Competitive strategy

Mrs B. is seen very briefly in the ED. Her notes from a previous admission to the Mental Health Unit of the same hospital two years ago are reviewed.

When interviewed, Mrs. B’s responses to questions were largely irrational or irrelevant to the topic at hand. In a more lucid moment, Mrs. B conveyed that she had pain, gesturing to her stomach. Her vital signs were stable; she was afebrile and normotensive.

Mrs. B’s psychotropic medications at the time included 400 mg Quetiapine daily in divided doses for delusions, hallucinations and agitation; 500mg of Sodium Valproate daily for mood instability and agitation; 100 mg of Sertraline daily for depression and agitation; and 4–6 mg of Lorazepam daily in divided doses for anxiety and agitation.

Her medical history was significant for hypothyroidism, coronary artery disease, atrial fibrillation, hypertension, hypercholesterolemia, and gastroesophageal reflux disease. For these conditions, she was taking 25 mcg Levothyroxine daily, 0.125 mg digoxin daily, 325 mg Aspirin daily, 50 mg Metoprolol twice daily, 40 mg Simvastatin daily, and 40 mg Pantoprazole daily.

Mrs. B. also had a history of recurrent urinary tract infections, chronic constipation, frequent falls, and osteoporosis. She had no known drug allergies.

She is admitted to the Mental Health Inpatient Unit.

Mrs. B’s blood electrolytes, renal and liver function tests, fasting glucose and haemoglobin levels, lipid profile, vitamin B12 and folate levels, calcium level and toxicology screen were all within normal limits. Mrs. B’s urinalysis with cultures and sensitivities revealed an Escherichia coli urinary tract infection. Consistent with infection, the FBC showed an elevated WBC count, and the ESR and C-reactive protein levels were elevated. Free T4 and total T3 were low, with an elevated thyroid-stimulating hormone level. EEG showed nonspecific generalized slowing, and a brain scan revealed mild age-related atrophy and no acute intracranial process. A chest x-ray showed no acute changes. ECG showed atrial fibrillation.

A physical exam revealed constipation but no other acute physical findings. Mini-Mental State Examination and some other cognitive screening were attempted but could not be completed because of her poor attention and cooperation. The Registrar diagnosed an acute confusional state.

Functional assessment showed that Mrs. B. needed some assistance with activities of daily living. She needed help with organising her clothing and bathing, but was able to bathe and dress herself neatly and appropriately. She walked slowly but steadily. She would frequently wander the unit looking perplexed and lost, was able to be redirected to rooms with ease.

Intermittently she was observed to react to unseen objects and mutter angrily to unseen people. This behaviour would cease when she was approached. She did not spontaneously communicate with other people but would respond if spoken to. She became spontaneously increasingly agitated about her whereabouts on a few occasions each day but was easily reassured.

Mrs B.’s son visited regularly and was empathic and understanding with his mother. He was able to give some background information. Mrs. B migrated to Australia as a child of German father and British mother. She was married at a young age and remained married until her husband died of a CVA in his 80’s, five years ago. Her husband is described as a quiet caring man, with traditional gender role values. They ran a small mixed business store attached to the family home most of their working lives. The son described her mother as having extended periods of low mood, being quite “normal” in interim periods. She had “strange thoughts” for as long as he could remember. For example, for a time, Mrs. B would eat only foods that were white. At other times she would refuse to stock certain items in the shop for inexplicable reasons. Still, in her adult life, she had actively participated in developing and running the family business with her husband and had raised two sons. She had limited social contacts outside of the shop but appeared to relate and converse well with her regular customers. When her husband died 5 years ago, she developed a major depressive disorder, single episode, severe with psychotic features and was admitted to the mental health unit.

  • What are the main goals of a care plan for her while she is in hospital?
  • After watching the video of a brief initial interview (within Module 4), document the detailed Mental State Examination findings for Mrs B. using the headings in Chapter 13 of the text. Submit your findings
  • What other assessment information can the nurse gather and how might you go about this?
  • After synthesising this information what would be your diagnostic formulation?
  • How would you collaborate with her and her family to plan her care?