00:01
Hi, I'm Jackie,
let's do a case study.
00:05
This case is entitled:
Clinical presentation challenges
in detecting mental illness.
00:11
I want to introduce
you to Cindy.
00:13
Cindy is on a
medical surgical unit
and she presents
with her parents.
00:17
The nurse on the unit
reviews the assessment notes
regarding Cindy's case.
00:21
Cindy was admitted for
evaluation of the onset
of diffuse abdominal
pain of unknown origin.
00:29
Let's learn a little bit
more about Cindy's case.
00:32
She's a 22 year old female
who actually came to
the emergency department
also accompanied by her parents
to be evaluated for some
generalized abdominal discomfort.
00:42
There was also noted to be some
slight tenderness on palpation.
00:46
Cindy lives in an
apartment above
the family owned
business where she works.
00:51
She's able to answer subjective
questions appropriately,
and she's cooperative
and she maintains eye contact
throughout the entire exam.
00:59
Cindy's parents add,
she's sleeping too much.
01:02
And that's not normal
for a young girl.
01:05
They also say that she
doesn't want to work
or spend time with her friends
like she used to.
01:13
It was decided based
on all this information
that Cindy should be
admitted to the unit
for further evaluation.
01:19
Some labs were drawn,
she had a CBC, a BMP
and the lipase.
01:24
And an abdominal
CT was also done.
01:27
Cindy denies fever,
nausea, vomiting,
and at this point,
she's afebrile.
01:33
The CT of the abdomen
was totally normal.
01:36
And the nurse now reviews
the laboratory results.
01:39
Take a look.
01:41
Hopefully what you'll notice
is that the only
slightly elevated
abnormal lab is her
white blood cell count.
01:47
All the rest of
them look normal.
01:50
So that brings us to
our very first question.
01:54
Which subjective findings
require immediate follow up?
Meaning we've got to
do them very soon.
02:01
This is a select all
that apply questions.
02:03
So there'll be more
than one answer.
02:05
Let's look at our options.
02:07
Excessive sleeping,
decreased social interactions,
white blood cell count,
reported not being
able to go to work,
CT result and abdominal pain.
02:18
Which one should we check?
Okay, let's look at the answers.
02:24
Excessive sleeping.
02:26
Well, this is definitely
an abnormal symptom.
02:29
It could mean any
number of things,
but it definitely requires
further investigation.
02:34
Decreased social interactions.
02:36
Well, this is a change.
02:37
Remember, the parents stated
this is not what's
into usually does.
02:41
So we need to
investigate this further
to figure out what's going on.
02:46
White blood cell count.
02:48
It was elevated,
but only slightly.
02:51
So it doesn't seem to indicate
that Cindy actually
has an infection.
02:54
So that one, we won't check.
02:57
Reported not being
able to go to work.
03:00
Again,
this is a change,
something is wrong.
03:04
And it's wrong to
the point that Cindy
is not able to engage in
her day to day activity,
it's important to go to work so
that you can support yourself.
03:11
So definitely, we're
going to check that one.
03:14
CT result.
03:15
If you remember,
the CT was normal.
03:18
So this does not require
any further investigation.
03:21
And finally, abdominal pain.
03:23
Let's go back to our
stem for just a second.
03:26
It says which subjective data.
03:29
If you'll remember
from the assessment,
the tenderness was
noted on palpation,
which would make an
objective finding
so we won't check that one.
03:38
That last one was tricky.
03:40
So let's look at the
08:15 nurses notes.
03:43
And let's think
about what's going on
as we move through this case.
03:47
So now,
the healthcare
providers coming in
to the room to
examine the client.
03:52
The nurse isn't in the room.
03:53
So the healthcare provider
comes back out to the desk,
and then says,
I think we need an interpreter
because they're Asian.
04:01
The healthcare
provider was informed
that the family
speaks fluent English.
04:06
The healthcare
provider then reports
that Cindy was minimally
interactive during the exam.
04:12
This seems different.
04:15
Afterwards, and this is
probably a few minutes later,
the parents come out
to the nurse's station
and now they're very upset
and ask if they
can just go home.
04:25
So the nurse goes into the room
to try to really mitigate
what's going on here
and really encourages
the client to stay.
04:33
And the client at this point
is no longer making eye contact
and is now noted to be
minimally interactive.
04:39
So definitely something
has changed here.
04:43
Finally, after speaking
to Cindy and her parents,
the nurse is able to
convince the clients to stay
and the parents agree
that they will stay
because they know it's important
to figure out what's going on.
04:54
So after reflecting
on the interaction
with the healthcare
provider and the client,
with the parents and with Cindy,
I have another question for you.
05:03
Can you complete the
following sentence
by choosing from
the list of options?
Let's look at the sentence.
05:10
The nurse is currently most
concerned about the clients _____.
05:15
You see that word most?
Not what is she concerned about?
But what is she the
most concerned about?
What is going off as alarm bells
that needs to be
addressed right now.
05:26
Look at our options,
somatic symptoms,
psychosocial symptoms,
or a change in demeanor.
05:33
Hmm.
05:34
All right,
somatic symptoms.
05:36
While we're talking about
abdominal tenderness
and things like that.
05:40
But we've actually
ruled out any life
But we've actually ruled out
any life threatening emergency.
05:45
So right now, that's
not the most concerning.
05:48
Let's talk about Cindy's
psychosocial symptoms for a moment.
05:51
Her parents reported decreased energy
known as anergia,
increased sleeping refer to as hypersomnia
and disengagement from her social group that she used to enjoy known as anhedonia.
06:01
These are concerning, but not life-threatening.
06:04
These are symptoms that will likely need interventions outside of the inpatient setting.
06:08
Cindy is currently displaying a significant change in demeanor from her arrival to the hospital.
06:13
She and her family members have been
calm and cooperative,
and interested in finding help for her symptoms.
06:18
However, after her interactions with the HCP she stopped making eye contact
and her parents asked if they could leave.
06:24
This abrupt change in demeanor is
concerning and needs investigation.
06:28
So that is the correct answer.
06:30
Change in demeanor,
it is the most concerning
symptom right now.
06:35
Now, let's take a look
at the 08:45 nurses note.
06:39
Cindy is requesting
water which she receives.
06:42
The parents are gone,
so she's by herself,
and she's noted to be tearful,
and wiping her eyes
with those tissues.
06:50
The nurse is being
comforting and empathetic.
06:52
And she tells her that the
nurses and all the staff
are there to help her.
06:56
And it really encourages
her to talk about
anything that's bothering her.
07:00
And this is what Cindy says.
07:02
She says people don't accept me.
07:05
And it's because
of my background.
07:07
Even the doctor assumes
things about me,
that my parents and I
can't even speak English.
07:13
So now I have a question for
you based on that interaction.
07:16
I'm going again going to ask you
to complete the following sentence
by choosing from
the list of options.
07:22
The nurse determines
that the client, Cindy,
is most at risk for _______
as a result, a perceived _______
from the healthcare team.
07:31
Hmm.
07:32
So let's look at our
options for the first blank.
07:35
Eloping prior to discharge,
aggressive behavior,
or additional stress.
07:41
So in this case, certainly
Cindy might want to leave,
it sounds like she's had a
really unpleasant experience.
07:47
But let's see if that's
the most important thing.
07:52
Aggressive behavior.
07:54
Well, the nurse is
probably not that worried
about aggressive behavior
that hasn't been any
demonstration of that so far.
07:59
She's been calm and cooperative.
08:02
Additional stress.
08:04
Well, let's think about it.
08:06
Cindy's had a really unpleasant
interaction with her provider.
08:10
And she might not be
feeling that great.
08:12
She already seems to be
experiencing some stress.
08:15
So what do you think
about this insert?
You got it.
08:19
Additional stress is
certainly something
that nurses going to be
concerned about at this point.
08:24
So that fills in
our first option.
08:26
So what is causing
the additional stress?
What is Cindy perceiving?
That is making the
situation more difficult?
Is it an inappropriate
bedside manner?
Incompetent medical care,
or a microaggression?
Pay attention to
the word perception?
Because that's key to
choosing the correct answer.
08:48
Inappropriate bedside manner?
Well, if something has happened,
that was inappropriate,
then that's just
going to be effect.
08:57
It sounds like an answer and
you might want to choose,
but let's see if we can find
something more specific.
09:02
Incompetent medical care,
the labs have been drawn,
and we've done a
good assessment.
09:08
And all those things
indicate quality care,
so incompetent medical care,
doesn't really fit.
09:14
Let's look at the third option,
micro aggression.
09:17
Now if you think about the
definition of micro aggression,
it's going to be a
perceived slight.
09:22
See the word perception.
09:24
So we know by the
definition that this fits
and it's very direct.
09:28
And if you remember what
Cindy statements were,
that the doctor felt like,
they didn't even speak English
just because they were Asian.
09:36
And that's definitely
a microaggression.
09:38
So microaggression is the
correct answer for this.
09:42
So altogether,
the nurse determines that
the client is most at risk
for additional stress as a result
of proceed micro aggressions
from the healthcare team.
09:53
Okay, I have another
question for you.
09:56
Now, the nurse has identified
some needs that Cindy has,
and we want to make
sure that we know
what the correct
nursing interventions
should be for the plan of care.
10:07
Now, Cindy may need more
than one intervention
for each of these needs.
10:11
So I want you to
think about that
as we go through the question.
10:15
Each category, each need may
have more than one response,
but it has to have at least one.
10:22
So the needs are, and there two.
10:24
First, establish a
trusting relationship
with the healthcare team.
10:28
And second,
provide culturally
competent care.
10:32
So those are our two needs.
10:33
Now, there are a lot
of words on this slide,
so how about we just
hide the second need
for right now and we'll
do this one by one.
10:41
So establishing a
trusting relationship
with the healthcare team.
10:45
What can the nurse do
to help this happen?
Can they provide clients
with uninterrupted listening,
avoid asking questions that are
not relevant to the client's care,
validate the client's
concerns and experiences
or provide clear communication
and set expectations.
11:05
Let's do it together.
11:07
Provide the client with
uninterrupted listening.
11:10
This means not jumping in,
not listening, so you
can get a word in --
Or clarify or do
any of those things
on interrupted listening.
11:20
Oh, yeah, this is
very important.
11:22
Remember Cindy's
feeling, not heard.
11:25
And so allowing Cindy to talk
and to go and explain things
the way that Cindy needs to
would be really important
for helping her to
feel seen and heard.
11:34
Avoid asking questions
that are not relevant to
the client's medical care.
11:39
Sometimes when we're
working with clients
that are different than us,
we have other questions
and curiosities.
11:44
This is not the time,
it's not appropriate to really use
other people to satisfy curiosity.
11:49
So we should stick to why
the client is with us.
11:53
This is not something
we should do.
11:56
Validate the client's
concerns and experiences.
11:59
Absolutely, we want to do this.
12:01
We want to make sure
that we let the client
know that we are listening,
that they are heard
and that are seen.
12:08
And then finally provide
clear communication
and set expectations.
12:12
This allows the client to know
what's going to happen next.
12:15
And this is very important for
establishing a trusting relationship.
12:20
Wouldn't you want to know
what's gonna happen next?
Exactly.
12:23
So this one, we would check.
12:25
So these are the three correct
answers for establishing
a trusting relationship
with the health care team.
12:31
Now let's look at
the second need.
12:33
Provide culturally
competent care.
12:36
Here are options:
Examined personal beliefs and
biases amongst the healthcare team.
12:42
Reassure the client that the
provider doesn't mean to offend.
12:46
Encourage opportunities
with the health care team
on providing care to clients,
different ethnicities
or finally referring
to the client
by their preferred
name and pronounciation
during communication
with other providers.
13:01
Let's see what our answers are.
13:03
Examining personal beliefs and
biases amongst the healthcare team.
13:06
Would that move the team toward
having the ability to provide
culturally competent care?
You bet.
13:13
Absolutely. It would.
13:15
We have to know what
our thoughts are,
especially implicit bias in
order to be able to provide
culturally competent care.
13:22
Reassure the client that the
provider doesn't mean to offend.
13:26
Sometimes this feels like
a way to soften the blow.
13:29
But recognize we can't
speak for other people.
13:32
A. We don't know
if this is true.
13:34
And B. Sometimes that
makes the person feel
like we're devaluing what their
thoughts and feelings are.
13:41
Encourage opportunities
with the healthcare team
to interact with clients
from other ethnicities.
13:46
This is a fantastic
intervention.
13:48
In order to be able to provide
culturally competent care,
it's helpful to make sure
that you're interacting
with people who have a
different experience than you.
13:56
So we'll definitely
check this one.
13:58
And finally refer to the
clients by their preferred name
and pronunciation and pronouns
during their communication
with other providers.
14:06
Absolutely.
14:07
Think about it as
simply as this.
14:09
If someone's name is John,
and I'm talking to the provider,
and I call them Tina.
14:13
Well, that doesn't work.
14:14
So think about it like that.
14:16
We want to use pronunciation,
make sure you know it,
we want to make sure we're
using the correct name
so that there's no
misunderstanding
and the clients are respected,
even when they can't
hear what you're saying.
14:27
So we would
definitely check that.
14:29
Here are the correct answers
for our second client need.
14:33
I have another question for you.
14:35
Now, the nurse has been
talking with Cindy for a while
and so Cindy makes
some statements.
14:40
We want to know what
is the most correct
and appropriate response
that the nurse can give
to three statements
that Cindy makes.
14:48
Here are the statements.
14:49
First one.
14:50
I don't really want that
health care provider
to treat me anymore.
14:55
Or second statement.
14:57
I'm scared I'll be treated
differently by the next nurse.
15:00
And our third statement.
15:02
I only have one close friend.
15:04
I think it's because
others judge me.
15:07
Let's see if we can find the
most appropriate response.
15:10
Again, I know there's a lot
of things on this slide.
15:13
So how about we remove and just
look at one option at a time.
15:17
Here we go.
15:18
I don't really want that health
care provider to treat me anymore.
15:23
What should the nurse say?
What's the most
appropriate response?
Here are the options.
15:28
That is the only health care
provider on call right now.
15:32
Ouch.
15:33
Well, that would be
pretty scary to feel like
Cindy has to put up with
whatever is out there.
15:37
Definitely wouldn't want that.
15:40
The next option.
15:41
You seem stressed,
please try to relax and
I'll bring you a snack.
15:45
Well, I love that
Cindy stressed,
we'll bring her a snack and that's
going to make it all better.
15:51
You're right?
That's not the best option.
15:53
Let's look at the last one.
15:55
Please share your feelings
about the treatment
you received from the
healthcare provider.
16:00
Okay, this option invites Cindy
to tell us about
what's going on.
16:05
Remember, we want
to build trust,
and this is definitely the
response that would do it.
16:09
Okay, let's look at the second
statement that Cindy made.
16:13
I'm scared I will be treated
differently by the next nurse.
16:17
What should the nurse say?
Option one.
16:20
After I give my handoff
report to the oncoming nurse,
we will meet with you to
discuss your care with you.
16:27
Hey, that's a lot of you's.
16:29
That sounds like something
that would be a great response.
16:32
But let's look at
some of the others.
16:34
Sorry for interrupting.
16:36
But all nurses treat
everyone the same?
Well, there are a lot of
problems with this statement.
16:41
First of all, the
nurse interrupted,
which we know from
our last question
is not the best way to proceed.
16:47
But do all nurses treat
everyone exactly the same?
Can we make a broad
statement like that?
Nope,
we can't.
16:54
So we wouldn't pick that one.
16:56
And finally, you
don't need to worry,
the next nurse will
provide great care
and treat everyone with respect.
17:02
Well, this is very similar
to the last statement.
17:05
We don't know if it's true,
and it really devalues
what Cindy has said.
17:10
So we're not going to
click that one either.
17:14
Let's look at Cindy's
final statement.
17:17
I only have one close friend.
17:19
And I think it's
because others judge me.
17:22
First of all that
statement breaks my heart.
17:24
But let's figure out what
response the nurse might make.
17:28
Option one.
17:29
I would like it if you could
tell me more about your friend.
17:33
Hmm, that sounds open.
17:35
Sounds warm.
17:36
And empathetic.
17:38
Might be the best option, but
let's see what else we have.
17:41
I came in to give you
some pain medication.
17:44
Well, nothing warm,
nothing open in that option.
17:48
So that wouldn't
be the best answer.
17:51
And finally, the
nurse could say,
I want to know more,
but I need to see
another client.
17:57
I'll be back as
soon as I have time.
17:59
Okay, let's be honest,
sometimes we are busy and
can't sit down and talk.
18:04
And if this were
the only option,
then it might be
the best option.
18:08
But we have option
one where it says,
I'd like for you to tell
me more about your friend.
18:12
And that definitely
really let Cindy know
that we're listening
that we're here
and all the options,
that's the best one.
18:20
Not saying we would
never say three,
might say it a little softer,
but one is a better answer.
18:27
So that's the one
we're going to choose.
18:30
Here are the correct answers
for all three statements.
18:34
Now let's look at the
nurse's note at 10:20.
18:37
The nurses working really
hard to reestablish
some trust that was broken with
the health care provider earlier.
18:43
So after receiving
permission from Cindy,
she talked to the health care
provider about the interaction.
18:49
And she explains how Cindy felt
and some concerns.
18:54
The health care
provider really agreed
and stated that really there
should be some follow up done
with the client
regarding those concerns.
19:02
And they identified and acknowledged
that those concerns happen.
19:05
And that's a great thing.
19:07
So my final question is this,
which statement
made by the client
indicates that a
trusting relationship
has been reestablished
with the health care team?
So reestablish,
what lets us know
that the interaction between
the health care
provider and Cindy
and how they feel about
everybody on the unit
has returned to a
trusting situation.
19:31
Let's look at our options.
19:33
Cindy might say,
I feel like I've been
depressed and isolated
and I feel like that
is because who I am.
19:41
Well, this is a
very open statement.
19:43
Somebody who's
willing to disclose
might be a good option.
19:48
But let's see what else.
19:49
The healthcare
provider talked to me
and apologize for the cultural
insensitivity that was shown.
19:56
Well, this is more of a
I don't know, like a report.
20:00
This is what happened.
20:02
Really doesn't let us know
that trust was established,
just to repeat back.
20:06
So that maybe
doesn't let us know
that's Cindy's feeling better.
20:10
Just a report of what happened.
20:12
Not the best option.
20:14
I only want to talk
to my assigned nurse
about what's going on.
20:18
Well, clearly there's some trust
between Cindy and the nurse.
20:21
But remember,
the question asks about
the entire healthcare team.
20:25
So this makes it sound
like there's some
attachment to a nurse,
not to the team.
20:31
So this is not the best answer.
20:33
Okay, the last option.
20:35
I was told my plan of care
was discussed this morning,
and I have a consultation
later with a crisis worker.
20:42
Well, yes, it's great
that Cindy received
some information.
20:45
Again, this sounds like
a checklist or report.
20:49
Anybody could have written this
doesn't let us know
that trust is back.
20:52
We should do these things.
20:54
But remember the question says,
what statement made
by Cindy lets us know
that a trusting relationship
has been reestablished.
21:02
Let's go back to
that first option
where Cindy is open and
expressing how she feels.
21:08
That’s the answer
that lets us know
that Cindy is
letting us back in.
21:12
So the best answer
is Option one.
21:15
Fantastic.
21:17
You did it,
and we are finished.
21:20
Great job.