CHCMH408B Provide interventions to meet the needs of consumers with mental health and AOD issues. Introduction
Case study of Susan a female patient age 40 years old. Name change due to confidentially and I had been given consent to obtain and access her personal medical file for the purpose of my study. In her 40s, Susan is beginning to experiencing bouts of unhappiness. she turned to alcohol. The trauma early in Susan’s life, coupled with the subsequent health problems had placed Susan at risk for developing a serious psychiatric disorder as an adult. Despite getting help for depression, her drinking gradually increased. Following the death of her mother in 2003, Susan’s addiction escalated to the point that she could not start the day without a drink. It was in great emotional pain, and her drinking increased. At this point, she was never sober. Recently she had turned herself to cannabis smokers. Susan had identifying her first problem. She wanted to get well and be normal allowing her greater freedom from the horrible side-effects of alcohol. She was placed on an antidepressant medication to assist her in functioning better. Her family is very supportive. She had a secure and stable family. Susan is fully aware of her mental state. She scored full in Mini mental state examination. Her speech is normal and calm. Therapeutic relationship
Susan and I had a nurse-patient relationship that's based on mutual trust and respect. I had been providing care in a manner that enables Susan to be an equal partner in achieving wellness. I had always make sure Susan has privacy when provide care and be sure that her basic needs are met, including relieving pain or other sources of discomfort. I too had actively listened to her to make sure I understand her concerns by restating what she has verbalized. I had maintained professional boundaries like respecting differences in her cultures. We as nurses help Susan achieve harmony in mind, body, and spirit when engaging in a therapeutic relationship based on effective communication that incorporates caring behaviours. It's a win-win situation in which the nurse and Susan can experience growth by sharing the moment with each other. Assessment
We did assessment for Susan as the first part of the nursing process, and thus form the basis of the care plan. The essential requirement of accurate assessment is to view Susan’s holistically and thus identify her real needs. Through the use of a scoring formula identification of evidence to support decision making and practice. The assessment tool will assist nurses to both articulate and quantify the nursing contributions to care. Susan’s chart provides information about his health status. It includes details about the current medical condition, treatment plan, related past medical history and other important data required to create a care plan.Vital Signs, regular monitoring of a patient's heart rate, blood pressure, temperature and respiratory rate allows the nurse to help prevent life-threatening complications and evaluate a Susan’s overall condition. Abnormalities can indicate a variety of problems ranging from anxiety to heart failure. Susan’s interview is the one of the most important assessment tools the patient herself. An initial detailed interview to get a full picture of Susan’s physical and mental status. Patient Safety Plan
There was a Patient Safety Plan for Susan. The purpose of the safety plan is to encourage Susan to identify calming strategies that may be of assistance to them while she is in hospital. This plan helps to list those things that can be assistance and encourage helping prevent a crisis developing that might place the patient and others at risk. The plan helps to list Susan‘s activities and strategies that find helpful in keeping calm. For example Susan likes listening to slow and sentimental music and doing artwork to calm her nerves. She does not like noise and being bullied these will act as triggers and she...
Please join StudyMode to read the full document