HLTENN009 Implement and monitor care for a person with mental health conditions

Instructions to Student

General Instructions:

• This is a skills activity where, in the role of an Enrolled Nurse and within your Scope of Practice, you must demonstrate evidence of specified essential knowledge in mental health.

• Each question to be answered.

Information / Materials provided:

Scenario,  links to documents, online topics, readings

Word limits and referencing requirements noted within assessment where applicable

Assessment Criteria:

To achieve a satisfactory result, your assessor will be looking for your ability to demonstrate the following key skills/tasks/knowledge to an acceptable industry standard:

• Key features of the Mental Health Act, Qld.

• The Enrolled/Division 2 nurse's role and responsibilities within the mental health environment.

• Rights of patients in a mental health environment.

• Nursing management of common mental health disorders.

• Specific medications and support strategies within the defined scope of practice.

• Mental health assessment and assessment of risk.

• This must not be a re-iteration of the elements and performance criteria from the Unit of Competency.

• Referencing (in-text and reference list) per APA 7^th ed referencing style to be used when acknowledging source material used.  Failure to use will result in an unsatisfactory result.

Number of Attempts:

You are required to satisfactorily complete all assessments listed in the table below to be receive a ‘Competency Achieved’ result for the Unit(s) of Competency. You are responsible for complying with TAFE Queensland’s assessment rules and complete assessment tasks honestly.  You need to follow all assessment instructions, including submission details and retain a copy of all assessment items.  You must submit assessment on or by the due date, unless an extension has been granted.  Failure to submit or complete assessment on or by the due date will result in a “did not submit/sit” (DNS) being recorded (unless there are exceptional circumstances) and you will have five (5) days to submit your second and final attempt. For more information, refer to the Student Rules.

Submission details

Insert your details on page 1 and sign the Student Declaration.

· TAFE Queensland Learning Management System: Connect   url: https://connect.tafeqld.edu.au/d2l/login

· Username; 9 digit student number

· For Password: Reset password go to  https://passwordreset.tafeqld.edu.au/default.aspx>

Instructions for the Assessor

The student will be provided with education and information on mental health assessment, risk assessment in the mental health field, common mental disorders, and a variety of issues pertaining to mental health and wellness.

Students may write on this form directly and submit as an electronic copy, but they must follow the format included here to undertake the required tasks

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.

In addition, assessors must hold current registration as a registered nurse with Nursing and Midwifery Board of Australia.

Assessor is allowed to use discretion in assessment in judging assessment evidence in context with scenario and/ or reputable resources used other than provided resources.

Note to Student

An overview of all Assessment Tasks relevant to this unit is located in the Unit Study Guide.

Mental Health Disorder groups

Mood disorders

· Bipolar Affective Disorder

· Depression

Anxiety Disorders

· Obsessive Compulsive Disorder (OCD)

· Panic disorder

· Post-traumatic Stress Disorder

· Social & Specific Phobias

· Eating disorders  

Organic Disorders

· Dementia

· Delirium

Personality Disorders

· Borderline Personality Disorder

Psychotic Disorders

· Schizophrenia

· Psychosis 

Mental health Disorder group

Common Signs and symptoms (classification)

Disorder group: Anxiety Disorders

Obsessive thoughts, debilitating behaviours leading to decline in functionality

Obsessive compulsive disorder

Racing thoughts, shaking, sweaty, feeling of choking, heart pounding

Post traumatic stress  

Flashback, nightmares, recurrent memory of traumatic event

Unable to attend social functions Intense anxiety around social functions, physical symptoms of anxiety

Eating disorders                  

Increased weight loss, poor appetite, sleep, social isolation, purging, vomiting, binge eating. BMI below 15.

Mental health Disorder group

Disorder group: Personality Disorders..................

Borderline Personality disorder

Fear of abandonment, unstable relationships, chronic feelings of emptiness, suicidal thoughts, Deliberate Self Harm, Poor self-image, impulsive, Angry.

Mental health Disorder group

Common Signs and symptoms (classification)

Disorder group: Organic Disorders.......................

Dementia

Memory loss, Difficulty communicating, problem-solving, planning and organizing. Confusion and disorientation

De Delirium

Acute confusion/ disorientation. Anger irritability, anxiety, mood swings. Disturbed sleep.

Mental health Disorder group

Common Signs and symptoms (classification)

Disorder group: Psychotic Disorders

Psychotic disorder

Schizophrenia

Positive symptoms: Paranoid, disordered thoughts, Hallucinations, Delusions

Negative symptoms: Apathy social isolation, poor diet, ADL’s

Fixed false beliefs

Substantially impair effective communication

Psychosis

Vivid, involuntary perceptions that are experienced as ‘normal’ and occur without an external stimulus

Usually experienced as voices that are perceived as distinct from the person's own thoughts

Mental health Disorder group

Common Signs and symptoms (classification)

Disorder group: Mood Disorders

Bipolar affective disorder

Elevated mood, manic, pressured speech, increased spending, lack of sleep, increased substance abuse.

Depression

Low mood, suicidal thoughts, poor sleep, no energy, Helpless / hopeless themes, poor appetite. Low energy.

Mental Health Disorder group

Therapeutic Treatment options

Medication Class

Therapeutic Treatment options

Psychotherapy

Nursing Interventions

Mood disorders

Mood Stabilizers (e.g. Lithobid, Depakene etc.), the mood stabilizer control manic or hypomanic episode as it reduce severity of these symptoms and may relive bipolar depression (Zalpuri & Singh, 2019)

Interpersonal therapy

(Interpersonal therapy focus on social role and relationships, and try to resolve the interpersonal problems, depression and symptomatic recovery, it also help in recuing hostile and self-destructive behaviour of the patient (Zalpuri & Singh, 2019).

• Follow organization policy and procedure to perform the complete assessment of the patient medical history including mental status to ensure effective treatment can be provided to meet patient need.

• Using therapeutic skills while communicating with patient to understand their feeling and thought, and to ensure their safety through monitoring.

Psychotic Disorders

Antipsychotics drugs such as aripiprazole (Abilify), risperidone (Risperdal), etc. are used to treat psychotic disorder as it help in reducing symptoms of certain psychotic disorder, the effect of the medication may take time of 1-2 week to show effective results (Gurin & Arciniegas, 2018).

Cognitive behavioural therapy or talk therapy is psycho-social intervention help in modifying negative thoughts, behaviour and feelings of the patient, improving emotional regulation and problem solving skills (Gurin & Arciniegas, 2018).

• Monitoring/observing the patient behaviour with compliance to organization policy and procedure to avoid breaching patient confidentiality, and safety by ensuring environment is safe.

• Using effective communication skills (both verbal and non-verbal) to approach patient with non-judgemental attitude to ensure positive alliance.

Anxiety Disorders

Antidepressant specifically the SSRIs (selective serotonin reuptake inhibitors) are widely used drug treat and prevent different anxiety disorders as it enhance the function of nerves in brain that control emotions (Orlova, Rizzoli & Loder, 2018).

Psychotherapy is a psychological method to treat the anxiety disorder by communicating with the adult to support them in manage their behaviour and solve the problem effectively (Prochaska & Norcross, 2018).

• Provide comfort and reassurance to patient by establishing trusting relationship with the patient by respecting patient personal space.

• Educate and inform patient about the anxiety triggers using effective communication skills and staying with the patient during panic attacks.

Organic Disorders

Cholinesterase inhibitors (donepezil, galantine, etc.) Is commonly prescribed medication as it block the normal breakdown of acetylcholine in brain (Orrico-Sanchez et al., 2019). 

Biopsychosocial therapy helps the health carer to design an effective patient-centered treatment plan to meet the need of the patient suffering from dementia (Mahoney & Casas, 2019).

Active listening skills, showing compassion, empathy, having patient to understand patient feelings and thoughts to provide better care. 

Check medical health record of the patient regularly to monitor the patient and deliver patient-centered care.

Personality Disorders

Anti-anxiety medications such as benzodiazepines help to promote a sense of well-being in patients with personality disorders (Bushnell et al., 2018)

Dialectical behaviour therapy (DBT) is a specific type of cognitive behavioural therapy that help patient to avoid negative thinking pattern and destructive behaviour, and support patient improve regulation of emotions. (Schroeder et al., 2018).

Be active in care, learn about the patient medical history

Inspect the patient environment, close monitoring to ensure patient is free from any injury. 

Tidal model is recovery model that used as foundation for interdisciplinary mental health care (Freitas et al., 2020). The three principles of this theory are-

Principle 1 (development of nursing care plan): it comprise obligation for practitioner listen actively to patient story (thoughts, feelings and concerns) to effectively understand the patient need so that effective patient-centered plan can be made to meet those need, it also help build therapeutic rapport with patient.

Principle 2 (Who provides the care): it is vital for practitioner/nurses while providing care to the patient suffering from mental disorder to provide care without judgement, model confidence, using personal experience to support patient.

Principle 3 (active collaboration):  the carer helps patient to be aware of their needs, help in developing self-belief that can help in attainment of health goals effectively.

Biopsychological perspective

Possible causes

Biological

Altered neurotransmitters levels, anatomical malfunction, acquired brain injury (ABI), substance abuse, infection, exposure to toxins, epilepsy, stroke, endocrine imbalance. Genetic factors – first-degree relative, prenatal infection, predisposition to mental illness, constitution.

Social

Death, divorce, cultural, stress, housing, homelessness, exposure to violent behaviours, childhood trauma (verbal, physical, sexual), social isolation, childhood neglect and abuse, attachment problems, parenting issues, substance abuse, environment, grief and loss

Psychological

Life experiences, low self-esteem, unintegrated sense of self, personality, lack of resilience.

The mental health act 2016 main objectives are to protect the right of people who are suffering from mental illness and this act certify that patient is provided care ensuring their safety and confidentiality, this act reinforce patient rights, also it permits health professional to admit the individual with the mental health problem without their consent if essential to ensure their safety and wellbeing (Patterson Procter & Toffoli, 2016).

Treatment authority is accountable for giving order for the treatment of an inavidual who they thought is unfit/ uncapable to make decision for themselves due to mental illness without taking consent from them and their family as it is been idenetifed that the person is risk of casuing harm to themselves or to others (Patterson Procter & Toffoli, 2016), thus, in order to ensure safety lawful authority oder different orders to detained and treat person suffering from mental illness and unfit to give consent.

The six treatment order and two special condition are:

If an invudual is subject to treatment authority

If an indvudual is sunject to a treatment support order

If an invudual sunject to examination authority

If a person subject to a forensic order

If a person sunject to recommendation for assessment.

Special condition:

A individual held while a recommendation for assessment is being made for the individual.

Identify three (3) criteria to apply to make a patient’s care involuntary

If person if suffering from mental illness and at risk of causing harm to themselves and others considering that person is subject to treatment authority, foresic order, examination authority, recommendation for assessment or individual got deatined while assessment is needed to be made by health professional in compliance to mental health act is called involuntary patient (Patterson Procter & Toffoli, 2016).

The three criteria that make patient care involuntary are:

• Person is suffering mental illness

• Person is not capable of giving consent for the treatment

• Due to absence of treatment person can cause harm to themselves or to others.

A person who is subject to treatment authority, forensic order, examination authority, treatment support order, recommendation for assessment or person got detained while assessment is being made for the individual made by doctors in compliance to mental health act 2016 is called involuntary patient (Patterson Procter & Toffoli, 2016).

The three criteria to apply to make patient care involuntary are:

• The person is suffering from mental illness

• Because of individual illness, and absence of involuntary treatment person can cause serious harm to themselves or to others.

• The individual does not have ability to give consent to treat the illness.

Patient has the right to be involved in their treatment plan, have the right to attain/obtain the second opinion from counsellor or psychiatrist. The patient also holds a right to take legal advice and have permission to talk to their family and friends.  If the patient is not happy with the service provided they can complain about the treatment provided (Patterson Procter & Toffoli, 2016). 

Types of Forensic orders

Rationale for use

Forensic order (Mental health):

 Court will take decision depending on person mental condition, this order is made if the person is unfit, and has instability due to any mental illness other than intellectual disability, or if the person has both mental and intellectual disability and needs involuntary treatment.

Forensic order (disability):

This order is made by tribunal depending on person unfitness in trail due to intellectual disability, and person need care for disability but does not need treatment for mental illness. (Patterson Procter & Toffoli, 2016)

Mechanical restraint: Mechanical restraint is the limit of an individual by the submission of a device to limit individual body movement though this not include medical appliance, to protect patient from the self-harm or in case if the doctor think patient may harm others (White, 2019). The authorized doctor can use mechanical restraint on the patient in mental health service if-

• The device approved by psychiatrist

• Chef psychiatrist permit to use physical restraint

•  Restraint can be used for three hours

• It is vital to ensure safety and comfort of the patient during the mechanical restraint

Also authorization did not permit use of mechanical restraint more than 9 hrs in 24 hrs.

Seclusion:  it means confinement of the person at any time in area where free exit is banned as there is no other way to protect patient from causing harm to themselves or others. A health practitioner may keep relevant individual (patient) in seclusion (not more than 3 hrs) if approved by authorized by doctor or chef psychiatrist, the patient is monitored throughout during the seclusion at interval of 15-20 minutes.

Physical restraint:  this involves restricting the patient movement to protect the person from physical harm, and to provide treatment to the patient and avoiding patient to cause serious damage to property, the restraint is permitted by authorized doctor or chef psychiatrist.

Type of Restraint

Authorization and Implementation, e.g. who authorize restraint and time period to be implemented?

Nursing Interventions required with implementation of restraint

Mechanical restraint:

Mechanical restraint is the limit of an individual by the submission of a device to limit individual body movement though this not include medical appliance, to protect patient from the self-harm or in case if the doctor think patient may harm others (White, 2019). The authorized doctor can use mechanical restraint on the patient in mental health service if-

• The device approved by psychiatrist

• Chef psychiatrist permit to use physical restraint

•  Restraint can be used for three hours

• Mechanical restraints can be used for a maximum of 7 days Also authorization did not permit use of mechanical restraint more than 9 hrs in 24 hrs.

• It is vital to ensure safety and comfort of the patient during the mechanical restraint.

• Using verbal and de-escalation strategies to to help patient safely gain control of their behaviour

• Record the required information related to patient

.

Seclusion

it means confinement of the person at any time in area where free exit is banned as there is no other way to protect patient from causing harm to themselves or others. A health practitioner may keep relevant individual (patient) in seclusion (not more than 3 hrs) if approved by authorized by doctor or chef psychiatrist, the patient is monitored throughout during the seclusion at interval of 15-20 minutes. if approved by authorized by doctor or chef psychiatrist, the patient is monitored throughout during the seclusion.

• It is vital for nurses to ensure that patient is monited throught while in restrain at regular interval to ensure patient comfort and wellbing

• Therapeutic communication skills to support patient feel comfortable

• Ensure vital needs are met of the patient, such as cloth, food,etc

Seclusion (emergency)

Phsycial restrain or sedation medication is the only way to protect patient from the treatment under the chief psychiatrist’s policies, the seclusion period is about one hour and authorised health professioanal is informed about the seclusion.

• Ensure seclusion complies with aurorize doctor authorization

• Documentation of need of giving sedative.

• Checking patient condition throughout.

The court decided authorized doctor decided the criteria for the treatment in the community, and court approves limited community treatment that involves process of patient receiving treatment in the community using graduated process to improve mental and behavioural condition of the patient. It applies to involuntary patient, forensic patient and classified patients.

Mental health review tribunal must permit for limited community patient for inpatient and authorized doctor will ensure appropriate condition under the parameter established by tribunal (Kisely, Campbell & O’Reilly, 2017).

Forensic or classified patient need approval from mental health court to authorize the doctor to assess limited community treatment as per requirement.

An individual have capacity to consent for treatment if they are capable of making decision, communicating the decision in some way and have understanding about-

• Their mental illness,  or symptoms or disease that effect their mental wellbeing (Day & Elliot, 2018)

• Understand purpose and need of the treatment

• Benefits of the treatment

• Risk of the treatment

• Consequences they might face if treatment is not received on time

The Chief Psychiatrist will ensure that a individual permitted to collect information about a patient under an information notice receives the information outlined in Schedule 1 of the Act. It is vital to maintain person privacy and confidentiality, the Chief Psychiatrist or other individual working under the act must not tell the  patient of the creation of a data notice. In any case, the patient might be recounted the creation of a data notice or the name of the candidate for the notification if: x the candidate demands the data be given to the patient, and x the Chief Psychiatrist or an approved specialist considers it is in the patient's eventual benefits its states the obligation for health practitioner to only disclose the information under the compliance with the Mental health Act. Data can be only shared either permiited by patient or chef psychiatrist or in special case when its absolutely necessary to share data. For example, the employee in care may disclose the information for identification purpose if victim of unlawful act in order to offer support service or to assist the individual who may be unfit/unsound at time of trial, or in preparation of health report for psychiatrist, to the lawyer who provide legal assistance to the patient, etc. (Moss, 2017). thus, by working in obligation to the guidelines under the mental health act can support carer to ensure the privacy and confidentiality of the patient. The information notice necessities also relate to individuals on a forensic order (disability) for which the Forensic Disability Service is accountable, and for disable patient director under foresnsic disability act 2011 is accountable for sharing/storing notices related to information.

Admission procedure:

• Chef psychiatrist will prepare a statement of rights to the patients, and list of support person (family member, carer, etc.) (Kelly et al., 2018)

• Under this rights person receiving care will inform about the right to complain about the treatment provided if unhappy with the care and process to make the complaint.

• Copy of the statement provided to patient (if requested)

• According to the statement of nominated support person made by practitioner the visit to the patient is permitted

• Patient has right to communicate through fixed telephone, or mobile.

• Proving timely and accurate information to the patient about the treatment

• Authorized doctor must share information to the patient respecting their culture, age, mental illness etc.

The role of authorised mental health practitioners is to provide treatment, support, care, etc. or refer the client suspected to be suffering mental health issues for examination to another health professionals who can support patients in better treatment. By following the rules and regulations stated in the mental health act 2016 the health professional has an ethical responsibility to take a decision in favour of patient health and wellbeing. As mental health tribunal made the examination authorities who authorized the health practitioner to involuntary examine the person (through Judicial order) and these recommendation to involuntary examine the person are made considering if person is unsound or unable to make decision for themselves due to mental illness and/or there is risk of person leaving or being absent from the service while recommendation is being made for the assessment or if the person is absent from another state and need warrant for detention (Waterworth, 2016). Examination authorities and recommendation for assessment are made by doctors and authorised health professionals if a recommendation fro assessment for doctor to detain and involuntary examine the patient if treatment order is made for the person. Magistrate will make examination order without person consent if the person need care and is unfit to make consent.

Right

True / False

Once a patient is in a mental health facility they no longer have the rights to privacy and confidentiality

False

Patients like to be respected and their wishes taken into account

True

Patients have the right to have their lived experiences ignored

True  

Patients should be able to continue to live, work and participate in the community to the fullest extent possible without discrimination, stigma or exclusion

True

Patients are unable to make a complaint regarding any facet of their assessment, support,

care, treatment, rehabilitation and recovery

False

Patients have the right to be considered capable of making a decision (by the service or person providing care)

True

Patients should be treated in the most facilitative environment with the least restrictive or intrusive response or treatment

True

Patients may have families, carers and support persons involved in their assessment, support, care, treatment, recovery and rehabilitation to the extent requested by them

True

Patients do not need to have their sexual orientation, gender and gender identity taken

into consideration in their treatment

False  

Effective communication skills: using effective communication skills both verbal and non-verbal help in ensuring that a person experiencing mental illness feel comfortable which key step in providing quality care (Webster, 2014).

Active listening: this also helps in understanding patient thoughts, feeling and discomfort that is helpful in providing therapeutic care.

Checking: considering the medical health record of the patient help in understanding the medical need of patient more effectively which crucial step in delivering patient-centered care.

Confirming: confirming the messages or information with the patient and other staff members is always supportive in delivering positive care to the person with medical illness and avoid ambiguity or medical errors.

Bill is a 45 year old man 75kg brought into the Emergency Department by his sister after intentionally lacerating one arm and his neck while heavily intoxicated on alcohol.

Bill is separated from his wife and children, he has a history of domestic abuse due to his alcohol consumption and often is verbally abusive to his neighbors. Bill is currently unemployed due to the recent loss of his driver’s license for Driving Under the Influence (DUI). His sister lives 4 houses away from Bill and seems to be the only person that he will talk to, she is often away and only sees Bill occasionally.

He is seen in the Emergency Department by the Mental Health Assessment Team (MHAT). Following assessment, Bill is admitted as a voluntary patient to the Mental Health Unit for assessment, observation and monitoring. Bill appears malnourished, dehydrated, and unwashed. He is flushed, ataxic and smells strongly of alcohol. His speech is slurred. He has a productive cough. He is given a provisional diagnosis of Major Depressive Disorder (MDD) and Substance Abuse (Alcohol).

A few hours later, Bill attempts to leave the Mental Health Unit without a medical review or authority. He becomes verbally and physically threatening toward nursing staff who are trying to persuade him to stay and be treated. Security is called and they physically restrain Bill when he lashes out at them and the nurses.

Following further assessment by the Medical Officer, Bill is placed on an involuntary Treatment Authority (TA) under the Mental Health Act 2016 (Qld). By this time, he appears physically exhausted, sobbing and stating that he wants to die.

Major depressive disorder referred as clinical depression, it impact individual behaviour and mood affecting person physical welling as well, there are different possible factors triggering the condition such as biological, social, and psychological, however due the depression person can experience range of behavioural and physical symptoms (Biehn et al., 2013), in consideration to the Bills case study five signs and symptoms of major depressive disorder are:

• High alcohol consumption (substance abuse)

• Abusive behaviour

• Verbally and physically threatening

• Restlessness , physically exhausted

• Suicidal thoughts (Bill said he wants to die)

It is been identified that person who is suffering from the any mental disorder significantly affects their family and friends (Nguyen, Chatters, Taylor & Mouzon, 2016).Bill behaviour has impacted his relationship with wife and children, mental illness has a significant effect on the relationship with family and friends. The four behaviour bill is showing impacted his family and friends are:

• Abusive behaviour (He is abusive with the neighbours that is the reason for his social isolation)

• Bill become verbally and physically threatening that probably would have scared people to maintain a distance

• High alcohol consumption has impacted bills behaviour to make right decision (due to this he is been abusive with his wife)

• Suicidal thoughts has concern his sister

All these behaviour has impacted his relationship with his family and friends.

The three common misconception about the mental illness are:

• People with mental illness are violent and dangerous (Kaur & Kaur, 2019).

• If person with mental illness became suicidal if their cries for help or thoughts were not noticed by others.

• If person has mental illness they are unfit for a job.

These are three common misconception about mental illness which is reinforced by Bill behaviour, for instance, Bill abusing the staff, Bill losing his job, bill stating he wants to die as he thinks staff didn’t understand his feeling.

There are few common misconception about mental illness such as people with mental illness are violent and dangerous, they are unfit to carry out any task that’s the reason they don’t hold on to a job, became suicidal if not given acknowledgment (Kaur & Kaur, 2019), as these misconception are supported by bill behaviour in the service it is possible that staff has believed these fallacies and have judged him and will treat differently giving rise to the discrimination.

For effective based practise when planning appropriate care delivery to bill it is vital to consider following:

The recovery oriented practise is vital to consider when planning the care delivery plan for bill, it is vital that bill take responsibility of their own recovery and health by defining goals, and riving motivation.  Considering the bill need is vital in making effective care delivery plan. For instance, as bill has agitation issue the psychologist/counsellour can support bill in providing strategies to control emotions and supporting in overall mental wellbing, taking support from community service provider to attain support for bill to improve better social gathering and job opportunity. Thus, it is vital to consider patient need when planning evidence based care delivery and incorporating the patient in the plan to ensure that patient fully participate and take responsibility to attain care goal (Piat & Lal, 2012)

As per mental health standard published by nursing and midwife board of Australia it is vital to maintain the dignity of the patient in the professional space (Papastavrou, Efstathiou & Andreou, 2016). It is vital as carer to care for bill respecting his culture, age, individuality, maintaining confidentiality, etc. through working in obligation to organization and federal policy, and demonstrating therapeutic skills will support in maintain bill dignity and uniqueness supporting effective patient-centered care. as per standards the two ways I can ensure bill dignity and uniqueness are:

Standard 1: by respecting his culture, value, belief and ensure thati work without any discrimination.

Standard 3:  working in compliance to this standard to ensure that I demonstrate therapeutic relationship with bill choices, expectation, life experience and situations, encouraging and supporting bill to identify his strengths, stay motivated to ensure speedy recovery and healthy wellbing. 

It is been identified that people who are suffering from major depressive disorder are usually agitated due to different elements such as embarrassment caused due to their behaviour/action, feeling insulted, denial/social isolation, if person is afraid (Scali et al., 2019). In Bills case the four common triggers for aggressive behaviour are:

• Social isolation: due substance abuse he is being abusive with his wife and neighbours, as he is separated from his wife this may be possible triggers for aggression as may have feel rejected or denied. 

• Embarrassment: Bill embarrassment of his action and behaviour might also trigger aggression

• Unemployment: feeling frustrated due to unemployment also contribute to triggering aggressive behaviour

• Insulted: Bill think people didn’t understand his thoughts, feelings and emotions, that make him annoyed triggering the aggressive behaviour.

The 6 nursing intervention I as EN will use deflect triggers or de-escalate a patient who is agitated or aggressive are:

3b1   Communication skills (2 skills)

Two effective communication skills:  I will ensure I use effective communication skills both verbal and non-verbal to prevent aggressive behaviour.

• -Verbal communication skills: demonstrating verbal communication skills such as soft voice tone, being clear, confidence, friendly talk, etc. will support in comforting the patient and improve rapport (Jalil, Huber, Sixsmith & Dickens, 2017).

• -Non- verbal communication skills: non-verbal skills such as eye contact, lowering the shoulder, calm and positive body language support in de-escalating the aggressive situation.  

3b2     Listening skills (2 skills)

• Active listening skills: active listening skills support in understanding patient perspective and thought help in preventing the aggressive behaviour.

• Understanding:  this help in building in trust and rapport with the patient that makes patient believe that their emotions are understood help in preventing the aggressive behaviour.

3b3   Other de-escalation skills (2 skills)

Two des-escalation skills:

• Respecting personal space: when patient feel agitated I will ensure I respect the personal space. Respecting patient emotions, culture, etc. help in comforting the patient and managing the situation.

• Verbal affirmation/monitoring: verbal affirmation such as I see, thankyou help in comforting the patient, and monitoring to avoid conflicting situation. 

I can seek support from senior doctor, chef psychiatrist, and bill sister to obtain guidance and support to deliver quality patient-centered care without any ambiguity and medical errors. They can help in making a more effective care plan to de-escalate aggressive behaviour of bill.  Taking support from the senior health professional help in managing the patient condition more effectively (Varghese, Khakha,  & Chadda, 2016).

The Queensland Drug and Alcohol Withdrawal Clinical Practice Guidelines offers guidelines for treating withdrawal from alcohol and other drugs (Wein traub, 2017). Elective presemtation is needed to identify withdraw risk, managing withdrawl symptoms by using crisis presentation, stablsiing medical and psychiatric condition.  Tho assess the correct dose of diazepam it is vital to consider following-

• Note the dose (in milligrams)

• Time to peak concentration 30-90m min

• Equivalent dose 5 mg

• Depending on half life of drug onset monitoring, duration 3-6 weeks

Patient may experience headache, anxiety, insomnia,muscle aching etc.

Diazepam is prescriped ofr anxiety, reduce alcohol withdrawl symptoms, seizure, (Wein traub, 2017), considering the bill case it is presecribed for alcohol withdrawl symptoms.

Two (2) contraindications to use diazepam

-depression

-low amount of albumin proteins in the blood

Route:

Diazepam can be administered both orally, and intravenously.

Explain one (1) commonly used approach:

Usually diazepam is given intervenously.

State five (5) Possible Adverse effects Bill could experience using Diazepam

• Tiredness

• Drowsiness

• Fatigue

• Muscle weakness

• Difficulty in breathing

• Communication: Asking Bill directly if he understand the use, administration, and effects of the medication or not by using effective verbal and non-verbal communication skills (Liu, Gerdtz & Manias, 2016).

• Asking open ended question: asking open ended question to ensure bill understand the medication use, and effect.

• Monitoring:  visual on-set observation of bill will support in ensuring bill understands the procedure.

• Obtain inform consent: obtaining consent from the patient help in ensuring bill understand the use, administration method and possible effect of the medication

Poor Oral Health

Nursing Strategies

• Consult dental providers to provide guidance on the appropriate dental care.

• Identify current and potential source of poor oral health

Possible causes of poor oral health

• Stress

• Alcohol

• Poor diet

Categories of risk identified

• Abusive 

• Suicidal thoughts

• Agitation and anger

• Self-harm

Detail any historical information that may indicate the potential for risk ( for example previous history or risk behaviours / threats)

• Extreme addiction to alcohol, substance abuse

• Bill is separated from his wife and children

•  he has a history of domestic abuse due to his alcohol consumption

• Verbally abusive to his neighbors.

• Unemployment

What environment factors may contribute to risk ( for example, access to drugs alcohol, access to weapons)

Environment factors like access to object that can cause harm such as knife, glass, blade, heavy objects, etc (Coffey et al., 2017).  Increase risk of physical harm, poor relationship with family effect the psychological wellbeing, access to drugs and alcohol effect the thinking capability of bill. These factors contribute to risk.

Is there any current evidence to suggest “planned intent” to engage in risk – related behaviours

As bill is suicidal, and his aggressive behaviour suggest to engage in risk related behaviours.

Are there any risk factors that indicate preferred staff allocation( for example danger to women, intimidation to men, need for 2 workers)

Bill become aggressive verbally and physically threatening toward nursing staff, it is vital when providing care two male staff or one female and one male staff is appointed so that the patient can be managed easily without any harm to patient or staff.  Also it is vital that security stay close to the room, panic button or phone in the room when providing care for aggressive patient.

What strengths and opportunities can you identify, from the consumer and /or services as resources to support this plan

The support from senior health professionals, counsellor, therapist, security and working in obligation to organization policy will help in making more patient-centered care plan so that more effective care can be provided without any physical harm.

State specifically the identified risk

Physical harm to both patient and staff.

The five domain related to recovery-oriented practise and service delivery are:

Domain 1: Promoting a culture and language of hope and optimism

-A service culture and language that makes a person feel valued, important, welcome and safe, communicates positive expectations and promotes hope and optimism.

Domain 2: Person 1st and holistic

- Putting people who experience mental health issues first and at the centre of practice and service delivery; viewing a person’s life situation holistically

Domain 3: Supporting personal recovery

-Personally defined and led recovery at the heart of practice rather than an additional task

Domain 4: Organisational commitment and workforce development

- Service and work environments and an organisational culture that are conducive to recovery and to building a workforce that is appropriately skilled, equipped, supported and resourced for recovery-oriented practice

Domain 5: Action on social inclusion and the social determinants of health, mental health and wellbeing

- Upholding the human rights of people experiencing mental health issues and challenging stigma and discrimination

(Tran et al., 2019)

Person 1^st and holistic: Putting people who experience mental health issues first and at the centre of practice and service delivery; viewing a person’s life situation holistically (Tran et al., 2019). I will use this domain in Bills situation when assisting with planning his nursing care, I will ensure that the information I gathered by talking to bill, I effectively communicate his need in the planning so that effective patient-centred plan can be made to meet the bill need. 

Bill has remained in the mental health care facility for 4 days and there is now talk of possible discharge. A case management meeting has been arranged to discuss a plan for moving forward

Members attending the case meeting

Why?

Psychologist

Psychologists will help in caring for the patient as the psychologist focus extensively on psychotherapy and treating emotional and mental suffering with behavioural intervention (Parikh et al., 2016). Psychologist will support bill to identify the emotional triggers, will support bill to control his emotions supporting better mental wellbeing.

Commnuitnu service provider

Community service provider will support bill in maximising health outcome, for instance, to increase social gathering through book reading events, helping bill to find the job build his strength, being independent, etc. 

GP

To check health of the patient and ensure effective treatment is given.

Dietician

Healthy eating improves overall health thus contacting dietician will support in provding better health diet for bill patient.

Yoga instructor

This will help in improving mental wellbing of the bill, as meditation improves mental wellbing patient (Rosell, Alexandersson, Hagberg & Nilbert, 2018).

Multicultural mental health Australia will support bill in participating in community event to increase social connection and support in better wellbing and lifestyle by providing guidance to about incorporating healthy activity Massimi et al., 2017), and will help bill to identifying own strength to recover fast and will support in finding employment opportunity.

Alcohol and other Drug council of australia can help bill to move forward in life, avoid substance and alcohol use, improve lifestyle that can help in avoiding stress and support in healthy wellbeing. These service support patient to strengthen their abilities and improve lifestyle by providing different opportunity and support ( Massimi et al., 2017).

Contacting them through the their webistes  www.mmha.org.au/About and  www.adca.org.au/  will support bill to meet his need, such as avoiding substance and alcohol use, find employment and improve lifestyle that can help in avoiding stress and support in healthy wellbeing. ( Massimi et al., 2017).

As EN in the case meeting of bill the three possible roles are-

• Collating information, record outcomes of case

• Informing patient general practitioner, psychiatrist about outcomes

• Result of diagnostic examinations, all relevant medical history details (Rosell  Alexandersson, Hagberg & Nilbert, 2018).

This will help in understanding the progress of bill treatment and needs to effective outcome.

Acknowledging the strengths of the bill, developing confidence, involving the patient in care and recovery plan for better outcomes is the first step in healthy wellbeing and better life. This outcome and be attained by using strength-based approach and implementation of therapeutic communication skills and working in obligation organization and federal policy (Walravens, Bierbooms & Ter-Horst, 2019), and procedure incorporating the concept of care to ensure that will help in delivering quality care and influencing bill to identify his strengths to take as much responsibility as possible for the decision that affects his life.