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Clinical Case

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by

Faye Martin

on 22 May 2014

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Transcript of Clinical Case

A Clinical Case :
Tom // Male // Age: 44

Maslow's Hierarchy
Clinical Information
Mental Status Examination
Bio-Psycho-Social
5 P’s: Presenting, Predisposing, Precipitating, Perpetuating and Protective factors
Multi-Axial Assessment
Severity of Psycho-social Stressors Scale: Adults
Suicide Risk

The Therapeutic Relationship
Tom's Story
Reflective listening
Empathy
Acknowledging individuality
Support for self-help
Reflecting genuine concern
Care consistency
Cultural Safety
The first step.
Provide accessibility
Nursing Interventions
Recovery Model underpins interventions (Happel et al., 2013)

Primary intervention for both issues - establish a therapeutic relationship (Happel et al., 2013)
Mental Status Examination
Consider Tom’s:
Living arrangements
Geographical isolation
Unemployment
Social interaction

Overcome geographical isolation
Connections & social networking
Phone, e-mail, Skype
Teleweb & Mindspot
Mission Australia
Community services
Faye Martin
Jennifer Esteves
Ellena McIntosh
Irina Ovsyankina
Taylor Corey

Synthesise
Referred by his GP to Mental Health Services following his dismissal from work
Complains of low mood and problems with stressors
Found stealing money from the accounts
Tom lives with his mother and father in the country
Has thoughts of running off the road
Forgetting things and being unable to make simple decisions
His mood appears quite low with evidence of self-blame, mental confusion and slowing
Feels very guilty that he is a burden on his parents
Unhappy living with his parents and would like to move out urgently

Appearance & behaviour

Appearance
Motor behaviour
Attitude to situation and interviewer
Speech form
Rate
Volume
Quantity of information
Speech content
Disturbance of meaning
Disturbance of language
Mood and Affect
Mood
Affect
Congruency

Form of Thought
Excess, absence, quality of thought
Continuity of ideas
Content of Thought
Delusions
Suicidal thoughts
Other
Perception
Hallucinations
Illusions
Depersonalisation/derealisation
 
Sensorium and Cognition

Level of consciousness
Memory
Orientation
Abstract thinking
Insight & Judgement
Extent of individual’s awareness of the problem
Can they make rational decisions
Risk Assessment
Potential for harm to self? – YES, although minimal
Although reports suicidal thoughts has never acted upon them, when questioned about this he appears to have no intention of acting on these thoughts and reports it is only to help him relax.

Priority issue 1 - Safety - Mental Health
Nursing Intervention - Education on counselling and/or psychotherapy

Counselling/psycotherapy effective treatment for depressive symptoms (Hall, 2013; Blair, 2012; Happell et al., 2013)

Counselling may be suitable for Tom due to short-term goal and crisis management (Happell et al., 2013)

Mental Health Plan available (Australian Government Department of Health, 2013)


Short-term goal - few days to 1 week

Tom can see GP for referral or approach practitioner directly if appropriate, set and keep appointment

Evaluation - appointment made and kept by Tom, self-reported improvement in mood and suicidal ideation
Priority issue 2 - Social needs
Nursing intervention - Connect Tom with housing resources to alter living situation

Living situation self-identified problem for Tom

Physically isolated, contributing to social isolation, problems with father, feelings of embarrassment

Lifestyle and environmental factors can contribute to depressive symptoms (Sarris et al., 2014)
Medium-term goal - several weeks

Educate on resources available - e.g. Housing Support (Australian Government Department of Social Services, 2013)

Tom can liase with resources to set expectations and begin organising move

Evaluation - appointments made and kept, housing changes planned or actioned, Tom's feelings towards living situation improved


Recovery Model
Hope
- counselling to work towards recovery
- living situation can change

Personal Responsibility
- appointments made and kept by Tom
- active role in counselling and arranging housing

Connectedness
- focus on mental health and recovery in counselling
- physically closer to social group, community, employment opportunities

Discovery
- support provided to rediscover mental health
- Tom capable of achieving own goals

Active Sense of Self
- actively contributing to counselling
- empowered to make decisions about own living situation
(Happell et al., 2013)
MSE + Clinical Formulation

Multi-Axial Assessment
Axis 1: Anxiety and Depression
Axis 4: Housing and financial problems, unemployment and problems with family/primary support group relationships

Severity of Psycho-social Stressors Scale: Adults
2 Mild – Family arguments
3 Moderate – Serious financial problems; trouble with boss
4 Severe – Unemployment

Suicide Risk
Low risk – Fleeting/ brief thoughts of either suicide or harming others, no current ideation, plan or intention.

Priority problems
  Living conditions.  
Relationship with parents/father
Employment 
Loss of social group 
Stress
  Suicidal ideation 
  Cognitive problems
  Depressive symptoms 

Safety – Mental health


Social – Withdrawal from family and friends

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Full transcript