Case Studies:

Case Studies:

 

A. Subjective (Jill)

 

1) You're working on a community team that responds to calls from the Edmonton Police Service (EPS). EPS received a call from Jill's mom, Cindy, who is concerned as there was a verbal altercation between Cindy and Jill. Jill is a 20 year old female who is living in Cindy's home. EPS member Cst. Vallee is on scene and you attend to assist them. Cst. Vallee asks that you assess Jill, but first, you speak with Cindy. Cindy describes Jill as being erratic. One minute she is fine and the next minute she will be screaming at her family that she hates them. She has not been able to hold down a job for the past two years, she always finds something wrong with her employer and feels that everyone turns against her. The fight tonight was triggered by Cindy talking to Jill about finding her own place to live and Jill became upset, feeling that her mother doesn't love her anymore. She recently broke up with her boyfriend of one year. Cindy isn't sure exactly why their relationship ended, but they did have a lot of fights, but then they would get along for a short time where they would make plans to move in together or get married.

You meet with Jill. She is calm and reports that her mother was trying to kick her out of the house with nowhere to go which is why she ""lost it."" She states that her mother only wants her out because her boyfriend doesn't like her. Jill endorses that she does think of suicide often. She identifies her nephew and her sister as a protective factor. She has no plan to kill herself and has not attempted suicide in the past. She does admit to cutting and shows you her arms which have numerous healed scars and some fresh superficial cuts that do not require medical attention. Jill wants to go stay with her sister for the night and will follow up with her psychiatrist in the morning. She agrees to a call from you tomorrow to ensure that she follows up with this plan and offer other supports if needed.

 

Please answer:

 

a. What is Jill's diagnosis?

 

b. What might be the differential diagnosis, if there is one?

 

2.. Cindy is concerned that Jill may be psychotic. She has seen a psychiatrist that she was referred to through her family doctor who prescribed her 25mg of Seroquel at night. Cindy doesn't know what diagnosis the psychiatrist gave her as Jill wouldn't allow Cindy to come to the appointments. Cindy did some research on the internet and discovered that Seroquel is an anti-psychotic medication. Jill hasn't taken it for the last month and Cindy is concerned that this is why Jill is acting in such an erratic fashion. During your interaction with Jill there is no evidence of psychotic symptoms or thought disorder.

 

Please answer:

 

a. Why would the psychiatrist prescribe Seroquel for Jill?

 

b. How does this medication relate to Jill's diagnosis?

 

3. Cst. Vallee is concerned that based on what Cindy has said about the Seroquel that Jill may be psychotic and asks if you feel that Jill should be brought to the hospital under a form 10. Cindy feels that this is the best option.

 

Please answer:

a. What teaching do you provide to Cindy and Cst. Vallee?

 

b. What teaching would you give Jill about the medication?

 

B. Subjective: (Georgia)

 

1. Georgia is 13 and lives with her mum, Emma, her dad, Nick, and her younger brother Sam, aged 10. At a recent parents evening, Emma and Nick were concerned to hear that Georgia has been struggling with her schoolwork and has fallen significantly behind in some subjects. There have also been some difficulties in friendship groups and Georgia is often involved in arguments with friends. On a positive note, her teacher is pleased to report that she is doing exceptionally well at sport.

 

Emma and Nick have noticed that Georgia has become more and more disorganized over the past 18 months. She has lost many items of school equipment and is often late leaving the house for school and for social events, as it takes her so long to get ready. Georgia is often restless and finds it difficult to concentrate, even on things that she finds enjoyable; for example, it is unusual for her to be able to sit and watch a film through to its conclusion. Emma remembers that she was a lot like this when she was a child, and has not been particularly worried until now. Both she and Nick are concerned about the fact that Georgia is struggling academically but are more worried about the fact that she appears to be having problems making and keeping friends.

 

Please answer:

 

a. Describe what the possible differential diagnosis and please explain the rationale.

 

b. Identify some common interventions used for the chosen diagnosis.

 

c. What are some special considerations for use of medications in adolescents?

 

2. Georgia has been working hard at her behavioral management program and is currently on a drug holiday and things are starting to turn around for Georgia and she is having less difficult in relationships and in her ability to manage her school work. However, she has noticed that she has been having difficulty sleeping and she is worried that it will make it more difficult to navigate the previously identified challenges.

 

Please answer:

 

a. Discuss some of the nursing assessment questions you would use to identify issues related to Georgia's concerns.

 

b. What are some common medications used for troubles with sleeping?

 

c. What are some alternate, non-medication methods to manage poor sleep?

 

Please include references. Thank you."

Case Study: Jill

 

 1. Jill’s Diagnosis Self-View and Differential Diagnosis

 

 a. Diagnosis:

 Borderline Personality Disorder (BPD) may be the reason as to why Jill is presenting with these symptoms. Key features include:

 

 Emotional Instability: Emotive instability (fear one moment and be filled with love the next).

 Interpersonal Issues: Talking and arguing row often with her family and she switched boy friends very often.

 Self-Harm: Cutting behavior is present but not in a more significant way though it remains to be a sign that requires individuals experiencing it to be checked by their physicians.

 Impulsivity and Erratic Behavior: Employment instability and relationship instability.

 b. Differential Diagnosis:

 

 Bipolar Disorder: Also defined as episodes of depression with episodes of mania or hypomania, which is consistent with Jill’s symptoms. Nonetheless, bipolar disorder often comprises mood episodes that are necessarily different, whereas Jill’s symptoms are perennial and interactively twisted.

 Major Depressive Disorder (MDD) with Borderline Features: Could also explain the emotional distress and self-harm observed in BPD patients; however, does not account for the instability of relationships and the chronic pattern seen in BPD.

 2. Medication and Diagnosis

 

 a. Why Prescribed Seroquel:

 Seroquel is a second generation antipsychotic drug used in treatment of mood disorders, and may be used to prevent episodes of depressed mood. It is sometimes utilised off-label in cases of treating BPD due to impulsivity and elevated emotional response.

 

 b. Relation to Diagnosis:

 Seroquel may also contribute to the stabilization of mood and symptoms which are severe mood fluctuations or emotional impulsiveness. In contradiction to current lack of psychotic symptoms, the medication might have been prescribed to prevent severe mood or impulsivity related to BPD.

 

 3. Hospitalization and Teaching

 

 a. Teacher educating for Cindy and Cst. Vallee:

 

 Criteria for Hospitalization: Elaborate that the subject of Form 10 is made, usually, when there are impaired capacity and high risk of self or others’ harm. Therefore, Jill current management plan of staying with her sister and seeing her psychiatrist, together with no active suicide plan and more, may fail to meet the criterion.

 Support Options: In which you talk about resources available in the community, services in cases of mental health crisis, as well as the need for outpatient follow-up.

 Monitoring: Stress ongoing evaluation of the environment in which Jill functions as well as assessment of her mental condition.

 b. Teaching for Jill:

 

 Medication Purpose: Tell him that Seroquel is useful when it comes to mood and that is why it can help to stabilize ones emotions. For the management of symptoms and reduction of exacerbation, it is a vital aspect.

 Side Effects: Counsel about possible side effects and the need to adhere to the prescribed medication schedule.

 Case Study: Georgia

 

 1. Differential Diagnosis and Interventions

 

 a. Differential Diagnosis:

 

 Attention-Deficit/Hyperactivity Disorder (ADHD): It entails laxity, disarray and potentially wandering attention. That is why Georgia possesses the typical manifestations of ADHD: restlessness, excessive level of disorganization, and difficulties when it comes to concentration.

 Learning Disabilities: Could cause difficulties in school performance but wouldn’t generally explain the restlessness and disorderliness.

 Anxiety Disorders: Bar in impaired concentration and takeover social interactions though not often associated with such severity of restlessness as ADHD.

 b. Common Interventions for ADHD:b. Common Interventions for ADHD:

 

 Behavioral Therapy: I still find that it assists with any organizational skills and controlling impulses.

 Medication: Stimulants (for instance, methylphenidate, amphetamines) or non-stimulants (for instance, atomoxetine) may enhance attention and decrease hyperactive signs.

 Educational Support: Embraces all arrangements in school; it may be additional assistance in the completion of tasks or the ability to take a test in a quiet environment.

 c. Special Considerations for Medications in Adolescents:c. Special Considerations for Medications in Adolescents:

 

 Dosage Adjustments: The adolescent’s bodies also respond to drugs in a different manner and hence necessitate right dosages.

 Side Effects: Youth are more vulnerable to the side effects such as alteration in appetite, sleep disorders and aggressive behavior.

 Monitoring: Routine follow-ups in order to evaluate its effectiveness and adverse effects is very important .

 2. Addressing Sleep Concerns

 

 a. Nursing Assessment Questions:

 

 Sleep History: For how long now has she has been facing a problem of poor sleep quality? Said another way, is it ‘getting to sleep’, ‘staying asleep’, or ‘waking up too early’.

 Sleep Environment: What does she sleep in and where does she sleep? What do you make of this location with regard to it’s suitability to produce restful sleep ?

 Daily Routines: What does she do daily and how does she expend her time with reference to her sleeping pattern?

 Current Medications: has she on any medications that will disturb her sleep or that needs to be taken at night?

 b. Common Medications for Sleep:b. Common Medications for Sleep:

 

 Melatonin: A hormone of the body that is believed to assist in regulation of sleep in individuals.

 Non-Benzodiazepine Hypnotics: For short-term sleep disorders it is possible to take medicines such as zolpidem (Ambien) or eszopiclone (Lunesta).

 Antidepressants: Selective serotonin reuptake inhibitors such as fluoxetine or paroxetine, and others including trazodone can also be used for sleep disorders off label.

 c. Non-Medication Methods:

 

 Cognitive Behavioral Therapy for Insomnia (CBT-I): Supports to deal with the distorted attitude towards sleep and to cultivate favorable perceptions and behaviours.

 Sleep Hygiene Practices: The three approaches include: adherence to a sleep schedule, following a regular sleep-wake routine, and preparingSleep environment.

 Relaxation Techniques: Activities like listening to music, going for a walk, taking warm bath, having a cup of tea or coffee, doing gentle stretching exercises like yoga, practicing deep breathing, taking a nap, having a pet, doing something creative, reading, having a bad temper, shouting at someone, destruction of objects, screaming, hitting the wall, or pounding on a pillow.

 References:

 

 American Psychiatric Association. (2013). DSM-5- Diagnostic and Statistical Manual of Mental Disorders (5th edition). Arlington, VA: Published by American Psychiatric Publishing.

 Joint as the National Institute of Health and Clinical Excellence (NICE) shortened its name to the National Institute for Health and Care Excellence in October 2013. (2018). Attention deficit hyperactivity disorder: diagnosis and management was unique and the intervention SPECFIX was more effective than a “regular” cardiac rehab program. Retrieved from NICE.

 Terman, Malcolm & Terman Judith (2001). Chronobiology: Biology Clock and Its Discos. Cambridge University Press