Case Scenarios:

John Keen’s Journey with Schizophrenia and Supportive Care

Background:

John Keen is a 36-year-old man who identifies as Indigenous and was diagnosed with Schizophrenia at the age of 18. His early adulthood was marked by a two-year period of hospital admissions due to psychotic features.

During this time, he experienced increasing fear and suspicion without a clear reason, leading to the belief that his neighbors were watching and reporting him to ASIO (Australian Security Intelligence Organisation). These delusions caused significant distress and confusion for John, affecting his ability to function in daily life.

Challenges with Work and Employment:

Despite the challenges posed by his condition, John managed to complete his carpentry apprenticeship. However, his struggles with consistent attendance at work led him to change employers to finish his qualifications.

As a contract carpenter, he requires additional support, such as help with bookkeeping and reminders of work-related dates and times, to manage his condition effectively.

Treatment and Side Effects:

John is currently treated with Haloperidol (Haldol Decanoate) IMI depot medication, administered every 4 weeks. While this treatment helps manage his symptoms, it comes with side effects, including increased sedation and mild oculogyric crisis (OGC) in the days following his monthly dose.

To address these side effects, John takes Cogentin orally during those 5 days. However, this raises concerns about his ability to drive and work, leading to occasional work absences during that period.

Impact of Stress:

Times of increased stress, such as the passing of his close uncle from a terminal illness last year, exacerbate John's symptoms. During this period, he experiences heightened feelings of fear and anxiety concerning his neighbors, which can last for several months before subsiding.

Supportive Care:

John benefits from the dedicated support of a Community Mental Health Nurse provided by his local Mental Health Service. The nurse maintains a positive professional relationship with John's family and works closely with him to ensure he stays connected to his support system, including family, friends, and community peers. The nurse's assistance is crucial in helping John manage his condition effectively.

Section 1

Question 1

1.Which category of mental illness does the patient’s diagnosis belong to?

John Keen's diagnosis of schizophrenia categorises him within the category of psychotic disorders.

Question 2

2).What co-morbidities would you typically associate with this kind of mental illness?

As with John Keen, many people with schizophrenia often have other co-morbidities, which further muddies the clinical picture. Depression is a frequent condition that is characterised by enduring melancholy or hopelessness. Anxiety disorders can sometimes coexist, exacerbating the person's misery. These illnesses include panic disorder and generalised anxiety disorder.

Substance use disorders are common, and people may turn to drugs or alcohol to treat their symptoms or self-medicate. Moreover, metabolic abnormalities can result in obesity, diabetes, and cardiovascular illnesses. These disorders are frequently made worse by antipsychotic medicines.

Cognitive deficits, although intrinsic to schizophrenia, can sometimes overlap with features of neurocognitive disorders. It is imperative for clinicians to be vigilant in identifying and addressing these co-morbidities to offer comprehensive care.

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Section 2

Question 1

1) Explain what is believed to be the cause of your patient’s mental health diagnosis ?

Schizophrenia, the diagnosis ascribed to John Keen, is a multifaceted disorder whose exact aetiology remains a subject of considerable research and debate. It is widely believed to arise from a confluence of genetic, neurobiological, and environmental factors.

Genetically, individuals with a family history of schizophrenia are at an elevated risk, suggesting a hereditary component.

Neurobiologically, imbalances in neurotransmitters, especially dopamine, and structural abnormalities in the brain have been implicated. Environmental triggers, such as prenatal exposure to infections, complications during birth, psychosocial stresses, or substance abuse in adolescence, might also play significant roles in precipitating the disorder.

While no singular cause can be pinpointed for John's condition, it is likely that a complex interplay of these factors has contributed to the manifestation of his schizophrenia.

Question 2

2) Explain the physical complications that are frequently associated with your patient’s diagnosis and how you would assist him/her to maintain their physical health.

Schizophrenia, as diagnosed in John Keen, often presents with several physical complications. Antipsychotic medications, like Haloperidol, can lead to metabolic syndromes, encompassing weight gain, diabetes, and cardiovascular issues. Additionally, sedentary behaviour, poor nutrition, and substance misuse prevalent among many with schizophrenia further exacerbate these physical health concerns.

To assist John in maintaining his physical health, it would be essential to monitor his metabolic parameters regularly, provide guidance on a balanced diet, and encourage regular physical activity. Collaborating with a dietician and physiotherapist could be beneficial.

Furthermore, promoting smoking cessation, if applicable, and moderating substance use are vital. Educating John about the importance of physical health in conjunction with his mental wellbeing and ensuring routine health check-ups would be pivotal in holistically addressing his needs.

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Section 3

Question 1

1) Describe how you would develop and maintain a therapeutic relationship with your patient in the context of Mental Health Nursing. Consider any diversity and/or background of the patient in the scenario. How does this therapeutic relationship have a positive outcome for him/her?

In the context of mental health nursing, developing a therapeutic relationship with John Keen, who identifies as Indigenous, necessitates an understanding and appreciation of his cultural background.

It is crucial to approach John with genuine respect, actively listening to his experiences and concerns. Building trust is fundamental, and this can be achieved by ensuring consistency in care, maintaining confidentiality, and demonstrating empathy.

Recognising the significance of his Indigenous identity, incorporating culturally appropriate interventions and seeking guidance from Indigenous health practitioners would enhance the relationship's depth.

This therapeutic bond, rooted in mutual trust and respect, facilitates better communication, allowing John to express his concerns freely and adhere to treatment plans. Consequently, such a relationship contributes positively to John's mental health outcomes, fostering a sense of validation and enhancing his overall wellbeing.

Section 4

Question 1

1) How does the Trauma Informed Care framework shape your nursing care with your patient?

Within the Trauma-Informed Care (TIC) framework, the nursing care for John Keen would be fundamentally restructured to recognise the pervasive impact of trauma on an individual's mental well-being.

Adopting TIC means understanding that John's behaviours and responses might be adaptations to past traumas, and not merely symptoms of his schizophrenia. By prioritising safety, trustworthiness, choice, collaboration, and empowerment, the nursing approach becomes more holistic.

For instance, ensuring John feels safe during consultations, offering choices in his care decisions, and recognising the potential triggers of past traumas can avoid inadvertent re-traumatisation.

Moreover, by acknowledging the importance of cultural sensitivity, especially given John's Indigenous background, TIC facilitates a deeper connection. This framework, when seamlessly integrated, fosters resilience, promotes recovery, and ensures that the care provided is both compassionate and effective.

Question 2

2) How could the Recovery Model of Care be implemented with your patient?

Incorporating the Recovery Model of Care for John Keen necessitates a shift from a symptom-centric approach to one that prioritises personal agency, empowerment, and holistic wellbeing. Recognising John's strengths, such as his carpentry skills, and building upon them is pivotal.

Collaborative goal setting, wherein John's aspirations drive the care plan, ensures that interventions are tailored to his unique needs and desires. By facilitating connections to his Indigenous community and reinforcing the importance of his cultural identity, the model promotes social inclusion.

Peer support, involving individuals who have journeyed through similar experiences, can offer John valuable insights and encouragement. Emphasising hope, empowerment, and personal responsibility, the Recovery Model reframes John's schizophrenia not as a permanent impediment but as a challenge that, with the right support and resources, can be navigated successfully.

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Question 3

3) How does the Recovery Oriented Care model and the Trauma Informed Care framework differ?

The Recovery Oriented Care model and the Trauma-Informed Care (TIC) framework, while both central to modern mental health care, possess distinct emphases. Recovery Oriented Care primarily focuses on empowerment, hope, and personal agency.

It emphasises the individual's journey towards achieving their aspirations and leading a fulfilling life, regardless of the presence or absence of symptoms.

It's anchored in the belief that every individual can recover, grow, and integrate into their community. Conversely, the TIC framework is predicated on the understanding that trauma pervades the lives of many individuals with mental health issues.

It emphasises creating an environment of safety, understanding potential triggers, and avoiding re-traumatisation. While Recovery Oriented Care champions personal growth and resilience, TIC prioritises safety, understanding, and responding to the effects of all types of trauma. Both models, however, advocate for individual-centred, compassionate care.

Section 5

Question 1

1)What common psycho-therapeutic intervention are used for your patient’s diagnosis? Include what makes them beneficial.

For individuals diagnosed with schizophrenia, like John Keen, Cognitive Behavioural Therapy for Psychosis (CBTp) is a common psychotherapeutic intervention. CBTp is tailored to address the specific needs of those with psychotic symptoms. It assists patients in identifying and challenging maladaptive beliefs and hallucinations, providing them with coping strategies to manage distressing symptoms.

Another approach is Social Skills Training (SST), which equips individuals with the necessary interpersonal skills to interact more effectively and assertively in social situations. Family therapy is also beneficial, given the pivotal role families play in the support system of those with schizophrenia.

These therapies are advantageous as they not only mitigate symptoms but also bolster the individual's social functioning, self-efficacy, and overall quality of life, complementing pharmacological treatments and fostering a more holistic recovery process.

For individuals like John Keen, diagnosed with schizophrenia, antipsychotic medications are the primary pharmacological intervention. These drugs are categorised into two main classes: typical (first-generation) and atypical (second-generation) antipsychotics. John's medication, Haloperidol, belongs to the first-generation antipsychotics.

While these drugs are efficacious in treating positive symptoms like hallucinations and delusions, they come with a range of side effects. Extrapyramidal symptoms, which include tremors, rigidity, and akathisia, are commonly associated with typical antipsychotics.

Additionally, John's experience of oculogyric crisis, a type of dystonic reaction, is a testament to these potential side effects. On the other hand, atypical antipsychotics, while generally having a lower risk of extrapyramidal symptoms, might be associated with metabolic side effects, including weight gain, diabetes, and dyslipidaemia.

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