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A Case Study in Nursing

Written Assignment of Case Introduction Mrs. Lee, a 45 year-old-woman who was diagnosed with generalized anxiety disorder (GAD), recently admitted to mental hospital. She was depressed with auditory hallucination. In this essay, the contributing factors of Mrs. Lee’s GAD condition will be explained first, followed by a discussion on her current health conditions. Then, appropriate nursing diagnoses are made in priority according to their significance. Furthermore, implementation of nursing care to her will be illustrated. Finally, a conclusion will be drawn to summarize the ideas.

Factors Contributing to Generalized Anxiety Disorder of Mrs. Lee Mrs. Lee was diagnosed to have GAD. Biological, psychological and social influences may lead to development of GAD (Hazlett-Stevens, 2008). Biological influence Being a middle-aged woman can be one of the risk factors. Feminist theorists and researchers suggested that women were having a higher chance in getting GAD because they are more dependent, passive and submissive than man (Hazlett-Stevens, 2008). Several researches also revealed middle aged women (45-49) had a higher prevalence rates (Wittchen, Zhao, Kessler, & Eaton, 1994; Kessler et al. 2005). Psychological influence Cloninger (1986) proposed a model that certain personality traits such as introvert contributed to the development of GAD. Mrs. Lee is prone to have GAD as being an introvert woman. Negative life events happened can lead to development of GAD in those people with predisposition because of the neurobiological reaction happened inside the brain (Barlow, 2000). Since changing of a living environment and cultural was a big event for her, it increases her likelihood to develop GAD. Social influence Poor relationship with family is another contributing factor.

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Sullivan (1952) viewed that problem in interpersonal relationships can generate anxiety. Mrs. Lee had poor relationship with her husband. Anxiety was aroused to reflect the insecure response generated by the damaged relationship. Prolonged marital problem was the stressor that makes Mrs. Lee prone to have GAD. Social theorists and researchers revealed that one’s socioeconomic status (SES) can influence the development of anxiety (Portman, 2009). Mrs. Lee’s family is receiving Comprehensive Social Security Assistance which implied that she had relatively low SES.

People like her from lower SES encounter more problems and stressors in living, thus more vulnerable to experience GAD (Corcoran & Walsh, 2006). Nursing diagnoses and interventions Apart from her diagnosis of GAD, she is currently suffering from depressed mood and auditory hallucination. Nursing diagnoses and corresponding interventions are made during hospitalization. The following nursing diagnoses are prioritized according to the urgent needs of Mrs. Lee. Risk of suicide Mrs. Lee has increased suicidal risk.

According to Roy (2000), middle- aged people, who have chronic physical pain, history of suicide attempts and low socioeconomic status, have increased suicidal risk. In addition, Mrs. Lee experienced auditory hallucination which is also recognized to be high suicidal risk (Schultz & Videbeck, 2009). Nursing interventions of risk of suicide Nursing assessment including comprehensive physical and mental status examinations should be conducted to Mrs. Lee on admission. The suicidal history should be recorded in details. Good nurse- client relationship is the basic requirement during hospitalization.

Developing a supportive therapeutic relationship to Mrs. Lee through frequent, brief contacts and an accepting attitude with active listening and being empathy can build up the rapport (Schultz & Videbeck, 2009). It is beneficial to assign a name nurse who is responsible for her at all times. Safety environment is also crucial. In this scenario, nurses should be particularly alert and keep all potentially dangerous items away from her such as sharps. In addition, nurses should check her locker and belongings carefully to reduce some otential hidden weapons. Moreover, nurses should be alert to the possibility of Mrs. Lee storing medications, obtaining medications or dangerous objects from other people. Nurses should check her mouth after medication administration to ensure they are swallowed. These can prevent her from accumulating medication for suicidal attempt. (Schultz & Videbeck, 2009) For closely observation, Mrs. Lee’s bed should be placed at an easy accessible position. She should be on suicidal observation and frequent, irregular intervals monitoring should be maintained.

Extra attention should be paid on the unstructured time and less manpower interval (Schultz & Videbeck, 2009). Furthermore, nurses should stay with Mrs. Lee while she is alone to prevent self-destructive activities. Also, we should maintain an effective communication with other health professions about her suicidal risk. We should concern her emotional changes such as from sad to happy, decreased communication, conversations about death (Schultz & Videbeck, 2009). These behaviours may indicate her decision to commit suicide.

Sedation and physical restraint should be applied as last resort if Mrs. Lee is attempting to harm herself or exhibiting uncontrolled emotion. Nurses should evaluate the use of restraints and terminate them when she regains control over emotional responses (Schultz & Videbeck, 2009). Drug noncompliance In view of Mrs. Lee’s past suicidal attempts of drug overdose, interventions on drug compliance is as important as suicidal observation. As Schultz & Videbeck (2009) stated drug noncompliance leads to re-hospitalization of mental health client, the poor drug compliance of Mrs.

Lee leads to exacerbation of mental illness. Nursing interventions of Drug noncompliance It is essential to explore and deal with the barriers contributing to her noncompliance. Education on medication and connection with symptoms can be given if found to be deficit. According to Fortinash and Holoday Worret (2007), understanding on therapeutic effects of medication can increase compliance, which helps to control psychotic symptoms. In addition, the non-judgmental approach is significant for clients to report honestly their medication regime (Schultz & Videbeck, 2009).

Disturbed Sensory Perception Mrs. Lee heard voice keeping on scolding her uselessness. According to Van der Gaag, Hageman & Birchwood (2003), the appraisal of the voice was closely linked to distress. The experience of auditory hallucinations is distressing, lower self-esteem and has a negative effect on quality of life (Newton et al. , 2005). It can also heighten anxiety and depression (Carter, Mackinnon & Copolov, 1996). Falsely perceiving the hallucination as reality may put Mrs. Lee into a life threatening condition. Nursing interventions of disturbed sensory perception

Auditory hallucination is potentially dangerous to Mrs. Lee, so exploring the hallucination content is important. Nurses should show concerning attitude and spend time with her, as establishing rapport and building trust is the foundation before talking about hallucination. Besides psychosocial measures, pharmacological measures are also crucial as combined treatment have better therapeutic outcome (Videbeck, 2008; Stuart, 2009). Fontaine (2009) pointed out that clients found having a real person to talk and listen is the most helpful intervention.

It enables them to discuss their thoughts and return to reality. Identification of Mrs. Lee misperceptions and limiting her engagement in negative personal evaluations due to hallucination is needed. Nurses should identify her strengths and give positive feedbacks. With aims to increase her sense of control, provide feeling of accomplishment, self-esteem built up can overcome her feelings of uselessness and refrain from self-harm. Disturbed Sleep Pattern Mrs. Lee complained of poor sleep which may associate with her neck and back pain (Alattar, Harrington, Mitchell, & Sloane, 2007).

According to Friedman, Brooks, Bliwise, & Yesavage (1993), increase sleep disturbance, which caused psychological distress, functional impairments and reduced quality of life, was associated with greater depression. Higher anxiety score is also associated with poor sleep quality (Cheng et al, 2008). Nursing interventions of disturbed sleep pattern Some sleep promoting measures can be done to enhance the therapeutic effects of treatment to sleep disturbance. Besides providing a non-stimulant sleeping environment to Mrs. Lee, nurse can encourage her to take warm bath and provide little amount of milk to her before bedtime.

They are proved to be natural sedatives which help to improve sleeping patterns (Fontaine, 2009). Encouraging her to avoid napping during the day as promoted physical tiredness would facilitate restful sleep at night (Schultz & Videbeck, 2009). Teaching her relaxation techniques and establishing the bedtime routine are essential to diminish sleep disturbance. Ineffective Coping Mrs. Lee emigrated from China to Hong Kong. Significant stress was experienced by her due to the changes from cultural beliefs and practice, language difficulties, occupational adjustment, discrimination and not feeling at home (Ayers et al, 2009).

Immigrants’ mental health would be strongly influenced when they are unable to form a valid appraisal of the stressors, lack of choices of practiced responses, and/or inability to use available resources (Schultz & Videbeck, 2009). She is introvert and has poor relationship with her husband leading to ineffective coping toward stress. Nursing interventions of ineffective coping Mrs. Lee manifested difficulties in dealing with anxiety. Therefore, she should be urged to express her feelings and distinguish the possible origins of anxiety.

Her stress and anxiety coping methods should be discussed with her together (Schultz & Videbeck, 2009). At the same time, problem solving skills should be reinforced, ie, finding out the problems, searching for different alternatives, weighing pros and cons of each alternative, and implementing the best one (Harrison& Hart, 2006). Helping Mrs. Lee to foresee future issues that may give rise to anxiety behavior is also crucial to minimize her anxiety level when she really comes across the problem (Schultz & Videbeck, 2009). Impaired social interaction Mrs.

Lee’s depressed mood is generally related to the impairment in her social activities (Segrin & Abramson, 1994) as shown by her poor relationship with husband and introverted personality. Nursing interventions of impaired social interaction To deal with this, the nurse should interact with her on a one-to one basis first, and then involve more and more clients gradually when she participated in activities. Moreover, the nurse could introduce social skills to her and give instructions and feedbacks at the time she practices with others. To build up a supportive network in the community, Mrs.

Lee should explore supportive people outside the hospital and foster interpersonal relationships with them (Schultz & Videbeck, 2009). Conclusion There are several nursing diagnoses identified in Mrs. Lee’s scenario. Risk for suicide is the most crucial diagnosis among all these because safety is the most important element to client. As a nurse, we should implement the nursing appropriately to prevent injury, enhance the drug compliance, minimize hallucination, improve sleep quality and coping skill, establish a better social relationship.


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