing the condition of the patient concern. Advocacy is rather an innate character or natural being or attitude of the attending nurse and that means caring for your patients with empathy and respect on their person whoever they are whatever forms of life they have now. Tact, pure concern and understanding of the patient’s mood and vulnerability are of primordial concern at first verbal contact with the patient. It is very possible to get the patient to obtain employment he can adapt through the Social Welfare program so he can have to focus his attention on and won’t be entertaining a lot of delusions. But if severity of the problem is detected then he may be back to hospital admission for primary care treatment again. National Health Service (NHS). NHS was set up in 1948 created to help people with varied illnesses being recognized as one of the best health services in the world by World Health Organisation (WHO). Patient’s choices come first and it has brought relevant changes to the structure of the NHS. Different organizations within the NHS relate to each other. (NHS UK). It has been very successful in its promoting fast no appointment advice in walk in treatments. It aims to have a high quality healthcare that is not naturally base on quota or quantity but one reliable care provider where sufficient NHS trusts funds patient’s needs and choices for where to get their treatment. Social Care Services in local community worked in conjunction with local NHS providers and organizations. Authorities and Trusts are different organizations that provides monetary support for developing and incurring health services in the local area to ensure local NHS organizations are performing well. A patient does not have to take much research or spend a time of a headache to search for interventions. At NHS even extended family’s can knock on the doors for reliable social and health care services within the individual’s reach and convenience. Nurses and carers. There are a variety of things that nurses or carers can do to help alleviate the situation of a patient suffering this kind of illness. Understanding more of the person and more of his lonely world can be very devastating but needs necessary care, attention and tact any person, more so nurses and carers should do. Putting ourselves in the shoes of the family and of the shoes of the patient can be very stressful and we can move on pity and concern towards making their care to their optimum advantage. It is like starting to do good so the other person will be comfortable and may be able to express well his concerns and his emotional diversities. In turn the goodness you start to bring out of the person and of the community will evolve and similar to a disease affect and influence other people and vibrates the wholeness and energy to a world full of good people. As nurses, we do have the limitations to help this patient professionally but delving on community responsibility we are bound by nature to give the best complement ever with our so called profession and that is social impact. The best remedy for people who don’t want to talk and is creating their own worlds. That will at least pull them down to reality a little. References Allen, Robert Clyde & Hill, Annette. The Television Studies Reader. Routledge UK. 2004. pp. 494-497. Bellack, Alan Scott. Social Skills Training for Schizophrenia: A Step-by-step Guide. Guilford Press. 2004. pp. 46-76. Cicchetti, Dante & Carlson, Vicki. Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. Cambridge University Press. 1989. pp. 4.  Corcoran, Jacqueline. Evidence-Based Social Work Practice With Families: A Lifespan Approach. Springer Publishing. 2000. pp. 487-488. Costelo, Charles. Symptoms of Schizophrenia. John Wiley and sons. 1993. pp 56-120. Gamble, Catherine & Brennan, Geoff. Working With Serious Mental Illness: A Manual for Clinical Practice. Elsevier Health Sciences. 2000. pp 42-43. Harbor behavioral healthcare. Schizophrenia & psychosis. 1995. Harbor Organization. Retrieve February 17, 2007 Hogarty, Gerard. Personal Therapy for Schizophrenia and Related Disorders: a guide to individualized treatment Guilford Press. 2002. pp. 220-221. Kingdon, David & Turkington, Douglas. Cognitive Therapy of Schizophrenia. Guilford Press. 2005. pp. 123. McKenna, P. J. Schizophrenia and Related Syndromes. Psychology Press (UK). 1997. pp. 219. MDF the Bipolar Organisation. MDF Bipolar section. Retrieve February 21, 2007 from the database of MDF Web Site http://www.mdf.org.uk/ Nelson, Hazel. Cognitive Behavioural Therapy with Schizophrenia: a practice manual. Nelson Thornes. 1997. pp. 1-2. National Health Service (NHS). NHS England. About the NHS. Retrieve February 21, 2007 from the database of NHS connecting for health Web Site http://www.nhs.uk/england/ aboutthenhs/default.cmsx#primarycare Robbins, Michael. Experiences of Schizophrenia: An Integration of the Personal, Scientific, and Therapeutic. Guilford Press. 1993. pp. 116   Schaub, Annette. New Family Interventions and Associated Research in Psychiatric Disorders. Springer. 2002. pp 14-15. Strauss, John. Schizophrenia. Springer.1981. pp. 168. Read More