Managing Complex Care in Deteriorating Situations
The nursing handover is an essential part of patient care and is also a legal requirement. Merten, Galen & Wagner (2017) have defined a handover as the transfer of professional duty and accountability for the care of a patient or groups of patients, to another person for example a clinician or nurse or group of professionals for a period that can either be permanent or temporary. The Situation Background Assessment Recommendation (SBAR) communication tool is now widely used to deliver effective handovers. Introduced to reduce adverse events in healthcare, the SBAR handover has been proven to enhance the quality of patient care (Muller et al., 2018). It has been suggested that the SBAR tool is an accessible way of framing conversations, most importantly the ones requiring immediate attention and response from the trained clinician (1000 lives plus Wales, 2012). Other studies have also shown that SBAR is an effective mechanism in handing over patient information (Beckett and Kipnis, 2009). Additionally, the SBAR enhances communication, teamwork and foster a culture of safer patient care (1000 lives plus Wales, 2012). Although widely used within healthcare, there have been suggestion that further studies in training need to be conducted to ensure that the tool is being used correctly (Beckett and Kipnis, 2009). This case study will use the SBAR format to discuss the care and treatment of an acutely unwell patient in an acute mental health setting. All names and places have been altered to comply with Nursing and Midwifery Council (NMC) standards which state that patient confidentiality must be maintained at all times (NMC code of conduct domain 1, 2018).
A 22-year-old was admitted on the Psychiatric Intensive Care Unit (PICU) on 1st November 2018 following an episode at home. She has been aggressive and verbally abusive to staff and patients. has also assaulted staff and patients. It has been reported that the patient is sexually inappropriate towards both staff and patients. The present concerns are that she may have taken illicit drugs prior to admission. She was brought in by police under Section 136 of the Mental Health Act (MHA) 1983. Under S. 136 police have the power to remove a person from a public place, when they appear to be suffering from a mental disorder, to a place of safety. The person will be considered by police to be in immediate need of care and control as their behavior is of concern. This gives the police the power to facilitate assessment of their health and wellbeing as well as the safety of other people around them. Nicki’s boyfriend rang the police to say that she had assaulted him and that he feared her. When police attended the address where she lives with her boyfriend she became angry and agitated and assaulted one of the police officers. She was placed under s.3 of the MHA (1983) for treatment. This states that, detention of the service user for treatment in the hospital is permitted based on certain criteria and conditions. These are that the person has a disorder of the mind and that the disorder can only be treated in the hospital and also that there is risk to their health, safety of the patient or risk to others (Section 3. Mental Health Act 1983 (reviewed in 2007). From the current observations, the patient appears to show psychotic symptoms.
Nicki is 22 years old. She has an older sister and lives with her boyfriend. She is close to her mother and visits her weekly. She had a normal childhood and enjoyed school. Her parents have been supportive throughout her life. She finished school with 11 GCSEs and then went to college to study a music and drama course but dropped out because she did not enjoy going to college. She has previously worked as sales assistant and is currently unemployed. She remembers being admitted on section at the age of 20 as she had become ‘very high’. The admission lasted for a period of 4 months and was discharged to the community mental health team. It was also recorded that before the last admission she had taken an overdose of paracetamol. Two weeks before the current presentation, her mother had contacted the community mental health team and expressed concerns that Nicki had stopped taking her medication, was drinking more alcohol and sleeping less. Her concern was that she was verbally and physically aggressive towards her boyfriend and that she needed to be seen by a member of the team. Currently she is prescribed 10 mg Olanzapine once a day and has PRN Lorazepam 2mg which takes at bed time. She has a diagnosis of bipolar I disorder, which means that has had at least one manic episode lasting more than one week in the past (Diagnostic and Statistical Manual of Mental Disorders 5, 2013).
Wrycraft (2015) has defined assessment as the focused gathering of information to gain a comprehensive understanding of an individual’s mental, physical and psychological health. Nicki’s has a diagnosis of bipolar I disorder. This is characterized by several recurrences of mood episodes (Diagnostic and Statistical Manual of Mental Disorders, 2013). My assessment is that she is presenting with mania and this has been exacerbated by drinking and taking illicit substances. A Midstream sample of urine (MSU) was taken and the results showed presence of amphetamines and cannabis. According to research, there is a direct link between substance misuse and psychosis in patients with bipolar (Stokes et al., 2017).
She appears to be in good physical health with no underlying medical conditions. Observations taken using the National Early Warning Score guide and recorded as follows: Respiratory rate = 17, Oxygen saturation rate = 99%, Temperature = 36.0, Blood pressure = 120/80, Heart rate = 91, She was alert during the assessment and has no pain. A NEW Score of 1 was recorded which meant that the observations should be repeated every 12 hours (“National Early Warning Score (NEWS) 2”, 2017). Nicki smokes cigarettes and admits to using illicit drugs. She has been given advice about stopping smoking but said she smokes due to boredom.
Eating and drinking
Nick is appeared slightly underweight. She reports that she would like to eat more healthily as she eats a lot of junk food. She would like to exercise more when she gets the motivation.
She appeared unkempt and was wearing several layers of clothing although it was not very cold. She tends to neglect her personal care when she is unwell but wash when prompted by staff.
She does not sleep for long and manages on 3 or 4 hours of sleep at night. She has naps throughout the day. She has tried relaxation before sleep but felt anxious and had to stop.
Nicki was uncharacteristically loud in her tone of voice and flirted with nurses and the psychiatrist. She expressed grandiose beliefs of being a Dr. of music. She stated that she had stopped taking her medication because she was feeling better. When asked whether she would be willing to restart her medication she said that did not like taking medication because it made her tired. She showed lack of insight into her condition which is a sign that she is a risk to herself and others. This psychosis has also caused violent and aggressive behavior (Royal College of Psychiatrists, 2015). On the ward, she has been going into other patient’s bedrooms and removing personal belongings. When she is told to stay out other patient’s bedrooms becomes violent towards both staff and patients. She also believes that she is relationships with various patients. McCandless and Sladen (2003) have suggested that during mania patients may become sexually disinhibited. Due to the risk to herself and others, a risk assessment was completed following which she was placed on Level 3 observation on a one to one basis and always within eye sight. This is according to the local health board policy (Safe and Supportive Observation and Engagement of Patients at Risk policy and guidance, 2016). A behaviour chart is in place for staff to keep a record and will be used for reviewing the observation at a later stage. Observation is being managed using female staff due to the patient’s sexually inappropriate behavior. During violent and aggressive incidents, staff have managed to remove her to the bedroom and on other occasions she has been put into seclusion to help her calm down. She is also a risk of self-harm and sexual exploitation. Staff have also noted an improvement since admission because she is now able to follow instructions. However, continues to be disruptive particularly at night because she is only sleeping for 3 hours on most nights. This is being managed using as and when (PRN) diazepam to help her sleep at night.
I recommend completing a comprehensive care and treatment plan that will focus on managing the current presentation and for the long-term when she is discharged. It is important to ensure that she is involved in the care planning process. She should continue to be observed on a one to one with female staff until there is an improvement in her current presentation. There is needs for a review of her current medication with a view to increasing the Olanzapine from 10mg to possibly15mg to stabilize her mood. She disclosed not wanting to take the medication because it made her feel tired, so also consider changing the medication to Lithium for long-term use. According to evidence, Lithium is more effective for treating Mania in bipolar (Geddes & Miklowitz, 2013). It has also been suggested that Lithium is more effective for long-term relapse prevention (Geddes & Miklowitz, 2013). Although Lithium has many reported benefits, adverse effects and low therapeutic index have countered these (Shine et al., 2015). Therefore, regular blood tests need to be done to ensure that she is taking the right dose. It has been suggested that another suitable choice for long-term management of bipolar disorder can be quetiapine (Miura et al., 2014). Encourage her to engagement with staff because this will promote a therapeutic relationship. Also encourage physical activity such as use of the gym as this offers a more productive way of using energy. Work with occupational therapist to regain access to hobbies like playing the piano.
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For long-term treatment it is important to prevent relapse. There is evidence to show that there is a very high instance of relapse in bipolar illness (Rodgers et al., 2012). There are a few ways to prevent relapse and one is by educating the service user to identify relapse indicators such increase in stress levels, non-concordance with medication or sleeplessness. Encourage family involvement in her care and treatment. I would also recommend psychological intervention in the form of cognitive behaviour therapy (NICE, 2014). This has been shown to improve outcomes for patients (Jones et al., 2015). Additionally, psychoeducation will help her to learn about bipolar. Psychoeducation has proved to be as effective in the long-term. After a five-year study in group psychoeducation, the results showed that there was a significant reduction in the illness and recurrence rates (Colom et al., 2019).
This case study has discussed the care and treatment of an acutely unwell patient on a ward setting. This has been demonstrated using the SBAR communication tool. It has been shown that mental health nursing assessment is an ongoing process that requires several skills such as interviewing, observation and the ability to engage with the patient. The case study has demonstrated that to manage a psychotic patient, there needs to be a comprehensive risk assessment to ensure the safety of everyone on the ward. It has also been discussed that medication is an effective way of managing mania in bipolar. However, the side effects of can have cause the patient stop taking medication. Hence, there several psychological interventions such as CBT that can be used alongside medication to manage the illness in the long-term. These recommendations are based on evidence and current nursing literature.
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- Stokes, P. R., Kalk, N. J., & Young, A. H. (2017). Bipolar disorder and addictions: the elephant in the room. The British Journal of Psychiatry, 211(3), 132-134.
- The Joint Commission. Sentinel event data: root causes by event type 2004–2014. 2014 http://www.tsigconsulting.com/tolcam/wpcontent/uploads/2015/04/TJC-Sentinel-Event-Root_Causes_by_ Event_Type_2004-2014.pdf (accessed 01 December 2018).
- Wrycraft, N. (2015). Assessment and Care Planning in Mental Health Nursing. Open University Press.
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