Case study Blog

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.
1. Document the detailed Mental State Examination findings for Mrs B.
2. What other assessment information can the nurse gather and how might you go about this?
3. After synthesising this information what would be your diagnostic formulation?
4. What are the main goals of a care plan for her while she is in hospital?
5. How would you collaborate with her and her family to plan her care?

Addit Reference –
This module will emphasise detection of the delirium syndrome, primary prevention, prevention of excess disability and distress as well as biophysical, environmental and interpersonal management of the emotional and behavioural symptoms. It is helpful to consider Delirium as the medical diagnosis and Acute Confusion as the nursing focus of care. In practice, the terms are often used interchangeably. Delirium is an abrupt change in mental status and behaviour with global and fluctuating impairment in cognitive processes and alterations in attention / consciousness. A Delirium is a medical emergency requiring immediate investigation and treatment.
DSM5 Diagnostic Criteria:
Key Features: Rapid and Abrupt onset of:
Impaired Attention
Lack of Awareness of environment
Change in at least ONE Cognitive Domain:
Recent Memory
Orientation
Language (i.e. rambled speech, mumbling, difficult to understand)
Perceptual Disturbance
Associated Features:
Change in sleep-wake cycle
Change in emotional states
Worsening of behavioral problems in the evening
Much of the information available about Delirium pertains to the hospital setting where patient observation is easier and data more available for systematic study. Recent transformations in hospital care have resulted in an increasingly rapid pace and technological focus, shorter lengths of stay, reductions in skilled nursing staff, and the use of unlicensed patient care personnel. The effects of these changes on the outcomes of hospital care remain unclear, particularly for patients 65 years of age and older, a population that accounts for almost half of all inpatient days and that is particularly prone to iatrogenic and nosocomial complications.

The incidence is likely to increase as the result of these changes in hospital care. Delirium often results from hospital-related complications or inadequate hospital care and can be viewed as a symptom of broader problems in the delivery of hospital services. More positively, monitoring the rates of delirium could improve quality of care, because delirium can be linked to processes of care and is highly sensitive to events that occur during hospitalisation. Indeed, the incidence of delirium during hospitalisation can serve as a window on aspects of the quality of hospital care that are not currently measured. (Inouye, Schlesinger, & Lydon, 1999)

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