logo

A case study of a community care unit/psycho-social rehabilitation: John, a pseudoonym to protect privacy and confidentiality

7 Pages2082 Words89 Views
   

Added on  2021-04-17

About This Document

John was diagnosed with Schizophrenia (schizo-typal traits) and schizophrenia, which was characterized by demotivation, low self-esteem, social withdrawal, anhedonia, negative view of self and ritualistic behavior. This case study presents, beginning with initial assessment, both subjective and objective data that were collected using mental state examination, following DSM-V and NANDA diagnosis. Assessment In order to attain a holistic insight of John’s mental state, assessment was performed which included mental state

A case study of a community care unit/psycho-social rehabilitation: John, a pseudoonym to protect privacy and confidentiality

   Added on 2021-04-17

ShareRelated Documents
IntroductionJohn (Pseudonym to protect privacy and confidentiality) was admitted voluntarily to a community care unit/psycho-social rehabilitation following a referral from the GP due to respite for parents. John was diagnosed with Schizophrenia (schizo-typal traits) and OCD, which was characterized by demotivation, low self-esteem, social withdrawal, anhedonia, negative view of self and ritualistic behavior. This case study presents, beginning with initial assessment, both subjective and objective data that were collected using mental state examination, following DSM-V and NANDA diagnosis. The preliminary findings were used to formulate a collaborative, evidence based recovery for future focused plan. The recovery plan is presented in a logical order: planning and implementation, expected outcomes of care, and finally evaluation and outcome measurements based on John’s objective data (Carey, 2016). AssessmentIn order to attain a holistic insight of John’s mental state, assessment was performed which included mental state examination, community risk and assessment plan, alcohol and other drug assessment, and behavioral and symptom identification scale (BASIS-32) (Dwyer, 2012). John’s current medication included Risperidone (Risperidol consta) 37.5mg IM injection depot for every two weeks. Although John was recommended to take ZOLOFT (OCD traits) tablets, he declined due to side-effects of the drug.Mental state ExamBeing a Greek, the 34-year-old John was dressed in a color t-shirt and cargo pants with small stains on color appropriate for weather. John appeared to be thin, having poor personal hygiene, rigid posture, poor eye contact and greasy hair. John could be described as “I’m doing laundry
A case study of a community care unit/psycho-social rehabilitation: John, a pseudoonym to protect privacy and confidentiality_1
and shower once every two days”. He looked anergic and walked very slowly, while the psychomotor retardation was a times slow to initiate tasks. John’s speech was slow in rate, soft, audible and answered to all the questions in a polite manner. Throughout the conversation, John seemed to be inactive in the interview. John’s mood was euthymic, hyper vigilant, non-depressedand mildly anxious. His affect was blunted since he had a very low facial expression, anhedonia, reactive and inappropriate gestures and wanting to pinch his cheeks every time and then throughout the conversation. However, Mr. John did not present any formal thought disorder although he was obsessed with cleaning vegetables and checking locks frequently. He also had some persecutory delusions because he occasionally stated that “someone is following when I goout”. John was also isolated, self-neglected and stayed in his bedroom for many hours, socially withdrawn without any friends. He usually reported that he used to isolate himself in his room since he was alert and oriented in terms of person, place, time and the environment. This patient also experienced difficulties in performing day to day life routines, household responsibilities and thus he had to be prompted severally, in order to get on board. He was also not impulsive and hence did not present with any perception disorders. John was dependent on his parents and he was poor in solving problems and making decisions. Risk assessmentThe community and risk assessment plan was used to assess the general vulnerability, dynamic risk, statics and falls, and nutritional risk. The general vulnerability of Mr. John included a history of childhood trauma and a record of being bullied at school. Rumination on events resulted in significant self-neglect, poor self-care and social withdrawal. John was isolative and never received any social support including from friends and he reported “I feel fear when I come out and I feel someone is following”. John had also been charged by the police for
A case study of a community care unit/psycho-social rehabilitation: John, a pseudoonym to protect privacy and confidentiality_2
removing license plates from a police vehicle. As a result of the persecutory ideas towards the police, John stated “The police will be here at any time to take me away”. However, this patient never had no known history of suicidal injury, deliberate self-harm or past attempts, and current thoughts of suicide or self-harm. Moreover, John was a non-smoker, non-alcoholic and non-drug abuser.Physical healthThe head to toe assessment was used to obtain the data, whereby John’s vital signs were found tobe within the limits (100% SpO2, 18 breaths per minute, 70 beat per minute, blood pressure 120/ 70 mmHg, and temperature 36.4ºC). Additionally, John never experienced any pain, and the BMI was 22, and hence considered to be normal based on Reinders et al., (2015). He neither had any abnormalities in gastrointestinal, respiratory and cardiovascular systems, nor did he present any pressure injuries or wounds on the skin.DiagnosisBy use of the Diagnostic and Statistical Manual of Mental Disorders, John’s presentation [Appendix-I], provided the requirement for diagnosis of schizophrenia disorder (American Psychiatric Association, 2013). John had this diagnosis for past 10 years, and was dependent on his parents since he was described as “I hope to become more independent, because my parents are very protective and do things for me”. He also expressed his desire to regain mental wellbeing and stated that “I want to be more motivated and possibly take on another study coursein future”. John had some persecutory delusions and negative symptoms of schizophrenia since he was amotivated, and asocialite. He also had negative views about himself and others includinganhedonia secondary to schizophrenia disorder, which could be related to childhood trauma.
A case study of a community care unit/psycho-social rehabilitation: John, a pseudoonym to protect privacy and confidentiality_3

End of preview

Want to access all the pages? Upload your documents or become a member.

Related Documents
Mental Health and Illness : Case Study
|14
|3542
|71

Promoting Mental Health and Wellbeing: Chung’s Case Study
|11
|2519
|417

Promoting Mental Health & Wellbeing
|5
|1369
|15

Case Study on Aggression and Ethical Considerations in Mental Health
|7
|1593
|75

[PDF] Drug Use Disorders and Recovery
|9
|2539
|40

Challenges in Mental Health Nursing
|13
|3201
|79