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226 PHYSICAL EXAMINATION

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THE CONSUMER WITH DELIRIUM

This case study illustrates the application and objective documentation

UNIT 2

of the mental health status and neurological assessment.

Mrs Nina Tabone is a 91-year-old lady who resides at home and presents with symptoms of delirium.

HEALTH HISTORY

CONSUMER PROFILE 91-year-old, widowed, lives home alone

CHIEF COMPLAINT Periods of confusion, distress and sleep disturbance

HISTORY OF THE PRESENT ILLNESS

PAST HEALTH HISTORY MEDICAL HISTORY Hypertension (idiopathic) for last 35 years

CASE STUDY 1

Consumer has been confused for short periods during the afternoon and evening, and spent a disturbed night, waking every 2 hours (approximately) and calling out in distress.

Osteoarthritis with reduced mobility in left hip (ambulates with walker) since a fall 8 months ago resulted in a fractured left neck of femur. Arthritis in hands with considerable deformity. Still lives home alone, but recently has had daughter staying with her since shehad COVID-19 a month ago. Has been treated twice over past 6 months forchest infection. Has had productive cough for past two days, sputum now green and yellow.

SURGICAL HISTORY Appendectomy at age 16

Left hip replacement 8 months ago (following a fall)

ALLERGIES Penicillin – rash

MEDICATIONS Ibuprofen prn for headache

Lisinopril 10mg mane for hypertension Lasix 40mg mane for uid Caltrate with vitamin D 600mg once daily for osteoarthritis

COMMUNICABLE DISEASES

INJURIES AND ACCIDENTS

SPECIAL NEEDS Self-ambulates with walker. Food preparation ability is now minimal; had been

BLOOD TRANSFUSIONS Denies

CHILDHOOD ILLNESSES Chickenpox, measles, mumps as child. No sequelae

IMMUNISATIONS Up to date

FAMILY HEALTH HISTORY Nil known

SOCIAL HISTORY ALCOHOL USE Nil

TOBACCO USE Nil

DRUG USE Nil

DOMESTIC AND INTIMATE PARTNER VIOLENCE

SEXUAL PRACTICE No longer sexually active

TRAVEL HISTORY Immigrated to Melbourne with husband in 1950s

Denies

Fractured left neck of femur 8 months ago

using Meals on Wheels, but since daughter has come to stay has not been able to manage as well as she used to before having had COVID-19

Widowed, usually lives alone, daughter staying with her since she had COVID-19 one month ago

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 227

CHAPTER 7

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HEALTH HISTORY

WORK ENVIRONMENT Retired

HEALTH MAINTENANCE ACTIVITIES

HOME ENVIRONMENT Lives at Bundaberg now in a lowset unit at the beach.

HOBBIES AND LEISURE ACTIVITIES

STRESS Becomes frustrated with deformed hands and decreasing ambulatory ability

EDUCATION Went to Grade 6

ECONOMIC STATUS Middle class

RELIGION Roman Catholic

CULTURAL BACKGROUND

ROLES AND RELATIONSHIPS

CHARACTERISTIC PATTERNS OF DAILY LIVING

SLEEP 6 hours/night, usually restful; no sleep aids used

DIET Low salt

EXERCISE Ambulates with difculty with walker

STRESS MANAGEMENT

Watching television and listening to speaking books

Sicilian

Mother, grandmother, great grandmother

Goes to respite twice a week, otherwise wakes early and has coffee and bread with butter. Has early lunch and dinner, and bed by 8 p.m. Days that she goes to respite, leaves the house at 10 a.m. and returns at 4.30 p.m.

Listening to music and speaking books

USE OF SAFETY DEVICES

HEALTH CHECK-UPS GP visit when ill, does not like to go to the doctor

Seat belt in care

PHYSICAL EXAMINATION

MENTAL STATUS 1 Physical appearance and behaviour:

a Posture and movements: lying on ambulance stretcher, curled up in left lateral position b Dress, grooming and personal hygiene: has been incontinent of urine (which is unusual), dressing gown

wadded up to waist, bed clothes twisted

c Facial expression: grimacing

d Affect: distressed 2 Communication: mumbling 3 Level of consciousness: awake, alert and disorientated; GCS = 14 oriented to person, not place, part of day

(morning, afternoon or evening), month or year

4 Cognitive abilities and mentation:

a Attention: unfocused, easily wanders, appears to be responding to things/people the nurse is

unable to see

b Memory: intact long-term, short-term confused about where she is and why she is here

c Judgement: unable to focus consumer to answer

d Insight: unable to assess – consumer not able to focus

e Spatial perception: unable to assess – consumer not able to focus

f Calculation: unable to assess – consumer not able to focus

g Abstract reasoning: unable to assess – consumer not able to focus

h Thought process and content: confused, distressed about not recognising room and people, talking to

people who are not present (particularly husband who is deceased)

i Suicidal ideation: unable to assess – consumer not able to focus

228 PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION

SENSORY 1 Exteroceptive sensation:

UNIT 2

CRANIAL NERVES I: Smells – did not assess, consumer too distressed and confused

a Light touch: equal and intact bilaterally b Supercial pain: did not assess, consumer too distressed c Temperature: did not assess, consumer too distressed

2 Proprioceptive sensation:

a Motion and position: did not assess, consumer too distressed b Vibration sense: did not assess, consumer too distressed

3 Cortical sensation:

a Stereognosis, graphaesthesia, two-point discrimination, extinction: did not assess, consumer

too distressed

II: Visual acuity with glasses; visual elds intact as focuses on nurse until leaves visual eld, unable to assess further. When responding to things the nurse cannot see, states she is calling the cat in the corner ofthe room to come and eat. There is no cat in the room. III, IV, and VI: EOM intact, pupils equal, round, react to light, accommodation (PERRLA) V: Did not assess, consumer too distressed VII: Intact; no facial palsy, ptosis or asymmetry; taste deferred VIII: Gross hearing intact; did not assess further, consumer too distressed IX and X: Intact gag reex, uvula midline; taste deferred XI: Did not assess, consumer too distressed XII: Tongue midline, speech mumbling

MOTOR

CEREBELLAR FUNCTION

DIAGNOSTIC DATA Sputum collected

1 Size: equal bilaterally 2 Tone: did not assess, consumer too distressed 3 Strength: did not assess, consumer too distressed, but gripping sides of bed with equal strength bilaterally 4 Involuntary movements: none 5 Pronator drift: did not assess, consumer too distressed

1 Coordination: unable to assess 2 Gait: unable to assess

EVALUATION AND CLINICAL REASONING FOR CASE STUDY

Considerations for making clinical decisions for this consumer need to take into account the scope of practice of the nurse assessing the consumer. Nurses in advanced practice positions, such as nurse practitioners and, depending on the role, remote area nurses with endorsement for advanced practice, may be able to make diagnostic decisions and prescribe medications without referring to a medical ofcer. The majority of nurses, however, work within a scope of practice in which nurses will collect the above information, consider all the data, refer to a medical ofcer and carry out the prescribed interventions, with some autonomy on assessing the consumer’s level of education required for providing additional advice. Nurses are often required to monitor the consumer’s response to these interventions, and to decide on what symptoms or developments are signicant to report to the medical ofcer. Being able to appropriately decide when this should occur relies on the nurse applying a good understanding of underlying pathophysiology, consumer symptoms, baseline data and critical thinking to consider all this information in a meaningful way for directing consumer care. Thisis the process that is referred to as clinical reasoning. Thephases presented in the clinical reasoning

cycle are stepped out below, drawing on information presented and collected during the health history and physical assessment. We then work through the cycle components that are relevant to this case study (cycle components are bolded).

Nurses have a positive impact on consumer outcomes and the use of systematic clinical reasoning skills in this situation is critical to supporting the consumer.

For Mrs Tabone, the 91-year-old woman who presents with confusion, sleep disturbance and distress, the following significant data needs to be considered.

Collecting cues/information

Recall and Review: In the rst instance you will need to reect on

what you know about delirium, confusion, and why and how this manifests in the elderly population.

Chief complaint and history of present illness

> Periods of confusion, distress and sleep disturbance over

past18 hours.

> Consumer has been confused for short periods during the

afternoon and evening, and spent an unrestful night, waking

every 2 hours (approximately) and calling out in distress.

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 229

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Processing information

Interpret: These symptoms and details of history outline the scope

of the issue for this consumer, and we would need to ensure that this is not their usual behaviour. For this we need to rely on the daughter’s knowledge of this consumer’s usual condition. Usually Mrs Tabone is alert and lucid and has not displayed thesesymptoms before.

Medical history

> Hypertension (idiopathic) for last 35 years. > Osteoarthritis with reduced mobility in left hip (ambulates

with walker usually) since a fall 8 months ago resulted in a fracturedleft neck of femur. Arthritis in hands with considerable deformity.

> Still lives home alone, but recently has had daughter staying

with her since she had COVID-19 a month ago. Has been treated twice over past 6 months for chest infection. Has hadproductive cough for past two days, sputum now green and yellow.

Interpret, Match and Infer: Mrs Tabone’s medical history is important to note as this tells us that she is vulnerable to recurringchest infections, especially as she has likely become frailer since her operation and her increasing immobility. Alsoherrecent infection with COVID-19 may make her more opento other infections.

Allergies

> Penicillin: rash

Medications

> Ibuprofen prn for headache > Lisinopril 10mg mane for hypertension > Lasix 40mg mane for uid > Caltrate with vitamin D 600mg once daily for osteoarthritis

Infer and Relate: Both use of medications and past allergies need to be accurate and considered as it will be likely that Mrs Tabone may need to have further medications prescribed, but we also need to see if any of the medications she has been on are new or could cause these types of symptoms.

Mental status

1 Physical appearance and behaviour:

a Posture and movements: lying in bed, curled up in left

lateralposition

b Dress, grooming and personal hygiene: has been incontinent

of urine (which is unusual), dressing gown wadded up to waist, bed clothes twisted

c Facial expression: grimacing

d Affect: distressed 2 Communication: mumbling 3 Level of consciousness: awake, alert and disorientated;

GCS= 14 orientated to person, not place, part of day

(morning,afternoon or evening), month or year

4 Cognitive abilities and mentation:

a Attention: unfocused, easily wanders, appears to be

responding to things/people the nurse is unable to see

b Memory: intact long-term, short-term confused about where

she is and why she is here

c Thought process and content: confused, distressed about

not recognising room and people, talking to people who are not present (particularly husband who is deceased)

Interpret: Mrs Tabone shows marked changes in mental status, is easily distracted by stimuli not apparent to the nurse, shows signs of confusion and is not oriented to the location she is in. Although Mrs Tabone is not usually orientated to date, she is usually orientated to her location, month and year. She has been incontinent of urine, unusual for this lady as she usually is able to ambulate in time to reach the toilet. Unable to focus Mrs Tabone without distressing her to undertake detailed mental status such as calculation etc.

Cranial nerves

> II: Visual acuity with glasses; visual elds intact as focuses

onnurse until leaves visual eld, unable to assess further. When responding to things the nurse cannot see, states she iscalling the cat in the corner of the room to come and eat. There is no cat in the room.

> III, IV and VI: EOM intact, PERRLA > VII: Intact; no facial palsy, ptosis or asymmetry; taste deferred > VIII: Gross hearing intact; did not assess further, consumer

toodistressed

> IX and X: Intact gag reex, uvula midline; taste deferred > XII: Tongue midline, speech mumbling > Motor – strength: did not assess, consumer too distressed,

butgripping sides of bed with equal strength bilaterally

> Involuntary movements: none

Distinguish and Infer: Assessment of some of Mrs Tabone’s cranial nerves show no signs of other neurological issues or symptoms of stroke or transient ischaemic attack. This allows us to rule out mechanical neurological issues and surmise that delirium caused by chemical imbalance or delirium caused by sepsis may be responsible for her change in mental status.

The above supposition of infection causing delirium would need to be further substantiated by undertaking respiratory assessment, and to also look for symptoms of sepsis such aspyrexia.

Match and Infer: Since Mrs Tabone has had recurring chest infections, has reduced mobility, has had a recent COVID-19 infection, has symptoms of a productive cough, the other symptoms (rapid onset of confusion, sleep disturbance, distress and visual hallucinations) AND lack of further neurological ndings (such as facial palsy, slurred speech) point to delirium asa probable cause of Mrs Tabone’s change in condition.

CHAPTER 7

230 PHYSICAL EXAMINATION

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Putting it all together – synthesise information

The nurse in this case would document all of these abnormalities, and refer to the medical ofcer. As it is likely antibiotics will

UNIT 2

be prescribed, the nurse will need to check that medication prescribed is not of the penicillin family (as consumer has allergy to this) or has contraindications or adverse interactions with MrsTabone’s antihypertensive drugs.

1 inhaling steam to help loosen secretions 2 continue use of ibuprofen for analgesia and comfort measures 3 rest and sleep as much as possible until symptoms improve;

this will aid the body’s immune response

4 orientate consumer regularly without distressing consumer 5 monitor consumer closely since confusion can increase risk

offalls, or higher risk for injury via hot drinks etc.

The nal step in the process is accurate documentation. The

Actions based on assessment ndings

The nurse should also provide additional education for interventions that do not require a doctor’s order, such as:

nurse must document ndings, referrals, interventions, advice andeducation given. The consumer would continue to have ongoing long-term management and follow-up by specialist medical staff in collaboration with general practitioner.

THE CONSUMER WITH EARLY ONSET DEMENTIA

This case study illustrates the application and objective documentation of the mental health status and neurological assessment.

HEALTH HISTORY

CASE STUDY 2

CONSUMER PROFILE Mrs Margie Thomms is a 53-year-old who lives at home with her husband.

CHIEF COMPLAINT Confusion and behavioural change, especially inappropriateness, angry outbursts and impulsivity with

hyperactivity, particularly pacing.

HISTORY OF THE PRESENT ILLNESS

PAST HEALTH HISTORY MEDICAL HISTORY History of anxiety and previous addiction to diazepam and alcohol treated

FAMILY HEALTH HISTORY Nil known

SOCIAL HISTORY ALCOHOL USE Nil (previous dependence as noted in medical history)

Husband describes gradual deterioration in cognitive function including memory loss, and lack of tact in social interactions over last six months to one year.

successfully after rehabilitation 10 years ago

SURGICAL HISTORY Previous caesarean section 20 years ago

ALLERGIES Nil

MEDICATIONS Fish oil

COMMUNICABLE DISEASES

INJURIES AND ACCIDENTS

SPECIAL NEEDS Independent with mobility

BLOOD TRANSFUSIONS Nil

CHILDHOOD ILLNESSES Chickenpox as a child

IMMUNISATIONS All immunisations up to date

TOBACCO USE Nil

Nil

Recent fall without injury

DRUG USE Nil (previous dependence as noted above)

DOMESTIC AND INTIMATE PARTNER VIOLENCE

Nil

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 231

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HEALTH HISTORY

SEXUAL PRACTICE Previously sexually active in stable relationship; now difculty connecting

emotionally and physically

TRAVEL HISTORY Immigrated from the United Kingdom to Australia 20 years ago

WORK ENVIRONMENT Former school teacher; currently on sick leave

HOME ENVIRONMENT Two-storey house with level external access

CHAPTER 7

HEALTH MAINTENANCE ACTIVITIES

HOBBIES AND LEISURE ACTIVITIES

STRESS Angry outbursts usually related to frustration or misunderstanding situation

EDUCATION University education

ECONOMIC STATUS Middle class

RELIGION Anglican

CULTURAL BACKGROUND

ROLES AND RELATIONSHIPS

CHARACTERISTIC PATTERNS OF DAILY LIVING

SLEEP 7 hours/night on ‘good night’; sometimes up several times at night

DIET Previously had healthy diet, now periods of binge eating

EXERCISE Walking was main exercise but now not motivated

STRESS MANAGEMEN T Listening to music. Previously enjoyed reading, however now unable to focus

USE OF SAFE TY DEVICES Nil

Previously played piano, however no longer showing interest. Enjoyed family gatherings but now has difculty with social situations – ranging from quiet and withdrawn to inappropriate and tactless in conversation

Anglo-Scottish

Wife, mother, grandmother

Previously managed household duties (cooking, laundry, shopping) but now unable to organise self to carry out these duties Difculty with initiating social gatherings with family

HEALTH CHECK-UPS Regular GP who has known her over 20 years

PHYSICAL EXAMINATION

MENTAL STATUS 1 Physical appearance and behaviour:

a Posture and movements: sitting in chair with stooped posture b Dress, grooming and personal hygiene: unkempt appearance – hair uncombed, obvious body odour;

foodstains on shirt; still maintaining continence as per family

c Facial expression: puzzled expression

d Affect: attened 2 Communication: some word-nding difculties; some preservation 3 Level of consciousness: awake, alert and disorientated; GCS = 14 orientated to person, not place, part of day

(morning, afternoon or evening), month or year

4 Cognitive abilities and mentation:

a Attention: difcult to keep on track in conversation; tangential conversation

b Memory: intact long-term, short-term confused about where she is and why she is here

c Judgement: does not demonstrate insight. Family expresses concern about her ability to manage her

nances and recently had to take away her credit cards as she was not able to manage her spending

d Insight: as above – lacking insight and empathy for others

e Spatial perception: normal, no neglect

f Calculation: unable to carry out serial 7s

g Abstract reasoning: not able to explain proverb ‘people in glass houses shouldn’t throw stones’

h Thought process and content: confused

i Suicidal ideation: no suicidal ideation

232 PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION

SENSORY 1 Exteroceptive sensation:

UNIT 2

CRANIAL NERVES Intact except for smell, which was impaired

a Light touch: equal and intact bilaterally b Supercial pain: normal

c Temperature: normal 2 Proprioceptive sensation: normal 3 Cortical sensation: unable to understand commands

MOTOR

CEREBELLAR FUNCTION

1 Size: no obvious wasting of muscle groups 2 Strength: upper and lower limb 5/5 bilaterally 3 Tone: normal 4 Involuntary movements: none 5 Pronator drift: no drift

1 Coordination: intact nger-to-nose test and heel-to-shin 2 Gait: no ataxia

DIAGNOSTIC DATA

MRI Report: signicant right hemisphere atrophy in the frontal and anterior temporal region

VITAL SIGNS & LABORATORY DATA

EVALUATION AND CLINICAL REASONING FOR CASE STUDY

Considerations for making clinical decisions for this consumer need to take into account the scope of practice of the nurse assessing the consumer. Nurses in advanced practice positions, such as nurse practitioners and, depending on the role, remote area nurses with endorsement for advanced practice, may be able to make diagnostic decisions and prescribe medications without referring to a medical ofcer. The majority of nurses, however, work within a scope of practice in which nurses will collect the above information, consider all the data, refer to a medical ofcer and carry out the prescribed interventions, with some autonomy on assessing the consumer’s level of education required for providing additional advice. Nurses are often required to monitor the consumer’s response to these interventions, and to decide on what symptoms or developments are signicant to report to the medical ofcer. Being able to appropriately decide when this should occur relies on the nurse applying a good understanding of underlying pathophysiology, consumer symptoms, baseline data and critical thinking to consider all this information in a meaningful way for directing consumer care. This is the process that is referred to as clinical reasoning. The phases presented in the clinical reasoning cycle are stepped out below, drawing on information presented and collected during the health history and physical assessment. We then work through the cycle components that are relevant to this case study (cyclecomponents are bolded).

For Mrs Margie Thomms, the 53-year-old woman who presents with confusion and behavioural change, the following signicant data needs to be considered.

All within normal limits

Collecting cues/information

Recall and Review: Reect on what you know about dementia,

focusing on frontal temporal dementia including presentation, ageof onset and pattern of illness.

Chief complaint and history of present illness

> Behavioural and cognitive changes in previously

healthy woman

Processing information

Interpret: The family is often a major source of information

when the consumer presents with dementia. Although in the rst instance the questions are addressed to the consumer, it is important to use family members as a resource when collecting data and interpreting assessment ndings.

Medical history

Although this consumer had a past history of both anxiety and problems with drug and alcohol addiction, she successfully recovered and there is no history of dependence currently. MrsThomms’ only medication is sh oil. There is no medication history that would suggest a cause for her behavioural changes. Vital signs and laboratory data are within normal limits.

Putting it all together – synthesise information

Mrs Thomms presents with a decline in her cognitive and behavioural function while maintaining her motor and sensory function. She is able to ambulate independently and manage most activities of daily living and is continent. Mrs Thomms is not able to carry out her normal roles both at home and in her

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 233

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professional role as a teacher. Because she has lost the ability to be empathetic towards others, this also affects her social role both within her family and within her social circle.

Actions based on assessment ndings

The priorities for this consumer are as follows.

In hospital:

1 Assess falls risk. 2 Assess level of agitation and risk to consumer, family and

staff members.

3 Provide a single room if possible and limit visitors to two

each time.

4 Manage periods of agitation; may need one-on-one nursing if

at risk of leaving the hospital. Avoid mechanical restraint as it may lead to escalation of agitation.

5 Discuss with team the pros and cons of medication to manage

behaviour if indicated.

6 Document ndings in progress notes and develop a

behavioural management program for staff members caring for Mrs Thomms.

THE CONSUMER WITH DEPRESSION AND ANXIETY

On discharge home:

1 Address safety and environmental concerns: safety of home

appliances, securing food to prevent bingeing, supervision when crossing roads given impulsiveness, driving restrictions and angermanagement strategies for Mrs Thomms and her family members.

2 Managing nances: may require referral to social worker to assist. 3 Managing challenging behaviours: educate family carers on

how to manage challenging behaviours as well as provide written information.

a Speak calmly. b Use simple one-step commands. c Positively reinforce appropriate behaviour. d Provide a restful environment at mealtime (quiet music,

soft lighting).

e Educate family to not engage in lengthy explanations or try

to rationalise with Mrs Thomms.

f Combat restlessness by engaging in walking program. g Consider community resources for a walking program and

other programs, and make appropriate referrals.

h Document in the progress notes the education provided to

family on discharge.

CHAPTER 7

This case study illustrates the application and objective documentation of the mental health status and neurological assessment.

HEALTH HISTORY

CONSUMER PROFILE Mr Joseph Shaw, a 25-year-old single male, currently living with parents

CHIEF COMPLAINT Reports low mood for 12 months, distress, sleep disturbance, panic attacks

HISTORY OF THE PRESENT ILLNESS

PAST HEALTH HISTORY MEDICAL HISTORY Nil

Consumer has reported suicidal thoughts over the past 2 months, has been unable to go out in public places over the past 6 months, experiencing increase in panic attacks, reports lowered mood for 12 months.

SURGICAL HISTORY Nil

ALLERGIES Nil

MEDICATIONS Cipramil 20mg mane

COMMUNICABLE DISEASES

INJURIES AND ACCIDENTS

SPECIAL NEEDS Nil

BLOOD TRANSFUSIONS Denies

CHILDHOOD ILLNESSES Chickenpox as child

Denies

Sporting injuries as teenager; no surgery required

CASE STUDY 3

FAMILY HEALTH HISTORY Mother: type 2 diabetes, father: hypertension

IMMUNISATIONS All immunisations as per requirement

234 PHYSICAL EXAMINATION

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HEALTH HISTORY

SOCIAL HISTORY ALCOHOL USE 6 standard drinks daily

UNIT 2

TOBACCO USE 20 cigarettes daily

DRUG USE Cannabis use, reports using 1 gram weekly

DOMESTIC AND INTIMATE PARTNER VIOLENCE

SEXUAL PRACTICE Sexually active, currently not in a relationship

TRAVEL HISTORY Nil

WORK ENVIRONMENT Currently unemployed

HOME ENVIRONMENT Lives with parents in family home, youngest child – not close to siblings; they are

HOBBIES AND LEISURE ACTIVITIES

STRESS Worried about future plans of studying and employment

EDUCATION Completed Year 12, was enrolled in Bachelor of Education, completed 2 years and

ECONOMIC STATUS Middle class background, both parents work full-time, only child still living at home

RELIGION Anglican

CULTURAL BACKGROUND

ROLES AND RELATIONSHIPS

Nil

signicantly older than him

Listening to music, watching television, art

has recently deferred university

English

Son, sibling

HEALTH MAINTENANCE ACTIVITIES

CHARACTERISTIC PATTERNS OF DAILY LIVING

SLEEP Disturbed sleep overnight, prefers to spend the day sleeping

DIET Poor appetite, reports that he has lost 6kg in the past 3 months

EXERCISE No exercise currently

STRESS MANAGEMEN T Listening to music, drawing, using THC and alcohol to help relax

USE OF SAFE TY DEVICES Nil

HEALTH CHECK-UPS Linked in with his local GP and sees her fortnightly

Prefers to spend the day in his bedroom, will have dinner with his parents; contact with friends is through social media

PHYSICAL EXAMINATION

MENTAL STATUS 1 Physical appearance and behaviour: young male, thin-built, tanned complexion, unshaven, wearing glasses,

stains on clothing, staring at the oor during conversation, poor eye contact, responsive to questions asked. Accompanied by parents to interview

2 Mood: reports low mood over the past 12 months, rates mood 3/10 3 Affect: at 4 Speech: softly spoken, normal rate, volume, tone 5 Thought form: logical and coherent in conversation 6 Thought content: reports feeling helpless and hopeless about future plans, suicidal thoughts for the past

2months; worried about his future and whether he will be better again. Reports panic attacks in public places and has been avoiding going out

7 Perception: denies perceptual disturbances

MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 235

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PHYSICAL EXAMINATION

8 Insight/Judgement: he is aware of the reasons for attending the appointment and displays intact judgement 9 Cognition: attention focused, is able to respond to questions asked, pausing at times between questions due

to feeling overwhelmed

10 Level of consciousness: alert and orientated to time, place, person 11 Memory: intact

DIAGNOSTIC DATA

Further psychiatric assessment required, physical observations taken

CHAPTER 7

EVALUATION AND CLINICAL REASONING FOR CASE STUDY

Considerations for making clinical decisions for this consumer need to take into account the scope of practice of the nurse assessing the consumer. Nurses in advanced practice positions, such as nurse practitioners and, depending on the role, remote area nurses with endorsement for advanced practice, may be able to make diagnostic decisions and prescribe medications without referring to a medical ofcer. The majority of nurses, however, work within a scope of practice in which nurses will collect the above information, consider all the data, refer to a medical ofcer and carry out the prescribed interventions, with some autonomy on assessing the consumer’s level of education required for providing additional advice. Nurses are often required to monitor the consumer’s response to these interventions, andtodecide on what symptoms or developments are signicantto report to the medical ofcer. Being able to appropriately decide when this should occur relies on the nurse applying a good understanding of underlying pathophysiology, consumer symptoms, baseline data and critical thinking to consider all this information in a meaningful way for directing consumer care. This is the process that is referred to as clinical reasoning. The phases presented in the clinical reasoning cycle are stepped out below, drawing on information presented and collected during the health history and physical assessment. We then work through the cycle components that are relevant to this case study (cyclecomponents are bolded).

For Mr Shaw, the 25-year-old single male who presents with low mood, suicidal thoughts and panic attacks, the following signicant data needs to be considered.

Collecting cues/information

Recall and Review: In the rst instance, you will need to reect

onwhat you know about anxiety, depression and substance use, and why and how this manifests in the young adult population.

Chief complaint and history of present illness

> Low mood for the past 12 months > Suicidal thoughts over the past 2 months > Panic attacks, sleep disturbance > Decline in functioning for the past 12 months > Substance use to help cope with symptoms

Processing information

Interpret: These symptoms and details of history outline the scope

of the issue for this consumer and we would need to conduct further assessments to assist with providing further information to clarify diagnosis and formulate a plan of care. For this we need to further assess Mr Shaw.

Medical history

> Mr Shaw’s medical history is not the reason for his presentation,

so it is not relevant in the current assessment. He is reporting physical symptoms of chest tightness and shortness of breath, but this is related to him reporting panic attacks.

Medications

> Cipramil 20mg mane > Mr Shaw was prescribed Cipramil by his GP 7 months ago.

He does report that he felt an improvement in his mood for 3 months after commencing Cipramil, but since then he has experienced further decline in his mood. He reports that he takes his medications daily. He will require review of his antidepressant medication due to reporting further decline in his depressive symptoms.

Mental status

1 Physical appearance and behaviour: young male, thin-built,

tanned appearance, unshaven, wearing glasses, stains on clothing, staring at the oor during conversation, poor eye contact, responsive to questions asked. Accompanied by parents to interview

2 Mood: reports low mood for the past 12 months, rates mood 3/10 3 Affect: at 4 Speech: softly spoken, normal rate, volume, tone 5 Thought form: logical and coherent in conversation 6 Thought content: reports feeling helpless and hopeless about

future plans, suicidal thoughts for the past 2 months, worried about his future and whether he will be better again. Reports panic attacks in public places and has been avoiding going out.

7 Perception: denies perceptual disturbances 8 Insight/Judgement: is aware of the reasons for attending the

appointment and displays intact judgement

9 Cognition: attention focused, is able to respond to questions asked,

pausing at times between questions due to feeling overwhelmed

10 Level of consciousness: alert and orientated to time, place, person 11 Memory: intact

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