In this scenario you are a new graduate nurse and working as part of a small multidisciplinary team in a large metropolitan 24-hour medical clinic.
A young woman has just presented. You notice that she is dressed in T-shirt and jeans with her hair neatly pulled back. Her jeans look scuffed and unwashed. She sits in the waiting room looking as if she might be softly muttering to herself. At times when you look at her she is looking at the ceiling frowning. When you ask her to fill in the intake form she gets up and quietly takes the form and proceeds to fill it in.
When it comes to his appointment time, the duty doctor asks you to sit in and assist him with the interview.
The young woman gives her name as Amelia.
Amelia is attentive and cooperative. She keeps good eye contact although fidgets with her hair and cloths while talking. She describes to the doctor about becoming increasingly nervous about cameras watching her at home. Asked what she does in response to the cameras, she says she no longer goes home and instead lives in her car. When you encourage her to talk more about the cameras she gives you a lot of detail about “spying” and also mentions that voices tell her “they” are watching her because she is a bad person.
She says she is scared and that her friend persuaded her to come and talk to the doctor and get some medication. Following a basic physical check-up and questions about her general health, the doctor He is provided with a script for 5mg olanzapine nocte for symptoms of a psychosis. He expressed concern about her well-being and asks you to talk to her before leaving the clinic to ensure she has adequate support. He made an appointment to see Amelia the next day.
Four short essay questions
1. Describe the key interpersonal skills you would have used in this interview to engage with Amelia. (400 words)
2. The doctor stated that Amelia has symptoms of a psychosis. Using correct clinical terms, describe three important signs and symptoms from the scenario that you agree would support the doctor’s clinical opinion. (400 words)
3. The doctor prescribed 5mg olanzapine nocte` for Amelia. Describe the education you will need to provide to her before she leaves the clinic. (400 words)
4. Explain why you would need to ensure “adequate support” for Amelia before she leaves the clinic. (400 words)
Interpersonal skill is the ability to communicate or interact well with other people. As a nurse, it is vital to not only have a sound medical knowledge but also be well aware of these skills because nurses are usually the bridge between patients and the medical specialists. The key interpersonal skills to be used in this interview are the following.
First and foremost, finding a comfortable environment is
important. The room should enhance the privacy
of the patient and attentiveness of the nurse towards Amelia. Curtaining the
room or a arranging the seating in a manner which is neither distant nor too
close hence threatening are small things which should be taken care of. Active listening is the most important skill
which will be used and it involves both verbal and non-verbal techniques. The
non-verbal techniques will include the doctors’ full attention towards the
patient and nods, facial expressions (especially eye contact), posture, voice,
gestures with your extremities and even the way you position yourself
physically. The verbal techniques maybe
the continuation signals such as I see, right etc. It also includes being clear
in what you say and staying calm, polite, interested, focused and to match the mood or emotion of the situation. Empathy, respect, warmth and support for the patient
are other core principle interpersonal skills which need to be mastered. It is
true that you cannot learn empathy overnight, and for someone who is just an
entry level nurse it may be particularly difficult. However small phrases such
as ‘that must be horrible for you’ can be used. It is noteworthy that empathy
is different from sympathy and while empathy usually helps the patient to open
up, sympathy might shut him down. (Division of
Mental Health, World Health Organization).
Negotiation, persuasion and influencing skills are another set of skills which will be important in this interview. It is done in order to find a mutually agreeable (Win/Win) outcome. In such a case it will involve persuading Amelia to start living in her house rather than her car. If Amelia is still reluctant to move back into her or house or does not want to use the medicine prescribed to her due to any reason, then conflict resolution and mediation skills must be employed. It means working with others to resolve interpersonal conflict and disagreements in a positive way. The end result would be that Amelia would be prepared to take the medicine prescribed to her. (“Interpersonal Skills Needed For Nurses”).
Psychosis is a disease in which one’s emotions and thoughts are impaired such that they lose contact with the external reality. It is basically a symptom of serious mental disorders and people who are psychotic may have either witness delusions or hallucinations. Delusions, most importantly are a series of thoughts which a person might suffer from and these thoughts are completely opposite to the actual reality. Secondly, hallucinations are the sensory experiences that involves the apparent perception of things that are not present in actual. For example, a person might hear different voices conversing or making comments at them. These experiences of auditory and visual hallucinations faced by the patients can be frightening. Some people also experience loss of motivation and social withdrawal symptoms.
Before diagnosing the illness, it is important to be aware of some of its symptoms. Following are some of the symptoms of psychosis;
- Depressed mood
- Problems regarding concentration
- Being distant from friends and Family
- Delusions and Hallucinations
- Fanatical thinking
- False Thoughts
Moreover, there is no proper research regarding the causes of the psychosis but according to the doctors, it might occur due to a genetic problem, alterations in the structure of brain or changes in the hormone levels.
In the given case, Amelia, a young woman has been diagnosed with psychosis on the basis of the following symptoms
- When she was in the waiting room she was seen muttering to herself and was found looking at the ceiling and frowning.
The above sign shows that Amelia is facing distorted thoughts and anxiety which is one of the major symptoms of psychosis.
- Secondly, during her meeting with the doctor, she was constantly fidgeting with her hair and cloths which depicted her anxiousness.
- Thirdly, she described to the doctor about being increasingly nervous about the cameras watching her at her home due to which she never goes home and prefer staying in her car. This shows her withdrawal from family and friends.
- Moreover, she showed another symptom of psychosis and that is suspiciousness. When talking more about the cameras at her home, Amelia mentioned about ‘spying’ and also talks about voices telling her that ‘they’ are watching her. This also shows obsessive thinking and concentration problems faced by Amelia (“Psychosis: Causes, Symptoms, And Treatments”).
After a normal physical check-up, the doctor prescribed Amelia for 5mg olanzapine note for symptoms of psychosis. Before taking the medicine, Amelia needs to know the exact dosage, mechanism and side effects of this medicine. This medicine is prescribed to the people who are suffering from psychotic symptoms. Once you take the medicine, and it enters your body, it binds to the following receptors in the body with high affinity;
- 5HT6 (Ki=4, 11, and 5 nM, respectively),
- dopamine D1-4 (Ki=11-31 nM),
- histamine H1 (Ki=7 nM),
- And adrenergic α1 receptors (Ki=19 nM).
The anxiolytic effect of this medicine is mediated through its effect on dopamine and 5HT receptors. There are certain types of psychotic disorders which include schizophrenia, bipolar disorder, depression and delusional disorder. The type of disorder Amelia faces is a bipolar disorder with major symptoms being a feeling of anger, sadness and being frightened.
When it comes to the dosage, since Amelia is an adult, the prescribed dosage for her is as follows
Initial dosage: 10mg orally once a day or 5mg twice daily
Maintenance dosage: 5mg orally once a day.
This would treat her bipolar psychotic disorder in an effective manner. Moreover, before consuming the medicine it is important for her to know the side effects of the medicine she is taking. Following are some of the side effects of olanzapine nocte;
- Increased Appetite
- Gain of weight
- Problems with memory
- Restlessness, dizziness and tiredness
- Constipation followed by other stomach problems
- Back pain and pain arms
Furthermore, the medicine can also cause adverse effects. It could cause unusual changes in one’s personality thoughts or behaviour. This is called the paradoxical effect of the medicine. Also, it can cause a metabolic effect which could result in the gain of weight as mentioned above. Studies have shown that olanzapine note has a greater risk of causing and exacerbating diabetes than any other normally prescribed antipsychotic drug. It may also decrease the sensitivity level of insulin.
However, the patient might also take some necessary precautions while consuming the medicine. The progress of the patient must be checked by the doctor on regular basis. Blood tests must be carried out for checking any unnecessary effects. The doctor must be informed right away if any rashes, swollen skin, breathing problems, unusual bleeding and cough is witnessed by the patient. If the above-mentioned side effects increase with time you have to immediately check with your doctor regarding any queries. Your body might face problems regarding the temperature. It might not cool down easily. So, in the case of any uncertainty, consult the doctor as soon as possible. (“Olanzapine Side Effects In Detail”).
Amelia has been diagnosed with psychosis. Patients with this disease are at risk of a number of things which should be foretold and dealt with in the first meeting with the health care team. It is due to this reason that adequate support is provided to Amelia before she leaves the clinic. The risks are mentioned below.
Patients of psychosis such as Amelia are seen negatively by the community. This perception changes their attitudes towards these patients and as such may make them arrogant and demeaning towards them. Sometimes this particular type of bullying is so much that the patient might start having suicidal tendencies and may think about taking his or her own life on more than one occasion. It is due to this reason that non-pharmacological intervention is provided to these patients to comfort them so that they do not feel isolated, dejected and miserable. (“60 Tips For Living With Schizophrenia; Tips For Coping, Handling Schizophrenia Crisis And Relapse Situations”).
Another aspect of psychosis is that the patient himself is anxious. He wants to know more about his problem, its treatment, and prognosis and how long will it take for the medication to work. So another aspect of adequate support is providing him with all these answers. Anxiety might not be just limited to this, but may also involve all aspects of his life. Depressed mood, for no apparent reason, can be another huge problem. Hallucinations and delusions are common too. While it is true that you cannot reason out these voices or sights, you can guide the patient on the appropriate response to these. For example, Amelia has been hearing voices and has resorted to stopping going to her home and instead lives in her car. Now, this particular reaction will cause her lose the quality of her rest and hence make her more irritable which would further worsen her condition. So she should be made aware of these consequences and then asked to temporarily move to friends or family members place where she feels safe and not been spied upon. Social withdrawal is another common symptom. (“Psychosis”)
adequate support, which is usually non-pharmacological and almost always
includes counselling, is not provided
then the patient has a tendency of slipping deep into one of these symptoms.
This will cause a sudden decrease in the quality of his life. As part of the health care team, it is, therefore, necessary that nurses provide these counselling sessions to patients of psychosis.
Division of Mental Health, World Health Organization, Doctor-Patient Interaction And Communication. Geneva: N.p., 1993.
“Interpersonal Skills Needed For Nurses”. N.p., 2017. Web. 16 Apr. 2017.
“Psychosis”. Sane.org. N.p., 2017. Web. 16 Apr. 2017.
“Psychosis: Causes, Symptoms, And Treatments”. Medical News Today. N.p., 2017. Web. 16 Apr. 2017.
“Olanzapine Side Effects In Detail – Drugs.Com”. Drugs.com. N.p., 2017. Web. 16 Apr. 2017.
The South London and Maudsley NHS Foundation Trust Oxleas NHS Foundation Trust, Prescribing Guidelines. 2009.
“60 Tips For Living With Schizophrenia; Tips For Coping, Handling Schizophrenia Crisis And Relapse Situations”. Schizophrenia.com. N.p., 2017. Web. 16 Apr. 2017.
“Psychosis”. Healthline. N.p., 2017. Web. 16 Apr. 2017.