Question

Rachael Tomkins is 55 years old and is a certified practising accountant. She works part time and lives with her husband Paul, aged 64 and daughter Marie, aged 17. Her grandmother Jean aged 90, lives in a small flat at the back of their house and her mother Mary, aged 72 lives in an Over 55s housing unit nearby. In her early 20s Rachael’s father, a Vietnam Veteran, committed suicide. Rachael is described by her family as reliable and caring. She has a small group of friends from her local parish church. Rachael has regular contact with her GP to manage her Diabetes Type 2. She is prescribed metformin and has been trying to lose weight. She also sees a psychiatrist Dr Lianne Yu for management of her symptoms of schizophrenia. She is prescribed Olanzapine and Lithium. She was diagnosed with schizophrenia in her early 20’s when she was studying at university. She was hospitalised with acute psychosis several times before her symptoms were stabilised. She was able to complete her university degree and has worked part time. The last time she experienced acute psychosis was 17 years ago, just after the birth of her daughter. Her symptoms stabilised, and she has been maintained in recovery for almost 15 years. This year has been a particularly challenging year for Rachael. Both her husband’s parents passed away within months of each other, her daughter commenced Year 12 and her grandmother had an infection in her middle toe, which resulted in a series of trips to the doctor, hospitalisation and finally amputation of the affected toe. Rachael has become irritable with her family, and has developed erratic sleeping patterns, a lack of interest in grooming, and avoided social interactions with her friends or family. She complained to them that her neighbours were spying on her. In the 48 hours before she was admitted to hospital two incidents escalated Rachael’s need for professional help. In the first episode she yelled and threatened the neighbour across the fence. She accused him of spying on her with a ‘trackamanometer’. Her husband intervened and took her back into the house. In the second incident later that day, Rachael started screaming at her family to evacuate the house because they would be bombed. Rachael insisted the news reader on the TV was giving her this important information and they must all get out of the house. Rachael ran onto the road. A concerned neighbour called the police, who were able to convince her to accompany them to the hospital. She was met by her psychiatrist Dr Yu who reports the following -Rachael is dishevelled, dressed in pyjama top and tract pants, no shoes, she has an exacerbation of auditory hallucinations, with persecutory delusions and disorganised thinking. Rachael agrees to be admitted because she says ‘I’m frightened’. Rachael is admitted for inpatient psychiatric care.
In hospital, Rachael is argumentative and resistive to staff interactions and interventions, and her family are frightened and bewildered by her dramatic deterioration.

1. Identify, from the case study, the positive, negative and cognitive symptoms of schizophrenia experienced by Rachael at this presentation to the mental health service and discuss her prognosis and recovery;
2. Considering the case study, outline some common challenges and nursing interventionsassociated with the clinical presentation of a person who has been diagnosed with schizophrenia;
3. Identify the two psychotropic medicationsprescribed for the treatment of the symptoms of schizophrenia experienced by Rachael, and consider the importance of effective monitoring, consumer experiences (side effects) and safety factors;
4. Draw an ecomap to make a pictorial display of Rachael’s family relationships and medical history; Summarise key features of the ecogram for Rachael and her family and their environment (identify family and community connections, strength and quality (supportive/not supportive) of connections between individuals and community support networks/institutions( Refer to the required text Chapter 22 for more information about Genograms and Ecograms).;
5. Develop three questionsyou would ask Rachael during an interview to complete an MSE. They could be from any MSE area. Explain the reasonyou would ask these questions.
6. Complete a risk assessment(template in this tutorial outline);
7. Rachael will be admitted to the mental health inpatient unit. Write a nursing care planbased on a nursing diagnosis.

Answer 1

Identify, from the case study, the positive, negative and cognitive symptoms of schizophrenia experienced by Rachael at this presentation to the mental health service and discuss her prognosis and recovery.

• Positive symptoms: auditory hallucination, paranoia, illusion
• Negative symptoms: lack of interest in grooming, avoided social interactions with her friends or family
• Her episodes of exacerbated schizophrenia can be clear from a typical prognosis on her past medical history, past medication history, and currently presenting symptoms.
• Complete recovery from schizophrenia is not possible. But the patient can have relief from the manifestations for long, as the patient in this study developed no symptoms for over 15 years and now it is triggered due to many emotional insecurities and problems in her life that happened so frequently one after another.

Outline some common challenges and nursing interventions associated with the clinical presentation of a person who has been diagnosed with schizophrenia.

• Resistance and refusal of the patient
• Difficulty in ensuring the administration of the drug
• Difficulty in managing the diet and daily routines of the patient
• Non-responders to the medication and therapy
• Nurses can be even threatened and injured by some patients

Identify the two psychotropic medications prescribed for the treatment of the symptoms of schizophrenia experienced by Rachael, and consider the importance of effective monitoring, consumer experiences (side effects) and safety factors

• Olanzaoine and Lithium were the two psychotropic medications prescribed for Racheal.
• Olanzapine has side effects like GI effects, breathing problems, dizziness, sedation etc. Any hypersensitivity should be ruled out initially.
• Lithium should not be given with Olanzapine, as both are known to have serious drug-drug interaction that causes fatal serotonin syndrome and increase the chance for neuroleptic malignant syndrome

Develop three questionsyou would ask Rachael during an interview to complete an MSE. They could be from any MSE area. Explain the reasonyou would ask these questions.

1. What is the threat you feel now? Please describe it.
2. What do you do to keep yourself happy?
3. Who are your favourite persons and what is your comfort zone?

These questions can altogether assess her emotional imbalance, paranoir, hallucinations, alertness, speech, behavior, triggers for current exacerbation, thought process, thought content, memory and reasoning.

Four questions are answered as per guidelines. Please do not hesitate to give thumbs up. All the best. Stay safe. All the best. Happy learning