CNA256 | Health | The Preliminary Step Of The Clinical Assessment

Chung is a 35 years-old male who moved to Australia from China five years ago. His parents, older brother and younger sister still live in China. Chung visited his family in China once after a year of moving to Australia. He has not returned to China since, because of his long working hours and need to undertake additional study for promotion.

Chung is a doctor working in Accident and Emergency in a busy inner-city hospital. He is studying for promotion to ultimately become an emergency medicine consultant. Two years ago, Chung was under investigation by the hospital Human Resources department due to a drug error. He was very tired and had been on-call over-night with frequent call outs to see patients. The drug error resulted in an eight-year-old boy being very sick, requiring intensive care admission. Chung used an intra-muscular medication to treat the boy but administered it intravenously. Chung was subjected to several work-place and medical board investigations and placed on practice supervision for 12 months.

Chung met his wife, Harriett, in Australia four years ago. Harriett is 30 years old. They married two years ago. Unfortunately, Chung’s parents and family could not attend the wedding due to the high costs of travel and his mother has severe arthritis in her hips, making travel very difficult. Chung found their wedding day emotionally difficult. He felt the ceremony lacked reference to his Chinese culture. On reflection, he feels that he wasn’t as involved in the wedding planning as he could have been, due to his long working hours. He simply agreed to the suggestions and plans made by Harriett and her family.

Chung and Harriett now have a three-week-old baby girl, Charlotte. Charlotte was born by caesarean section, due to birth complications. Harriett has had an infection in the operation site since the birth, resulting in lots of pain, frequent dressings and difficulties moving around. Chung was off work for one week after the baby’s birth. However, he has now returned to working shifts, often working through the night, where he may go without sleep for 20 - 24 hours. Harriett’s parents are staying with them to support Harriett while Chung is at work. However, he finds that Harriett’s parents are very involved with baby care even when he is home. Given this, Chung finds he gets very little time and space to be with his new daughter.

You are visiting the family in your capacity as a community nurse supporting Harriett with the caesarean section wound care or as a midwife undertaking a post-natal visit. During your visit to the family, you notice Chung looks flat in mood and tearful. His affect is sad and restrictive. He is slumped in his chair, with rounded shoulders and starring at the floor for long periods. You inquire about his health. He has very limited eye to eye contact with you. His speech is slowed and purposeful. On occasions, you need to repeat your question several times to get a reply. However, you do manage to obtain the following information from Chung. He has been feeling increasingly anxious during the past two months, given his continuing long hours, shift work, the high pressure of an Accident and Emergency department, Charlotte’s birth and his wife’s health. He has been having palpitations, chest pains and breathlessness for six to seven weeks. He asked a colleague at work, another doctor, to assess him for cardiac issues several weeks ago as he had been experiencing thoughts that he was going to have a heart attack and die. Chung has been feeling very low in mood for the past six weeks, experiencing sleeplessness, particularly initial insomnia and early morning wakening at 3am. He has lost five kilos in weight during the past month, due to reduced appetite and missing meals. He feels he is worthless and a failure at work within his medical role and he is letting his wife and new daughter down. He has been experiencing fleeting thoughts of suicide for the last week. He is aware of high lethality medications which he could take to overdose. Currently, he is hopeless and helpless and wants to die. He states he feels his situation is self-imposed and that treatments will not be of help at this time.

1. Using relevant literature critically discuss the mental health status of the client in the case study.

Your work should make reference to two (2) components of the Mental State Examination (MSE) related explicitly to the case study and the DSM V.

2. Critically discuss two (2) factors which have contributed to the development of the client’s current mental health status.

You should demonstrate your knowledge of the Stress Vulnerability Model. Your work should clearly identify the contributing factors; make reference to the case study and relevant literature.

3. Respect, empowerment and hope are three (3) positive aspects of mental health recovery. Using relevant literature and the case study, critically discuss how these three (3) principles could positively contribute to the client’s journey of recovery.

1. The case study selected for this assignment focuses on Chung, who is suffering from symptoms such as persistent sadness, restrictiveness, hopelessness, lack of self-worth, suicidal thoughts along with palpitations, breathlessness and chest pain. Lastly, it has to be mentioned that he also had been experiencing anxiety and sleeplessness as well. From the set of symptoms that the patient had been experiencing, the patient could be suffering from a co-occurring psychological disorders. Hence, it is crucial to assess the mental health of the patient which can be done with the help of mental state examination and DSM 5.

Mental state examination is the preliminary step of the clinical assessment that Chung will require for the diagnosing the condition (Cumming et al., 2013). Mental state examination generally has 15 interrelated elements that help in recognizing whether or not the patient has any significant mental illness or not. The 15 elements that are present in the mental state examination include appearance, behavior, consciousness, orientation, speech or language, attitude, mood, thought content and thought process, attentiveness, memory, and intellectual functioning. Among the 15 given elements, Chung had alterations in speech, mood, suicidality, and thought process and content. Exploring further, Chung had been in a sad flat mood with extreme hopeless

In order to arrive at an accurate diagnosis, a more extensive, specialized and systematic diagnosis method is needed to be used. DSM 5 or the Diagnostic and Statistical Manual of Mental Disorders is the 5tth revised edition introduced in the year or 2013 by the American psychiatric association (American Psychiatric Association, 2013). This acts as a comprehensive and systematic diagnostic tool that helps in the critical taxonomical diagnosis of the psychiatric disorders that the patient is experiencing. There are 19 different diagnostic criteria for diagnosis and each if the criteria has a very systematic and taxonomical pathway which helps the mental health professional arrive at the exact mental illness is a systematic step by step procedure. In this case, Chung had been detached from his family and culture, had an extremely stressful professional life, an ill wife and new born daughter that he does not get to spend time with, and all of these factors have given rise to persistent chronic depression. However, along with that, he also had frequent panic attacks and was suffering from palpitation, chest pain, and breathlessness which is significant symptom of severe anxiety. Along with that, he had also been experiencing frequent panic attacks fearing death due to heart attack. Therefore, as per the DSM 5 criteria the patient is suffering from panic disorder under the section of anxiety disorders that stemmed from the chronic depression (American Psychiatric Association, 2013).

2. The cause of the mental health disorders have been very difficult to determine due to the complex developmental trajectory of these diseases. However, consistent research on the pathways of implementation of change in the mental illness symptoms has given rise to a varied range of different models and frameworks that can help in understanding the developmental trajectory of the mental health disorders. The stress vulnerability model is one such model which aids in discovering how the psychological disorders develop and how different factors interact in developing the disorder (Zannas & West, 2014). There are five different elements that are present in the stress vulnerability model, including alcohol and substance abuse, medication use, social support, stress and its coping and meaningful activities. All these elements have a significant impact on the biological vulnerability of the patient, while addressing tem can reduce the psychotic symptoms that the patient is suffering with, the lack of the same can induce varied degree of stress and can give rise to various psychotic disorders in the patient (Townsend & Morgan, 2017).

In case of Chung, the patient had various external and internal factors that acted like a stressor in his life aggravating or facilitating the psychological distress. Firstly, occupational or job related issues is the first factor that induced a considerable amount of stress in his life. Exploring further, the patient had been working as a doctor in the emergency department of the hospital. Bragard, Dupuis and Fleet (2015), have discussed that the emergency department health care staff generally have to suffer from a considerable trauma and burnout which again is a very crucial stress on the mental health and wellbeing status of the patient. Along with that, Chung had also been investigated for a medication error he committed, which might have had a considerable impact on the coping skills and stress enduring capacity of the patient. Along with that, he had to do long shifts as well due to the financial burden on him for his wife’s illness post birth of his daughter and to care for the new born, by working 20-24 hours straight without sleep. This had also been a considerable impact on the mental state of the patient.

The second factor that contributed to the stress that the patient had been feeling has been the lack of any social support. Chung had no connection with his culture and family for close to five years to a point where most important events of his life like his wedding and the birth of his daughter was spent without his family members. Hence, the lack of any connection with his own family and culture had been a considerable impact on his ability to cope with the stressors in his life. Along with that, his wife also had been ill since the birth of his daughter and he did not have enough time to connect with his daughter either which also aggravated his lack of social support and facilitated the chronic depression and anxiety that the patient had been suffering with (Uchino, Bowen & Kent, 2015).

3. Mental health can be defined as the overall state of psychological, emotional and social health and wellbeing of an individual. On the other hand, mental illness can be defined as the diseased condition that develops mild to severe impact on the psychosocial or emotional wellbeing of the patient by directing or indirectly altering and causing distortions in the thought and behavior which results in a massive inability to cope with demands of life. As mentioned by Drake and Whitley (2014), the journey from mental illness to adequate mental health can be considered as the journey of recovery for the mental patient. Now recovery for mental illness includes more than just addressing the different symptoms of the mental disorder, rather the recovery process of a mental illness is associated with addressing the emotional, psychological and socio-cultural aspects of the mental illness. Hence, it can be concluded that the recovery is needed to b oriented towards a more holistic approach to caring, so that the overall health and wellbeing of the patient can be addressed.

The mental health recovery model can be an excellent framework that can be used to implement holistic care approaches for the patient (Storm & Edwards, 2013). The recovery model for mental health disorders is associated with a holistic patient centered approach to the mental health care. This model is based on two guiding principles of mental health care, one focusing on encouragement for the patients for recovery and entertaining a patient directed approach to recovery. Similarly, the mental health recovery principles for the practice by the Health.gov.au, (2018) illustrates 6 individual principles for the mental health recovery for the patient. These principles include uniqueness of the patient, real choices, attitudes and rights, dignity and respect, partnership and communication, and evaluating recovery. These principles guide the mental health professional as a recovery oriented framework to implement a holistic approach to the recovery. Among the various principles that have been illustrated by the government health document, three very important aspect of recovery model which also bears intricate link to the condition of Chung is respect, empowerment and hope. The principle 4 states safeguarding the dignity and respect of the patient is crucial for accelerating recovery of the mental patients. Having a therapeutic relationship with mutual respect for the patient, his beliefs and culture will facilitate a sense of empowerment and being valued. Empowerment is a crucial element of the care being provided to a mental patient (Ruotsalainen et al., 2015).

The inability to control their life is a significant contributor to the hopelessness and lack of self-worth. Providing the power of decision making or valuing the choice or beliefs while planning and implementing care will empower Chung and aid in the process of recovery. Lastly, hope is another crucial element of care delivery which allows the patient to have a positive and optimistic view on life and helps accelerate recovery. The third principle of the framework, ‘attitudes and rights’ also guides that instilling hope in a mental patient can accelerate recovery and improve the co-operation or eagerness in the patient to gain recovery. Engaging Chung in community engagement activities and involving his family and friends in the recovery oriented care planning will allow Chung to regain hope and attain optimistic expectations from life. Entertaining therapeutic traditional or culturally safe treatment measures that are in accordance to his Chinese roots can also facilitate recovery for him (Hungerford et al., 2018).

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bragard, I., Dupuis, G., & Fleet, R. (2015). Quality of work life, burnout, and stress in emergency department physicians: a qualitative review. European Journal of Emergency Medicine, 22(4), 227-234.

Cumming, T. B., Churilov, L., Lindén, T., & Bernhardt, J. (2013). Montreal Cognitive Assessment and Mini–Mental State Examination are both valid cognitive tools in stroke. Acta Neurologica Scandinavica, 128(2), 122-129.

Drake, R. E., & Whitley, R. (2014). Recovery and severe mental illness: description and analysis. The Canadian Journal of Psychiatry, 59(5), 236-242.

Hungerford, C., Hodgson, D., Bostwick, R., Clancy, R., Murphy, G.(2018). Mental health care (Third edition). John Wiley & Sons, Milton, Qld

Kidd, S., Kenny, A., & McKinstry, C. (2015). The meaning of recovery in a regional mental health service: an action research study. Journal of Advanced Nursing, 71(1), 181-192.

Principles of recovery oriented mental health practice. (2018). Retrieved from https://www.health.gov.au/internet/main/publishing.nsf/content/CFA833CB8C1AA178CA257BF0001E7520/$File/servpri.pdf

Ruotsalainen, J. H., Verbeek, J. H., Mariné, A., & Serra, C. (2015). Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev, 4.

Storm, M., & Edwards, A. (2013). Models of user involvement in the mental health context: intentions and implementation challenges. Psychiatric Quarterly, 84(3), 313-327.

Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing: Concepts of care in evidence-based practice. FA Davis.

Uchino, B. N., Bowen, K., & Kent, R. (2015). Social support and mental health. In Encyclopedia of Mental Health: Second Edition (pp. 189-195). Elsevier Inc..

Zannas, A. S., & West, A. E. (2014). Epigenetics and the regulation of stress vulnerability and resilience. Neuroscience, 264, 157-170