CASE STUDY: Emily
CASE STUDY: Emily
• For this case scenario use your knowledge of Mental Health Care and Promotion and, explain in detail how you would use this knowledge to develop a care plan.
• Use the clinical reasoning cycle and nursing process as the framework of your assignment.
Emily is a 19-year-old female, brought into the Emergency Department at 1700 by her parents. Emily lives with her family; mother Ruth, father Robert and Emily has a younger brother Harry who is 15 and has mild autism.
Emily’s parents report that Emily had called her boyfriend Daniel from University at 1400 after she had received a fail grading from a subject she had been struggling with. Emily had stated to Daniel that she wanted to kill herself and was speaking in an upset manner and crying. After getting Emily to go to the Library to wait for someone to come to her, Daniel phoned Emily’s parents and as he was at work, asked them to assist Emily to get home.
Once home, Emily continued to voice negative thoughts. Concerned about the suicidal content of Emily’s thoughts, her parents persuaded her to come to the hospital for an assessment.
You are working with the Triage Nurse today. When the nurse examines Emily, it is noted that Emily speaks in a distressed manner, has difficulty completing sentences and is speaking derogatorily about herself. When asked by the Triage Nurse, Emily denies having taken any medications or substances that would be of cause for concern regarding an overdose.
When asked if she can vouch for her safety, Emily states that she would only be safe is she was not left alone. The Triage Nurse informs Emily that a Psychiatric Consult will be immediately arranged and Emily has agreed to comply with an admission should the Team determine it necessary.
Issues arising from the case:
• Initial Triage Assessment
• Psychological Assessment by the Consultation-Liaison Team
• Social Determinants of Health
• Mental Health Act compliance
• Preparing a person for admission to an inpatient unit.
? Critically discuss the framework for mental health promotion
? Critically discuss the importance of risk prevention and reduction
? Critically discuss the Recovery Model of Care and it’s application in an acute health care setting
? Evidence based health care to person’s affected by Mental Illness
? Compare and contrast a range of potential interventions that can be delivered by the Multi-disciplinary Team
? Discuss legal and ethical considerations of the acutely unwell adult experiencing a mental health problem or mental illness
? Discuss interventions including pharmacological and psychological that would meet the needs of the acutely unwell person, their family/carers and the community.
Sa02: 98% RA
ECG: Sinus Rhythm
19 year old female self presented to Health Care Emergency Department in company of mother and father. Parents received a phone call from her boyfriend Daniel this afternoon asking them to collect Emily from the University library. Parents report that Emily had called Daniel in a distressed state saying that she wanted to kill herself. When Emily was collected from the University, she continued to voice thoughts of wanting to die and it is this that prompted her parents to bring her to the E.D.
Emily agreed to speak to a member of the Psychiatry Consultation-Liaison Team but asked for her parents not to be present during interview. Emily has agreed that they can be informed of the outcome of her interview and involved in any future care prescribed.
On commencement of the interview, patient immediately stated that she had taken an overdose of 9 paracetamol tablets and 5 ibuprofen at 1600 today. Patient stated that she has been considering the overdose for the past week and states that she made the decision to take the overdose today if her end of semester results were not “good”. She states that she purchased the medications from Woolworths yesterday and took today them after her parents brought her home from Uni. When asked why she had taken the overdose, she stated she had to take the overdose not to check out but to make others know how she is feeling. Patient did not tell family of overdose, and regrets doing so now. States she will not take another overdose for some time to come as she feels very embarrassed.
• States fed up feeling low, anxious and under pressure
• States her friends pressured her to go on an overseas trip with them to Bali in the New Year and that she needs to make a decision if she can continue with the plan to go.
• Does not have enough leave from her place of work and will not have enough money to spend like her friends will.
• Currently wanting to do a gap year in 2018 but is not sure what she will do when on this time out.
• Unsure if she wants to continue her studies and does not know what course she would undertake instead.
• Feels being home not doing anything is making her parents displeased with her.
• Has little money as her work is only part-time 12 hours a week.
• States has been using “Headspace” in the past to help, but was told that she is more complicated than what Headspace could provide.
• Has seen a psychologist in the past but parents insurance no longer covers this.
Mood: Currently states feels numb, states in the evening when she is alone in her room she thinks too much, states mood always low.
Sleep: Goes to bed around 12mn-1am and uses phone until she falls asleep. States she knows that screen usage can mess up her sleep patterns, but doesn’t want to get offline and disconnect from her friends. States sleeps through the night most times of about 7-8 hours, waking by 10am unless she needs to go to work.
Appetite: States not hungry
2kg weight loss past 1 month – states not sad about losing weight.
Purging past 1 month to lose weight and this has increased in frequency this past week in lead up to University results.
Goal weight of 49kg.
No prior history of eating disorder
Current weight 55.4kg, Height 165cm BMI 20.3kg/m2
Energy: Low. States prefers to do nothing
Motivation: States can never decide what to do and feels more comfortable doing nothing.
Interests: Works as a receptionist at an animal shelter part time and enjoys it.
Worthiness/Hopelessness: Feels mood gets worse when she looks to the future.
Concentration: Oriented to time, person, place. Intact.
Anxiety/Agitation: Feels like she wants to run away
Shortness of breath/tight chest on and off
Gets overwhelmed by most things, especially when she needs to do well. States this is self enforced.
Suicidal Ideation: 2 years ago started cutting. Lasted approx. 1 year.
Cut total of 10 times
Bruised self x1 time
Burnt self x1 time
Overdose ibuprofen 1 month ago during exams, no treatment, told mother a week after event.
Denies any current thoughts of self harm or plans to self harm
States now she has taken overdose does not feel need to take further overdoses and will not need to do so for some time.
Protective Factors: Mother and Boyfriend and x2 female friends from school years.
Thought to take overdose 1 week ago, and decided yesterday to take it
States overdose was not to kill herself but to show others how she feels about her life stresses at present.
Nil auditory or visual hallucinations.
Nil ideas of reference
Nil thought disorder
PAST MEDICAL HISTORY
Broken R) wrist when 12yo
Nil pregnancy in past
Nil contraception in use
Nil history of intercourse.
FAMILY HISTORY OF SIGNIFICANCE
DRUGS & ALCOHOL
Illicit Drugs- Nil
Prescription misuse- Nil
Completed year 12 ATAR 86.85
End of 1st year Uni: GPA 92.8
Lives with parents in family home of 30 years
Has a younger brother 15 yo with mild autism
Friends (both from high school)
Boyfriend Daniel (dating since year 10)
Headspace (10 sessions/year, currently completed 6/10, next apt 12/11/17
o Emotional Deregulation
o Purging and vomiting past 1 month goal to lose weight
• Physical completed
• ECG – Done
• Bloods for FBC, UEC’s, LFT, TFT, Paracetamol CMP @ 1915hrs
• Psychology numbers provided
• DBT preferred method psychology
• Appt with Headspace
• GP provide reference for Psychology
• CATT number
• DIeticican at University phone number provided
• Message left with eating disorders clinic to follow up with GP.
Can be discharged after passing Urine and clear blood results
Nil admission warranted unless medically indicated, however can be admitted to short stay unit until blood results and urine output confirmed.