Nursing Case Study


This reflective case study will provide a written account of the care delivered to a client by myself. Its aim is to enhance the reader's knowledge of the importance of the nursing process and allow discussion to take place at each stage. It will firstly give a pen picture of the chosen client while offering a rationale for the choice. The care delivered will then be analysed using the elements of the nursing process as a structure while identifying any ethical considerations. The case study will make theoretical observations when required. It is hoped that the interrelation of each stage of the process will be identified and by undertaking this study that knowledge, skills and future practice can be improved.

Pen Picture

Carol is a 63-year-old lady known to the mental health services. She is retired and lives on her own in a one bed roomed flat, on the outskirts of a large city. She has a quiet disposition, and isolates herself socially. She has few friends and spends the majority of her time socializing with her daughter. Carol has suffered from mild depression since 1980 following the death of her mother. Her mother was diagnosed with cancer after admission for a hip replacement. In 1996 carols depression deepened, following her own admission for a hip replacement. At this time she had her first contact with the current mental health services. New symptoms such as a ringing in her head and anxiety and agitation were identified. She spent a four-month period on the acute ward, attempting suicide three times. Her reasons for this involved a primary goal of escaping the unbearable noises and voices in her head, which made her increasingly anxious and agitated. Treatments at this time included a course of ECT in combination with anti-depressants, with, Lorazepam 0.5mgs, qds available as PRN (as required) for agitation and anxiety. More recently she has had four separate admissions usually lasting about 3-4 months presenting each time with similar symptoms. Admission this time was warranted as carol had taken an overdose of 7 x 7.5mg Zopiclone Tablets (Sleeping aids) and 10 x 500mg Paracetamol Tablets. Again she blamed a considerable increase in the intensity of her noises and voices and the feelings of anxiety and agitation.

Rationale for choice

Carol offers both colleagues and myself a dilemma. In four recent attempts to help carol efforts have been ineffective. Probably lending to carols apparent lack of enthusiasm for suggestions made by staff. I viewed carol as a challenge, feeling the need to take this up by carrying out her care under supervision, as her primary nurse. On several occasions I had been with carol when she was experiencing these symptoms of anxiety, I felt the need to 'do something' yet felt unable. Dexter & Wash (1995) suggest this leads to a mutual anxiety provoking relationship. In order to avoid this a reflective case study could go some way to gaining a better understanding of what occurred.

The nursing process

The nursing process is a series of nursing actions toward the client (Ward 1985). It is a process by which on evaluation, re-assessment should take place. Fig 1 should help illustrate the nature of this process.

Figure 1.

As illustrated above there are four parts to this process, each dependant in some way, on the other. With this in mind let us look at the first phase, Assessment.


Ritter (1989) defines assessment as the collection and documentation of information regarding the client. Beck et al (1993) define it in terms of the collection of data that reflects the mental health status of a client in relation to the five dimensions of a person. The Physical, Emotional, Intellectual, Social and Spiritual. They also state that for a comprehensive accurate assessment to be done the 'whole person' must be examined. The nursing assessment used in practice utilised these theoretical concepts (Appendix A). This concept can be viewed throughout mental health nursing today (Higgins et al 1999). Within the care delivered to Carol this was addressed as the nursing assessment utilized the holistic framework described by Beck et al (1993). Methods of assessment varied from observation to interview format. It can include gaining information from the family and other agencies involved. This component of the nursing process can be aided with the use of specific measuring tools. The previous assessments done on previous admissions served as a summary of Carols care so far. Included was evidence of multiple recorded entries based on observation on a daily basis. These indicated a pattern of admission to the services. Since 1996 when her noises and voices began. The documentation of previous ward rounds and physical examinations were evident. Again patterns emerged. All of her suicide attempts were to escape from the intensity of her noises and voices combined with her feelings of anxiety. An idea shared by Schnyder et al (1999) who state this is a recognized reason for suicide. It was recognized since 1980 that she had suffered with varying degrees of depression. Possibly initiated by the death of her mother. In 1996 she deteriorated when having a hip replacement. A possible link is evident here as the same experience was shared with her mother. As for the noises and voices little concrete information was available. Suggestions of the cause being Tinnitus were littered throughout the notes. O'Toole (1995) suggest links between this condition and depression, and even suicide. Unfortunately this condition is very difficult to diagnose (Slater & Terry 1987). Descriptions of it vary from buzzing to humming to jet engine noises and shrieking choirs of voices (O'toole 1995). At that time the noises were being treated as a psychotic feature. Questions regarding the symptoms which carol was experiencing were raised. Did these suggest tinnitus or auditory hallucinations? Surprisingly no record of any assessment of her noises and voices were evident. Maybe a Hallucination Interview Schedule (HIS) (Appendix B) may have proved useful. With its aim being that of eliciting phenomenological data about a client's sensory experience, very useful in this case as the cause is unclear. Despite this whatever the causes, the effect of the experience on carol increases her levels of anxiety for which there are several common signs (see Table 1).
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Table 1. Common signs of acute anxiety

• Feelings of fear or dread

• Trembling, restlessness, and muscle tension

• Rapid heart rate

• Light-headedness or dizziness

• Perspiration

• Cold hands/feet

• Shortness of breath

As mentioned earlier carols primary source of socialisation when at home comes from spending time with her daughter. NIMH (2000) suggests that the family is of great importance in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive without helping to perpetuate the person's symptoms. If the family ...

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