Living with a long term condition - Essay Example

?Living with a long term condition INTRODUCTION Background The patient Angela (not her real was admitted into the mental health unit after she was brought in to the emergency room by her daughter. Before the admission, Angela was being managed at home by her daughter. Angela was diagnosed at the age of 54 with paranoid schizophrenia, and was initially admitted to a mental health unit for management. She stayed in the institution for four years. With significant improvements, she was discharged for home and community management. She was doing well under the care of her daughter, but after two years at home, many of her symptoms recurred including her hallucinations, paranoia, delusions of grandeur; she was also manifesting disorganized speech and thought processes. She was hearing voices and was often heard talking to her hallucinations; she also insisted she was a Queen and must be treated as such; and she was easily distracted and had trouble organizing her thoughts. She was also refusing to take her medications. After appropriate evaluation, she was admitted to the mental health unit. I met the patient after being assigned to her care as a mental health nurse. In evaluating her condition, she has been schizophrenic for six years now with her symptoms being manageable for the better part of four years, but due to an untoward incident – the death of her husband, her symptoms have become unmanageable again. Angela is now 56 years old, has had two grown children, and has been recently widowed. She has worked as a school teacher up to the time when her initial symptoms manifested. She has since opted for early retirement due to her condition. When she was brought home after four years in the mental institution, she has had a limited social history. She has opted to not engage in any social interactions because she felt ashamed of her condition. Her family members have remained supportive of her and they have done their best to maintain social interactions with her. Within the mental health unit, she is a shy and socially awkward person. At times, she can also be gregarious with other people, especially when her delusions of grandeur are manifesting. However, she also tends to be suspicious of everyone including the health staff and the patients. This makes her resistant to interactions and to the medical interventions which the health staff are administering. Long term conditions are those conditions which basically require prolonged medical care (London Health Observatory, 2011). The World Health Organization (Department of Health, 2005) describes that long-term conditions or chronic conditions are health issues which call for continuous care over a period of years or even decades. It includes conditions like cancer, HIV/AIDS, diabetes, hypertension, and mental disorders including schizophrenia, depression, Alzheimer’s disease (London Health Observatory, 2011). The patient’s mental illness is considered a long-term condition because it would require continuous management. In short, it is a life-long disease which would require constant supervision and treatment. The patient would have to take medications for the rest of her life to manage her symptoms and she would have to be monitored in order to ensure that her symptoms would not endanger her life and the life of other people. 2. PLANNING THE CARE a. What interventions were planned – what is the evidence based for this? Interventions which were planned primarily included the administration of antipsychotic medications. The management of schizophrenia most often includes antipsychotic medications (Brown University, 2012). The patient was to be placed on Risperidone (Risperdal) which is an atypical antipsychotic. Risperidone is currently preferred as an antipsychotic because it does not cause agranulocytosis, which is commonly seen in clozapine, another antipsychotic (National Institute of Mental Health, 2012). Risperidone however can increase a patient’s risk to diabetes and hypercholestolemia; as a result, regular monitoring of the patient’s blood sugar and cholesterol levels was planned into the treatment (NIMH, 2012). In relation to the expected side-effects of the antipsychotic, which included symptoms like rigidity, tremors, and restlessness, appropriate muscle relaxants were also prescribed. The management of side-effects of antipsychotics is as important as the management of the disease symptoms itself because the side-effects can interfere significantly with a person’s regular functions and other mental functions (Aronson, 2008). Supportive psychotherapy was also planned for the patient, both individually and group based (Buckley and Pettit, 2007). Social skills training groups were also planned with the patient. Group therapies or peer support groups were planned as a venue for patients to share their experiences with each other “about how to cope with daily life after a psychotic episode” (Castelein, Mulder, and Bruggeman, 2008). The group sessions were planned as 16 sessions with 90 minutes each and scheduled once every two weeks. About eight to ten patients were included for each session; and one mental health nurse was to be assigned to the group. First, each patient was to be encouraged to work with a partner, sharing their positive experiences with each other for the past two weeks. Secondly, the experiences were to be shared by the pair to the group for about ten minutes. The nurse would initiate the general discussion. Thirdly, the patients would choose a subject for the session with the themes relating to their illness, how they were living with their disease, or about how they were coping with job challenges. A 15 minute break shall be appropriate after the theme is selected. Fourth, the group is again grouped into pairs where the patients share their experiences with each other (as far as the theme is concerned). Fifth, the participants were to gather for a final session where they would then share their feedback and experiences with the group. Finally, the nurse would summarize the session and what they could take away from the session. This type of session has been effective in other applications because it has been known to encourage group participation and socialization among the patients (Griffith, 2007). The presence of the nurse as mental health professional also provided the necessary support and guidance for the peer session, helping anchor the discussions and helping the patients understand and cope with their symptoms. The schedule of the session spread out over 16 sessions was also meant to provide sufficient sessions for the therapy and schedules which would be convenient for all the patients (Castelein, et.al., 2008). Individual psychiatric sessions with the patient were also planned (Turkington, et.al., 2006). These sessions included cognitive behavioural therapy. Cognitive behavioural therapy has been developed to manage the residual symptoms of pharmacologic treatment on schizophrenia patients (Turkington, et.al., 2006). Now it is highly recommended as a therapy for schizophrenia patients. In this type of therapy, the link is made between thoughts and feelings as well as actions (Hansen, Kingdon, and Turkington, 2006). With these links established, the process of working through a patient’s feelings and actions are developed. The CBT was planned to run for 20 sessions, with one session carried out once a week and one hour for each session. The CBT was also scheduled with a psychiatrist who was highly qualified to conduct the sessions. The sessions were to start with an assessment of the patient’s thoughts and feelings with the therapist listening attentively to these (Hansen, et.al., 2006). The engagement stage would follow with the therapist emphasizing what the therapy is all about. The Socratic Method during the therapy was to be emphasized in an attempt to evaluate the patient’s understanding of his condition and his ways of coping with his symptoms (Gubbard, Beck, and Holmes, 2007). Solid attempts to emphasize the patient’s perspective was also planned in order to evaluate his feelings of stress and to ensure flexibility in dealing with his condition. These sessions were to be evaluated in order to establish their efficacy and their impact on the patient (Gaudiano, 2005). b. Were there any alternatives that were considered – what was the reason these were not considered? The alternative which was considered for the treatment of the patient was the use of Clozapine. Clozapine is also an effective schizophrenia medication because it helps manage psychotic symptoms including hallucinations and significant breaks from reality (NIMH, 2012). However, this medication was not chosen because it can cause agranulocytosis, or a loss of white blood cells which can then compromise a person’s ability to fight off infection (NIMH, 2012). Individuals who take clozapine have to have white blood cell counts once or twice a week and this can total to enormous costs for the patients. Nevertheless, this treatment is ideal for patients who do not respond to other medications (NIMH, 2012). This type of treatment was not used for this patient because the family was already having financial difficulties. Constant white blood cell counts were added costs which they could not afford to carry out once or twice a week. Moreover, the patient was already responding well to Risperidone, so there was no apparent need to shift to Clozapine. c. How did you involve your patient/client and/or carers? Involving the patient and the carers in the process was difficult. First of all, the compliance of the patient with the medication intake was already low when she was admitted. She did not want to take the medications because she said that she did not like the side-effects of the antipsychotic medication. Secondly, the patient was also in an antisocial mood and did not like to socialize with the other patients and this included the interactions during the group therapy sessions. Lastly, the carers were also very busy with their personal lives and had trouble setting aside time to attend meetings with the therapist to discuss the management of the patient’s symptoms. Nevertheless, I was eventually able to gain the patient’s as well as the carer’s cooperation by focusing on psychoeducation (Bauml, et.al., 2006). Psychoeducation involved the process of educating the patients about their medication, its indications, and its intended benefits. Educating the patient about the side-effects of the medication and the various remedies which can be used in order to counter the side-effects was also an important part of the health education process (Battaglia, 2011). As I was able to educate the patient about her medication and the need for her to take the medication, I was able to gain her cooperation. Family support was also an important element of gaining the patient’s cooperation. The patient’s family visited regularly and I also expressed to them the relevance of the patient’s medication and the importance of the support they could give to Angela (Pharoah, Mari, and Rathbone, 2010). After educating them also about the importance of the patient’s compliance with her medications as well as their show of support for their family member, I was able to convince the family that they needed to be more proactive in the management of Angela’s symptoms. I also suggested possible ways by which they could show their support. These suggestions included more regular visits from all of the family members, assisting in some of the patient’s activities, and joining in the family therapy sessions (Wen-Yi, et.al., 2011). I also suggested that by simply listening to Angela, they would be able to lend their support and to motivate her to take her medications and be involved in the therapy sessions. 3. DELIVERING AND EVALUATING THE CARE What happened when you delivered the planned care? When I delivered the plan of care, it was initially met with resistance from the patient and also from the family. As was mentioned above, the patient did not want to take her medications nor did she want to participate in the therapy sessions (Valenstein, 2004). The family was also too busy to assist in the management of the patient’s symptoms. After adjustments were made, the plan was able to accomplish most of its goals after a slow start. With various adjustments based on patient preferences and conditions, I was able to eventually able to gain the preferred outcomes for the patient (Blashki, et.al., 2004). What worked well and why? The Risperidone (Risperdal) worked well because it was able to manage the patient’s symptoms. Her hallucinations were reduced, and sometimes were completely non-existent. She did not report hearing any voices anymore, nor did she have delusions of grandeur after weeks of treatment with Risperdal. Risperdal is the one of the more effective antipsychotics as it can help reduce hallucinations and other symptoms of schizophrenia (NIMH, 2012). Unfortunately, patient still experienced side-effects like fatigue, agitation, and increased salivation. However, with the administration of medications to counter these side-effects, she was more inclined to comply with her medication intake (Aronson, 2008). Moreover, her dosage was also adjusted in order to reduce the manifestation of the EPS. Management of these symptoms also helped to reduce anxiety and increased the patient’s cooperation to her treatment plan (Kane, 2006). What didn’t work – why didn’t it work? What might have worked better? The cognitive behavioural therapy did not work well for the patient. This therapy was carried out as individual sessions and during these sessions, the patient felt threatened by the set-up. She expressed that she felt like her personal space was being threatened during these sessions. The CBT also increased her paranoia and suspicious nature. She was not comfortable with the cognitive-behavioural therapy because she also felt that she did not have any other choice but to talk with the therapist, whereas, in the group therapy, she could choose not to talk and still feel that she was getting the mental help she needed. I believe that a community-based treatment would be more effective for the patient (O’Donnell, 2003). This would make the set-up for the patient less threatening and more comfortable (Kinter, 2009). Community treatments have also been known to reduce hospital admissions (Kopelowicz, et.al., 2003). These treatments would also likely improve the socialization of the patient with the community. What is the evidence for this? Various studies have been carried out reviewing the applicability of community treatments in the management of schizophrenia. One of the common benefits and advantages which emerged in these studies is that community treatments help to reduce hospital admissions of the patients (Li, 2005). There is also a better monitoring possibility for these patients and such monitoring helps improve medication compliance which eventually reduces the severity of symptoms. It also helps organize services into a team approach where all the mental health professionals would coordinate their expertise and services with each other in order to establish a coherent mental health plan for the patient (Lauriello and Pallanti, 2011). Community treatment is more effective than cognitive behavioural therapy because it is less confrontational to the patient and it also contributes to the socialization process of the patient. It is also more efficient because it is an organized treatment; and it incorporates treatment and rehabilitation interventions (Li, et.al., 2010). It is a useful tool because it is a treatment which helps reduce incidents of institutionalization of mental health patients. It therefore ultimately improves the quality of the patient’s life, and also allows the patient to live a more holistic and well-rounded existence (Shean, 2004). The community-based treatment is also meant to meet the diverse needs of the patient and also to ensure his social adjustment (Rubin, et.al., 2011). It also helps strengthen the patient’s link with her community, allowing her to reconnect with her old friends and colleagues who may want also to socialize with her. By establishing a more community-based treatment, a greater support system is also established for the patient through her friends and family members. Her social network also becomes more stable and supportive through community based treatment (Swanson, et.al., 2004). The study Chan, et.al., (2003) sought to compare the quality of life of patients with schizophrenia under hospital, long-stay care home, and half-way house care and to establish the various factors impacting on the well-being of patients. Their study was able to cover about 204 subjects in these treatment settings and evaluated in terms of the WHO Quality of Life Measure and the Global Assessment Scale. The study was able to establish significant differences in the quality of life of the subjects staying in the three different settings. Results were mostly in favour of the community setting in terms of better quality of life. The authors were also able to emphasize the importance of negative life events which saw a significant decrease over time (Chan, et.al., 2003). In general, the authors established that over time, community-based treatments for schizophrenia had a positive impact on the quality of life of the patients. Negative life events did not improve with the treatment however, they showed significant improvements after proper adjustments in treatment were made. 4. CONCLUSION My client was discharged from the mental health unit after two months of treatment. Her medication compliance was significantly improved and she was doing well in the group sessions. Her hallucinations were reduced and her agitation was as good as eliminated. She was also more focused and less paranoid. Her delusions of grandeur were also eliminated and she was more in touch with the reality of her life. The plan for her discharge was carried out by coordinating with the family members and the mental health practitioners in her community. Future appointments for group sessions were also planned and scheduled with the patient. The local mental health practitioner was contacted by the psychiatrist, referring the patient and explaining the details of the mental health plan. A future meeting with the local mental health professionals was also planned and scheduled with the patient and her family. After caring for this patient, I learned that there are various treatments which can work well for some patients, but not well for others. It is important therefore to establish a patient-centred approach to mental health care. I also learned that psychoeducation is a crucial addition to the practice and that it can help improve patient compliance with medications. Once patient compliance is achieved, the rest of the patient’s treatment can be carried out smoothly. It is therefore important for the mental health professionals to be knowledgeable about their patient’s condition in order to relay the correct information to the patient and ease his anxiety. Finally, I learned that family and community support is an important aspect of patient care. It can improve the patient’s motivation to get better, as well as make the patient feel more comfortable in his home setting. The patient’s family would also understand the patient’s condition better and be more engaged in contributing to the patient’s well-being and recovery. References Aronson, J. (2008), Meyler's Side Effects of Psychiatric Drugs, London: Elsevier. Battaglia, J. (2011), Compliance With Treatment in Schizophrenia, Medscape [online]. Available at: http://www.medscape.org/viewarticle/418612 [accessed 02 March, 2012]. Bauml, J., Frobose, T., Kraemer, S., Rentrop, M., & Pitschel-Walz, G. (2006), Psychoeducation: A Basic Psychotherapeutic Intervention for Patients With Schizophrenia and Their Families, Schizophr Bull., vol. 32(Suppl 1). Blashki, G., Keks, N., Stocky, A., & Hocking, B. (2004), Managing schizophrenia in general practice, Australian Family Physician, vol. 33(4): 221-226 Brown University (2012), Schizophrenia [online]. Available at: http://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/Schizophrenia.pdf [accessed 01 March 2012]. Buckley, L. & Pettit, T. (2007), Supportive Therapy for Schizophrenia, Schizophr Bull., vol. 33(4): 859–860. Chan, G., Ungvari, G., Shek, D., & Dagger, L. (2003), Hospital and community-based care for patients with chronic schizophrenia in Hong Kong--quality of life and its correlates, Soc Psychiatry Psychiatr Epidemiol., vol. 38(4):196-203. Castelein, S., Mulder, P., & Bruggeman, R. (2008), Guided Peer Support Groups for Schizophrenia: A Nursing Intervention, Psychiatric Services, vol. 59(3):326. Department of Health (2005), The NHS Improvement Plan: Putting people at the heart of public services [online]. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084476 [accessed 01 March 2012]. Gabbard, G., Beck, J. & Holmes, J. (2007), Oxford Textbook of Psychotherapy, London: Oxford University Press. Gaudiano BA (2005), Cognitive behavior therapies for psychotic disorders: current empirical status and future directions, Clin Psychol, 12:33–50 Griffith, L. (2007), Brief Supportive Psychotherapy for a Patient with Chronic Schizophrenia [online]. Available at: http://www.innovationscns.com/brief-supportive-psychotherapy-for-a-patient-with-chronic-schizophrenia/ [accessed 01 March 2012]. Hansen, L., Kingdon, D., Turkington, D. (2006), The ABCs of Cognitive-Behavioral Therapy for Schizophrenia, Psychiatric Times [online]. Available at: http://www.psychiatrictimes.com/schizophrenia/content/article/10168/51321?pageNumber=2 [accessed 01 March 2012]. Kane, J. (2006), Clozapine in Schizophrenia, Medscape Education, vol. 11(2) Kinter, E., Schmeding, A., Rudolph, I., dosReis, S. & Bridges, J. (2009), Identifying patient-relevant endpoints among individuals with schizophrenia: an application of patient-centered health technology assessment, Int J Technol Assess Health Care, vol. 25(1):35-41. Kopelowicz A, Zarate R, Gonzalez Smith V, Mintz J, Liberman RP (2003), Disease management in Latinos with schizophrenia: a family assisted, skills training approach, Schizophrenia Bulletin, 29 (2):211–27. Li, H., Pearrow, M., Jimerson, S. (2010), Identifying, Assessing, and Treating Early Onset Schizophrenia at School, London: Springer. Lauriello, J. & Pallanti, S. (2011), Clinical Manual for Treatment of Schizophrenia, New York: American Psychiatric Pub. London Health Observatory (2012), Long Term Conditions [online]. Available at: http://www.lho.org.uk/LHO_Topics/Health_Topics/Diseases/LongTermConditions.aspx#1 [accessed 01 March 2012]. Medscape (2006), Clozapine in Schizophrenia [online]. Available at: http://www.medscape.org/viewarticle/547174 [accessed 01 March 2012]. National Institute of Mental Health (2012), What medications are used to treat schizophrenia? [online]. Available at: http://www.nimh.nih.gov/health/publications/mental-health-medications/what-medications-are-used-to-treat-schizophrenia.shtml [accessed 01 March 2012]. O’Donnell C, Donohoe G, Sharkey L, Owens N, Migone M, Harries R, Kinsella A, Larkin C, O’Callaghan , E. (2003), Compliance therapy: a randomised controlled trial in schizophrenia. BMJ, 327:834 Pharoah, F., Mari, J., & Rathbone, J. (2010), Family intervention for schizophrenia (Review), Cochrane Collaboration [online]. Available at: http://www.eiyh.org.uk/silo/files/family-intervention-for-schizophrenia.pdf [accessed 01 March 2012]. Razali SM, Hasanah CI, Khan A, Subramaniam M (2006), Psychosocial interventions for schizophrenia, J Ment Health, vol. 9:283-289 Rubin, A., Springer, D., & Trawver, K. (2011), Psychosocial Treatment of Schizophrenia, London: John Wiley & Sons. Shean, G. (2004), Understanding and treating schizophrenia: contemporary research, theory, and practice, London: Routledge. Swanson, J., Swartz, M., & Elbogen, E. (2004), Effectiveness of Atypical Antipsychotic Medications in Reducing Violent Behavior Among Persons With Schizophrenia in Community-Based Treatment, Schizophrenia Bulletin, vol. 30(l):3-20. Turkington, D., Kingdon, D., & Weiden, P. (2006), Cognitive Behavior Therapy for Schizophrenia, Am J Psychiatry, vol. 163:365-373 Wen-Yi Su, Jen-Hao Yeh, Ying-Chin Hung, Pei-Lin Huang, & Wen-Chung Shao (2011), The Nursing Experience of Assisting a Patient with Chronic Schizophrenia in Vocational Rehabilitation, Tzu Chi Nursing Journal, vol. 10(1): 120-128 Valenstein, M., Blow, F., Copeland, L., McCarthy, J., Zeber, J., QMon, L., et.al., (2004), Poor Antipsychotic Adherence Among Patients With Schizophrenia: Medication and Patient Factors, Schizophrenia Bulletin, vol. 30(2):255-264. Read More