Abstract total brain injury from a motorcycle

Abstract

This paper explores the
analysis of a patient with a psychiatric disorder from a student nurse’s
perspective along with the references of several notable authors by following
the nursing process. Through this paper there is an exploration of specific
types of diagnoses such as: disruptive mood dysregulation disorder, total brain
injury, seizures, and alcohol/drug dependency that contribute to one patient’s
overall psychiatric status and contributing behaviors that are documented as
attributes and antecedents.

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Analysis
of A Patient with A Psychiatric Disorder

My
patient that I chose to do my analysis on was a 60-year-old male that was
admitted with the diagnosis of disruptive mood dysregulation disorder. He was
admitted on 1/4/17 from a correctional facility after assaulting a fellow
resident in the nursing home. He has a history of seizures, his first
presenting at a very young age, which appeared to make him decline ever since.
Some of his other diagnoses are alcohol and marijuana dependency, total brain
injury from a motorcycle accident which left him in a coma for one year,
seizures, and hypertension. Some of the main concepts affected with this
rationale would be safety, mood and affect, cognition, and coping. His general
appearance appeared to be appropriate for age and appropriately matched. This
client’s illness appears to be a chronic one spreading out over the length of twenty-one
years. The patient’s acuity level is yellow, which allows the patient grounds
access with the accompany of a staff member. The patient is not allowed to be
off the unit without supervision.

Attributes
and Antecedents

The
patient appears to like staying to himself, but will answer questions and
interact if the opportunity presents itself. He stated, “I don’t really talk or
like to talk to these people.” For family issues, he stated that he does not
have any family, though the chart indicated that he grew up with his mom and
stepdad, is still currently married and that no divorce papers were ever filed.
For his spirituality, it was documented in the chart the he was “doing what God
is telling him to do and he is reading his bible.” While this patient has several
diagnoses, there are only a few noted attributes and antecedents pertaining to
certain diagnoses. For example, chronic cognitive impairment related to total
brain injury, mood disruption dysregulation disorder, and seizures are diagnoses
that contributes to him presenting with disordered and pressured speech, odd
interactions, shuffling gait, lack of hygiene, and was noted to wear many
clothes in warm weather upon admission. Another presenting attribute for mood
dysregulation disorder is that the patient has developed hypertension.  He also has a history of alcohol abuse as well
as use of marijuana that may have contributed to his overall cognitive decline.
 

When
comparing the attributes and antecedents, Halter does a wonderful job in
documenting examinations that help assess a patient when demonstrating certain
characteristics. For example, in the mental status examination Halter addresses
the following that matches up with this patient’s presenting factors for total
brain injury and disruptive mood dysregulation disorder: “grooming and dress,
level of hygiene, peculiar body movements, odd gestures, balance or gait,
speech-rapid, disorganized, articulation problems, cognition problems-confusion
and anger” are a few of the attributes that the patient was presenting when
being admitted. For the attributes of seizures, Halter states that “many
neurological conditions are associated with anger and aggression. For example,
temporal lobe epilepsy and traumatic injury to certain parts of the brain result
in changes to personality that include increased violence. Many patients with
brain injury have severe behavior disorders that disrupt their lives.” (Halter, 2014) In reference to the
patient’s alcohol and marijuana abuse, Halter discusses the neurological
factors that are presented when somebody has and addiction problem and over
time, build up a tolerance. “Psychoactive substances and certain behaviors can
hijack this reward pathway circuit, releasing as much as 10 times the amount of
dopamine as usual. The brain responds to this imbalance by resetting the
pleasure threshold, decreasing or down regulating the number of receptors
attempting to reach homeostasis. This is the mechanism that is responsible for
drug tolerance.” (Halter, 2014) Building up a drug tolerance is what
leads somebody to constantly keep seeking more and more drugs and alcohol so
that a level of satisfaction is obtained. For somebody with a cognitive
disorder already, this can send them in to a spiraling rage.

Upon
conducting the abnormal involuntary movement scale (AIMS), the patients
presented with no awareness on the muscles of facial expression. There was no
indication of frowning, blinking, smiling or grimacing. The score was also the
same in the areas of lips and periorbital area, jaw, upper body and lower body
for extremity movements, trunk movements, and global judgments. This score of a
zero indicates that this patient does not present with abnormal movements. For
the patient’s Mini-Mental Status Exam (MMSE), he scored a total of 15 out of
30. He was not oriented to time or place, could not follow a three-stage
command, write a sentence, or copy a design. He could however name common
objects, spell world backwards, name a pencil and watch, repeat the following:
“no ifs, ands, or buts,” and obey the following: “close your eyes.” The patient
does not have problems with his teeth and does not wear dentures. He is able to
eat solid foods with no complications, allowing for adequate intake of
nutritional needs.

Planning and Goal Setting. The
clinical goal of the patient’s treatment is control of manic/mood symptoms.
This is being treated with medication therapy and group therapy, although the
patient states “I don’t go to my therapy even though I probably should.” A
safety plan has been initiated to keep the patient and other patient safe from
self-mutilation and assault since the patient’s diagnosis can contribute to
violent behavior. The patient will also practice deep breathing and relaxation
techniques since upon admission and follow up visits the patient reports “I
don’t know what calms me down.” Per patient’s chart. A decrease in the level of
substance abuse will be attained. This goal is currently being met by the
patient remaining at Terrell State Hospital for over a year now. One of the
most important goals is that the client will maintain stable neurological
function. This goal unfortunately, is not being met since there has been a
notable decline in cognition since admission in January two thousand seventeen.
The patient has been moved to a different unit than when he was initially
admitted indicating that he is regressing cognitively and needs extra attention
by the staff. The patient’s perception of perception of his own goals are that
in three months, he wants to “get out and have fun.” In one year, he “wants to
get a job so he has money” and then in five years he wants to “go to social
security and get community housing.”

Although
some of his goals are realistic, there are several factors that hinder his
personal goals. Though he is physically fit without any hinderances, he does
not have the emotional, social, financial and lifestyle choices in place that
will be able to help him meet such goals. Since he came from a nursing home, it
is apparent that he needs help with care. Financially I believe he does receive
social security and compensation from the VA in Dallas, TX. Since he is
considered incompetent to stand trial for the three aggravated assault charges
pending against him, is appears that even if he were to leave Terrell State in
the future, he would serve time in a county jail for these charges. Some of the
more realistic goals that were proposed was that he should attend therapy so
that he could have better coping skills. He said, “I know I need to because I
get angry, but I don’t want to.”

Implementation. For
the psychopharmalogical treatments, this patient is taking the following
medications to aid in managing his diagnosis of disruptive mood dysregulation
disorder: He is taking levetiracetam Keppra 500 mg twice daily by mouth, which
is an anticonvulsant by class. This medication “may inhibit nerve impulses by
limiting influx of sodium ions across cell membrane in motor cortex.” The
nursing implications that need to be addressed so that the medication is
therapeutic is to “monitor BUN, seizure activity, blood studies such as RBC,
Hct, Hgb, and assessing mental status such as behavioral changes and suicidal
thoughts.” Side effects include: psychosis, suicidal
ideation, decreased Hct, Hg, RBC, infection, and abdominal pain. A
contraindication is hypersensitivity. Pertinent lab values are BUN, Hct, Hgb,
and RBCs.” (Mosby’s Drug Guide for Nurses, 2011) This patient is also taking Lorazepam, Ativan 1 mg
orally at bedtime. This medication has a “functional class of a
sedative/hypnotic, antianxiety agent and a chemical class of benzodiazepine.
The action is potentiating the actions of GABA, an inhibitory neurotransmitter
which depresses the CNS. Nursing implications are: assess degree of anxiety, assess
for alcohol withdrawal symptoms, monitor CBC and hepatic studies, monitor
seizure control and assess mental status. Pertinent adverse effects are
tachycardia, cardiac arrest, and apnea. Contraindications include: pregnancy,
hypersensitivity, closed-angle glaucoma, psychosis, history of drug abuse,
COPD, and sleep apnea. Pertinent lab values are CBC and hepatic studies.” (Mosby’s Drug Guide for Nurses, 2011) Lastly, the patient
is also taking risperidone 4 mg po twice daily. “It is in the antipsychotic
class. The action is that it may be mediated through dopamine type 2 and
serotonin type 2 antagonism. The nursing implications are: assess mental
status, monitor I, monitor bilirubin, CBC, liver function tests monthly,
and identify for neuroleptic malignant syndrome. The side effects are
tachycardia, heart failure, seizures, and renal artery disease.
Contraindications for risperidone are breast feeding, hypersensitivity and
seizure disorders. Labs that should be evaluated for this drug are: prolactin
levels, CBC, and liver function tests.

When
comparing the patient’s diagnosis of disruptive mood dysregulation disorder
(DMDD), I find that it is a very interesting diagnosis. There is still a lot to
be learned about this particular diagnosis in that there is still no specific
treatment regimen for it. There have been ongoing studies since the 1990’s when
this disorder was recognized, but no sure set of medications and therapies has
been 100% effective. Documented from a journal article, apparently there has
been some success by using  “An open-label trial using low doses of
risperidone in youth with SMD showed significant reductions in irritability scores (Krieger et
al., 2011). It is important to emphasize that there
have been no pharmacological studies on DMDD, and extrapolating data from SMD
may be problematic given that there is surprisingly little overlap between the
two conditions.” (Psychiatr, 2015)(Krieger et al., 2011). In a different journal article, it also presented evidence that
risperidone is effective for this diagnosis by stating: “Risperidone and
aripiprazole are FDA approved for the treatment of irritability (including
aggression, temper tantrums, self-injurious behavior, and quickly-changing
moods) associated with autistic disorder in children and adolescents. Papadopoulos
and colleagues identified nine RCTs of aggressive children and adolescents
being treated with risperidone. All nine of these studies showed greater
reductions in aggression with risperidone compared to placebo in subjects with
CD, ODD, ADHD, autism, and MR/ intellectual disability (ID). The overall effect
size of risperidone was quite high (0.9)” (Tourian, 2015) By using these two sources of
information, it matches up with the current care that the patient is receiving
at Terrell State Hospital since one of his medications is in fact Risperidone.
In the instance of patient/family education, and referrals, there does not seem
to be a plan in place for theses at Terrell State Hospital. It could be
indication that the patient does not have any family on file to be contacted and
that he came from the forensic unit and is there because he is incompetent
cognitively to stand trial. For psychotherapies and support groups, though, the
patient appears to have everything in place at Terrell State. There are therapy
sessions scheduled during the week that the patient can choose to go to where
they can aid the patient and encourage effective coping mechanisms for his
anger. These therapy sessions are known as group psychotherapies which “is
often done in conjunction with individual psychotherapy as part of an ongoing
plan of feedback in which intense one-to-one work is interspersed with
opportunities to relive and work through early life experiences in a supportive
group.” (Halter, 2014) Five evidence-based nursing
interventions that would be appropriate for this patient are “empowering the
patient by involving him in goal setting and treatment planning: this increases
the treatment adherence and improves treatment outcomes, developing and
maintaining sustained therapeutic relationships; trust in providers is key to
achieving treatment adherence, Safety is of utmost importance not only for the
patients, but for other patients and staff as well. Providing supportive
psychotherapy, focusing on the here and now; this aids in maintain rapport and
positive self-esteem and reduces maladaptive coping. Caring for the person due
to the lack of poor hygiene and health practices” (Halter, 2014) is very important
not only for health reasons, but also for the dignity of the patient.

Evaluation. The
evaluation of the effectiveness of current treatment and nursing interventions
is a positive one in most aspects such as being able to keep the patient’s
moods stable, adequate nutrition and hygiene status, and also the patient
having therapeutic levels of his antipsychotic medications. I enjoyed getting
to see the psychiatric side of nursing in that it gave me exposure to certain
situations that nurses are put in and the overall job of the nurse in this
field. Unfortunately, I believe that the patient’s prognosis is that he is
cognitively declining as evidenced by charted documentation that the client has
appeared to be regressing since he had a seizure when he was young followed by
a TBI. He was also switched to a different unit so that he could be helped
more. When asking the client questions, he would respond to some questions, but
not all. I believe that this patient will remain in Terrell State Hospital
unless notable cognitive advancement is made in the future.