NSB204: Mental Health Case Study - Assessment and Care Planning

This case study focuses on Jamila, a 32-year-old Afghan refugee presenting with symptoms of post-traumatic stress disorder (PTSD), anxiety, and fatigue. The assignment requires a holistic assessment, including a mental status examination, clinical formulation using the 5Ps framework (presenting, predisposing, precipitating, perpetuating, and protective factors), and a comprehensive nursing care plan. The case study explores the patient's history of trauma, family conflicts, and challenges as a refugee, impacting her mental well-being. The solution addresses therapeutic engagement, the development of a therapeutic relationship, and high-quality care strategies, including evidence-based psychotherapy and the SBAR approach for clinical handover. The assignment emphasizes the importance of mental health nurses in assessing, treating, and providing quality care to patients with PTSD, considering both psychological and physiological factors.

Running head: Case Study: Mental Health Safe
Case Study: Mental Health Safe
Name of the Student:
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Author’s Note:

Case Study: Mental Health Safe
Table of Contents
Part 1: Holistic Planning and Assessment..................................................................................3
Mental Status Examination....................................................................................................3
Clinical Formulation..............................................................................................................3
Presenting Problems...............................................................................................................4
Predisposing factor.................................................................................................................4
Precipitating factors that has given birth to the problems......................................................4
Perpetuating factors................................................................................................................4
Protective factors....................................................................................................................5
Plan for nursing care..............................................................................................................5
Clinical Handover..................................................................................................................5
Part 2: Therapeutic engagement and clinical interpretation.......................................................6
Development of a therapeutic relationship................................................................................6
High-quality care to the patient..............................................................................................6
Reference:..................................................................................................................................8

Case Study: Mental Health Safe
Part 1: Holistic Planning and Assessment
Mental Status Examination
The case study reveals the life fact of a middle-aged woman, named Jamila, who is an
Afghan aborigine. Community-based post-traumatic stress and surviving as a refugee in the
refugee camp and later on in Australia has shown the woman different difficult phase of life.
Jamila has faced a lot of difficulties and family conflict in her childhood. She is married, and
her husband works nowhere also they have two sons who are teenagers and obtaining
education. She faced a lot from childhood, and it is like a trauma which she undergoes still
now. Fear about the past and anxiety about the future has broken her down. She is fair in
complexion and well responsive and speaks good English (Torous et al., 2019). But her state
of mind is not well. She feels insecurity and keeps silence for all time, bending her head
towards down. She is very anxious as she could not sleep for three months consecutively. She

Case Study: Mental Health Safe
is going under different kind of moods, sometimes irritable and sometimes fatigue. She has
described feeling excessive fatigue which left her unable to get out of bed. She has faced a lot
of family duels, where she witnessed a murder in the family by the other person. When she
remembers and speaks about her past life experience, she gets tears in her eyes. Hence, it is
proven she has the same feeling of fear which has laid her into the trauma (Torous et al.,
2019). She is now facing difficulty in adjusting to her husband as her husband stays at home
all day and interfere in her housekeeping and cooking. She is feeling insecure, as their
relationship might be broken. She has not obtained a formal education, but she has learnt
English by communicating with her sons and watching English learning class. Her mental
status has made her look like a middle 40 aged women by her face.
Clinical Formulation
5Ps formulation is based on five ingredients– (1) Presenting problems, (2) Predisposing
factors of the patient (3) Precipitating factors that has given birth to the problems, (4)
Perpetuating factors which is a mechanisms to attempt to cope with the problem of the
patient, (5) Protective factors.
The 5Ps is applied with the intention to help the patient to get out of trauma, anxiety and
mental disorder. This formulation is related to CBT (Cognitive Behavioral Therapy) to
understand the patient’s problems and the source of the problems have been identified in
order to serve better treatment (Hollis et al., 2015). The 5Ps factors are related to the patient’s
physiological, biological and social factors.
Presenting Problems
Presenting problems is important to develop problems. In the case of Jamila, her present
problem is post-traumatic stress and future anxiety. She is responsive but talks less. She
engages herself in thinking all the time for the future. Her behaviour also fluctuates with the
mood. She sometimes gets irritated and feels excessive fatigue. The worst experience in her
childhood of family conflict, murder laid her teary after remembering. She has fled away with
her husband in a refugee camp in Pakistan from Afghanistan. To manage Jamila
psychotherapy cab be implemented on her for getting out of her PTSD.
Predisposing factor
Detail analysis of Jamil's life needs to be understood, and her reactions need to be observed,
which can take her down, but it is a benefit of this factor (Hollis et al., 2015). Jamila's social
position also led her in the trauma. She is living in a two-bedroom residence which is small,

Case Study: Mental Health Safe
and the residence is situated beside a busy road, and in Australian society, her entire family
hardly gets respect and appreciation because they are from Afghanistan. There are cultural
distinctions between the Australian and Afghanistan. She needs to follow the treatment of
mental health professionals.
Precipitating factors that has given birth to the problems
The precipitation factors include the internal and external factors of the patient which are
obtained from presenting problems (Newman et al., 2015). At the age of Jamila, she receives
a difficult life. She has a negative thought about their future as her husband is unemployed,
and she does not have formal education to work anywhere. Her husband does not want to
work and has no idea of work.
Perpetuating factors
Based on Jamila's present situation, the problems can be defined on her cognitive,
behavioural, and psychological responses. Jamila has the problem in the long term basis, and
now she finds difficulties in sleeping from the past three months (Mechanic & Olfson, 2016).
She needs to be under observation of developing trauma, anxiety and negative thoughts
through the clinical observation.
Protective factors
Jamila has the potentiality in learning, and she has the effort to learn things as she has learnt
English speaking with her own. The ambition and learning attitude can benefit her in
treatment.
Plan for nursing care
Jamila is a post-traumatic stress disorder patient (PTSD). She has experienced an adverse
condition from the childhood days. She even faces domestic violence as in their community;
the killing of someone in the family occurs very often. The nurses have to critically treat the
patient and care for her trauma to save the patient from the risk. The nurses have to identify
the patient problems and impacts of the patient for delivering good treatment. The person
who is going under PTSD, there are four kinds of symptoms, and in case of Jamila, she also
experiences – re-experience, avoiding, negative thought in mood and cognition, changes in
behaviour and activity. The nurses have to care for the PTSD patient by delivering a number
of psychotherapy and medications (Golberstein, Eisenberg & Downs, 2016). The CBT can be
applied by focusing merely on the trauma. Rather than CBT and medication, supplemental

Case Study: Mental Health Safe
therapy can be applied to the patient though it has various controversy in managing
symptoms.
There are specific nurses for the care of PTSD patients, the mental health nurses. The
emergency ward improves fatigue and promotes the patient in a normal state. The patient
who suffers from domestic violence can face a long time in developing PTSD. The nurses
have to apply evidence-based practice and treatment by identifying PTSD patient symptoms.
The mental health nurses can distinguish the patient's present memory and past memory.
They have to understand the problems better and apply relaxation techniques. The patient
needed to be under control as there may be a problem while the patient remembers about the
life event and reactions and anger can come out. The nurses need to intervene the thought of
suicide of a patient instead should encourage (Simms et al., 2018). The nurses need to apply
the de-escalation techniques and PRN medicines if prescribed. The nurses are required to
meet the ineffective coping of the patient. Therefore, a useful strategy can be applied to
prevent the negative outcomes of the patient. The nurses have to make the patient understand
the therapeutic help and should assess the level of anxiety of a patient by developing a
relationship.
Clinical Handover
The clinical handover is related to the SBAR approach. This approach implies for ingredients
in nursing care for mental health, which means the Situation, Background, Assessment, and
Recommendation (Townsend & Morgan, 2017). This is a technique through which
communication can be made promptly and properly. This is a popular communication system
in health care settings which is very effective, and so it is used widely by the mental health
nurses and the physicians.
Part 2: Therapeutic engagement and clinical interpretation
Development of a therapeutic relationship
In the case of a patient like Jamila evidence-based psychotherapy for PTSD patient can be
helpful to moderate the patient. As Jamila is very responsible and concern about the family
future, she can be given this therapy instead of internet-based treatment. Jamila has no
suicidal thought; only she has the anxiety and phobia from the past, which has made her
PTSD patient. From the case study, it is visualized that she has normal Respiratory Rate (RR)

Case Study: Mental Health Safe
21, normal body temperature with 37.5-degree centigrade, bodyweight is 5 kg more
compared to the height. The patient has trauma, and so the depression comes to her (Acharya
et al., 2017); it may be an effect of gaining weight. She is 32 years but looks like mid 40
women by her face. Her pulse rate is normal, with 113 bpm, and normal BMI is 32. The only
clinical problem that has been derived that she has a high BP 140/90 which can be controlled.
She is unable to sleep for the past three months and cannot cope with her mood.
Jamila only needs to have better communication with the therapist. Prolong exposure therapy
can be applied in evidence-based psychotherapy. The clinical psychology includes the
"pattern of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD"
(Olfson Druss & Marcus, 2015). The therapist must know the rupture in the therapeutic
relationship. Prolonged exposure therapy engages the patient through the sessions of the
treatment procedure. The therapist has to chart for the patient PTSD symptoms during the
treatment process. Prolong exposure helps to reach the goals through the procedure of
treatment.
High-quality care to the patient
Nurses have a major role in delivering quality care to the PTSD patient. The recognition of
PTSD is first to need to be done from the detailed history of the patient life and present
thought. The patient with having PTSD needed to be a detail health record and check up by
the nurses in the sake of giving the patient quality care (Naslund et al., 2016). The nurses
have to measure patient's BP, BMI, RR, Height and Weight, Pulse Rate. After hearing the life
experience from the patient, the nurse must treat according to the reactions shown by the
patient. Quality care involves a comprehensive screening and evaluation of the patient. The
PTSD patient has to be treated under evidenced-based practice, and high-quality care can be
provided by the screening process, which needs to be arranged by the mental health nurses.
The nurses need to be careful while prescribing the medication and can refer to a specialist
for better medication and treatment. The nurses need to ease the mind of the patient during
the assessment, which is all effective part of quality caring to the PTSD patient by the mental
health nurses.

Case Study: Mental Health Safe
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