Psychiatric-Mental Health Nursing: From Suffering to Hope

CRITICAL THINKING Claudine—Initial Onset Claudine presents to the emergency department (ED) after having a panic attack while driving to work. She pulled over and called 911 because she was hyperventilating and having pains in her jaw and shoulders; she feared she was having a heart attack and would die. The ED medical evaluation ruled out a heart attack and other physiologic reasons for her symptoms, and referred Claudine to you for a psychiatric evaluation to rule out anxiety-related panic attacks. Precipitants include difficulty in her marriage and fear of a job change or layoff in her school district. Claudine reluctantly agreed to the referral, although remains concerned about her physical health. Claudine sought help independently from the healthcare system. She is hesitant to engage in psychiatric treatment, but on some level sees a need to obtain help, which indicates some insight about her problems. During the intake interview with Claudine, you learn: “Sometimes I have chest pain and trouble breathing and feel like I’m going to die.” Claudine describes episodes of difficulty breathing with hyperventilation, rapid pulse, chest, shoulder and jaw pain which start “out of the blue.” She has had these episodes with increasing frequency over the past month, and this episode is the second one this week. During these episodes she fears that she will die. Claudine reports she has been under a lot of pressure at work and home recently, and she fears that if she is laid off at work that will make her marriage problems worse. She complains of fatigue and irritability, trouble sleeping, and difficulty concentrating at work. Claudine tells you it is hard to get her mind off her financial concerns, especially since her husband Joe was laid off last year and had to take a job at another company with a much lower salary. Claudine reports that her mind constantly goes over and over these worries. You conduct a mental status exam of Claudine to elicit more information. Your findings include: Claudine is neatly dressed and groomed and appears her stated age of 43 years old. She makes good eye contact and freely shares her history. She appears tense, restless (foot tapping, frequent position changes), and hyper-alert to her surroundings. Her speech is rapid but understandable, and circumstantial. Her mood is anxious and she has full range of affect, tearing slightly when discussing her father, smiling with discussion of children. She appears anxious and describes a “tense feeling inside” that at times “feels like every nerve is jumping.” She easily describes a range of emotions, although identifies feeling “detached” and like she isn’t real or a part of things when her anxiety increases or during episodes of hyperventilation. While she describes feeling sad at times, she denies depressed mood. She reports increased irritability lately, denies mood swings or episodes of euphoria or elated mood. She denies thoughts about taking her own life, stating that she would never do anything to harm herself due to responsibilities to her children and her religious beliefs. She denies ever having been suicidal in the past and has never made a suicide attempt. She denies homicidal thought or intent and denies history of violent or aggressive behavior. Thought is logical, goal directed, and although circumstantial, she returns to the focus with cues. Describes ambivalence and difficulty with decision making at work and home related to finances. Identifies difficulty concentrating and inability to read due to rumination about her job and marriage, resulting in distraction at work and difficulty completing tasks. Claudine is alert and responsive to questions; she is oriented to person, place, time, and situation. Normal recall of recent and remote experiences, able to identify 3 of 3 words. Able to repeat 6 digits forward and 5 backwards, and completes serial sevens without difficulty. Good fund of information, able to perform simple calculations. Able to abstract with interpretation of proverb (rolling stone gathers no moss: “if you don’t stick with things success is unlikely”). Has good judgment, and some insight of connection of stressors to anxiety symptoms, but less of relation to panic symptoms. Claudine identifies this as the first time she has ever had a mental health problem requiring intervention. Application 1. Based on these findings, what additional assessment data should you collect? 2. What is/are Claudine’s chief complaint(s) and presenting problem(s)? What other symptoms or issues do you think require nursing intervention? Answers Although the ED has ruled out any medical causation, the psychiatric nurse will want to review Claudine’s medical record and ensure her medical and drug history are complete; in Claudine’s heightened state of anxiety she may have omitted important information. Additional assessment data would center around the domains and would include any history of trauma, nutritional intake, sleep habits, use of substances such as alcohol, her family make-up, available resources and social supports, health insurance status, and what Claudine normally does to try to relieve stress and how helpful those activities are for her. Claudine’s chief complaint centers around her statement “Sometimes I have chest pain and trouble breathing and feel like I’m going to die.” The additional physiologic symptoms she is experiencing are also of concern. These symptoms are consistent with symptoms of panic level anxiety described in chapter 13, Disorders of Anxiety, Stress, and Trauma. Helping Claudine find ways to reduce her persistent worrying will likely assist in reducing the extent of her physiologic symptoms. Box 9-3 Demographic Information Referring to the case study featuring Claudine Assessment Data Claudine is a 43-year-old, White, married female. She is the mother of three school-age children. She lives in a house in a nearby suburb and works as a middle-school teacher. Application Claudine’s demographic information can be used to identify how her symptoms have affected her ability to work and parent. Critical Thinking Questions Carl is a 26-year-old single African American male who completed 10th grade, is currently unemployed, and living in an urban homeless shelter after being thrown out of his brother’s house. 1. How do Carl’s demographics compare to Claudine? 2. What kinds of needs might Carl have compared to Claudine? 3. What community resources would help Carl now? What resources are available to patients in your community? Answers Carl does not have the employment and housing stability that Claudine has. He is younger and less educated. Carl would benefit from finding stable employment and shelter. Further assessment is needed to determine why he was thrown out of his brother’s house and his current level of daily functioning. Community resources that would be likely to help Carl include employment training programs, programs that assist people with finding housing, and helping him find access to health care. CRITICAL THINKING Claudine—Part 2 Claudine reports that she has been taking over the counter diphenhydramine 25mg PO QHS prn or Tylenol PM two tablets PO QHS prn (acetaminophen 500mg and diphenhydramine 25mg) for sleep with some relief. She states that her primary care physician prescribed Ambien (zolpidem) 5 mg PO QHS prn approximately 12 months ago after the death of her father, and again 6 months ago with job stressors, but only gave her 10 tablets each time. The Ambien helped her get to sleep at night, but she fears she will “become addicted” to sleep medication. Claudine reports that she does not have any major health problems. Other than giving birth naturally to her children, she has never been hospitalized nor had any major medical or surgical procedures. She has a primary care physician who she sees for an annual physical. She reports a history of gastroesophageal reflux disease and states that this has been treated in the past with Prilosec. She is visibly overweight and says she has attempted to diet in the past, but in the past year has not felt able to work on losing weight because of other stressors. Her only physical exercise is that associated with work (she stands a lot while teaching), and household chores. She denies smoking. She drinks up to 3 or 4 glasses of wine daily and denies history of other substance use. She has increasingly disturbed sleep including difficulty falling asleep (DFA) and middle of night awakening (MNA), resulting in approximately 4–5 hours of sleep per night; she denies snoring or other sleep disturbances. She has a history of “tension headaches,” which have increased recently to one or two per month and are successfully treated with extra strength Tylenol (acetaminophen two 500mg tabs PO Q 4-6 hours prn); there is no associated aura or nausea. She has normal vision and hearing, her teeth are well cared for and she has dental cleanings and exams regularly. Testing of Cranial Nerves I-XII are within normal limits. Her respiratory rate is 20 and regular and there is no history of wheezing or asthma. She has seasonal allergies but denies food or drug allergies. She reports recent awareness of her heart pounding and reports she can feel it most at night in bed. She has palpitations several times daily that she also notices and fears there is something wrong with her heart. Her pulse is 76 and regular and her blood pressure is 134/88. She denies shortness of breath (SOB) on exertion, or dyspnea with the exception of the panic episodes. APPLICATION What additional information do you need to get a full picture of Claudine’s physical health? Why is this important? Based on the information provided here, what additional concerns do you have about Claudine? How would or should these inform her care plan? What information related to family medical history would be pertinent? Answers Claudine is manifesting many physiological symptoms of stress resulting from hyperarousal of the hypothalamic-pituitary-adrenal (HPA) axis due to elevated levels of adrenalin, cortisol, and norepinephrine (see chapters 3, 13, and 16). Illnesses that may manifest or be exacerbated by stress include obesity, migraines, hypertension, GERD, sexual dysfunction, chronic pain, sleep disorders, insulin resistance, hypothyroidism, asthma, hypercholesterolemia, and chronic fatigue. Additional diagnostic tests to determine morning cortisone levels and a standard comprehensive metabolic panel, lipid profile, hemoglobin A1C, thyroid panel, complete blood count with differential, and urinalysis will help determine the full extent of her physiological health and further guide her treatment plan. Claudine should also be evaluated for changes in liver enzyme function related to alcohol intake. It would also be important to understand her menstrual cycle and if she is peri-menopausal as hormone changes can also contribute to anxiety and sleep disruption. Claudine’s sleep disturbances are likely to be both related to her anxiety and contributing to it. In addition, her diet and lack of exercise are not providing her with the physiological support she needs at this time. Although her palpitations and slightly elevated blood pressure may be directly related to her anxiety, she would likely benefit from a referral to a cardiologist for further evaluation to rule out the possibility of cardiovascular disease. Her frequent use and dependence on medication for sleep can potentially contribute to cognitive changes and make it difficult to concentrate and remember. In turn, this could affect her ability to function on the job. Claudine may benefit from a sleep study as she may have sleep apnea related to her obesity. Oxygen deprivation resulting from sleep apnea may be contributing to her anxiety and irritability during the day. Sleep medications will only intensify the problem. Daily alcohol intake also impairs normal sleep. Information related to family medical history might unearth risk factors for heart disease, mental illness, or other disorders with symptoms similar to those Claudine reports. These could provide some direction for additional assessment and referral. CRITICAL THINKING Claudine—Part 3 Claudine has worked as a teacher in the same city since graduation from college. Prior to the birth of her children, she was active in communities at the school and in the community. Although she was raised in the Episcopal Church, she reports attending only occasionally as an adult, finding it helpful when she is struggling. She has not attended recently, reporting “I just don’t feel up to it.” Claudine describes herself as extroverted and social, although she tends to keep most difficult problems private. Although she reports having two very close friends and being close to her sisters, whom she sees regularly, Claudine says she has not shared anything about how she is feeling with either her siblings or her close friends. Her most significant relationship is with her husband, whom she describes as her “best friend.” As she began dating him, she focused more of her activity on their relationship and less on her other friendships, interests, and activities. In the past they argued infrequently, but lately nearly weekly. The conflicts have never become physical in nature. Most often they focus on finances and the children. She feels hurt that her husband is “taking out his frustration with work on me,” which has led to her further disengagement in the relationship. Her three children are ages 6 to 10 and are healthy and doing well in school. She has good relationships with her children, who seek advice from her and tell her their problems. Claudine played soccer in high school and enjoyed the physical activity, after high school her activities have included hiking and biking. She enjoys sewing and craft projects although she rarely does one for her own enjoyment, more frequently getting her children started with activities and projects. She spends most of her free time making sure her three children are involved in activities they enjoy and transporting them to and from activities and sports. She and her husband are enthusiastic football fans and regularly watch or attend games. She is an avid reader and is a member of a local reading group, although she has felt too busy to attend regularly in the past year. What are Claudine’s strengths at this time? How might these inform her plan of care? How might they impact her participation in treatment? What areas for growth can you identify? Answers Claudine’s strengths include that she has a strong social support group, even though she has not felt comfortable sharing very personal information with them. Claudine is able to state activities she does enjoy, which might be incorporated into her care plan to help her reduce her stress level and to meet some of her emotional needs, especially as she describes herself as extroverted and social. Additional supports include her religious base of support and her current relationship with her husband. She could reconnect with a bible study group to gain additional support to cope with all the current stressors in her life. There are many possible areas for growth, and these should be identified in collaboration with Claudine in order to increase the likelihood that she will participate in the plan of care. Areas to discuss with Claudine include reaching out to her sisters or friends; making time to engage in physical activity to reduce stress and possibly lower her weight; developing good sleep hygiene habits; and reducing her alcohol intake to help with symptoms of reflux as well as ensure use of alcohol is not further impairing her sleep.