DEIB Case Study: Presentation Challenges in Detecting Mental Illnesses (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    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.

    About the Lecture

    The lecture DEIB Case Study: Presentation Challenges in Detecting Mental Illnesses (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course NGN DEIB Case Studies.

    Author of lecture DEIB Case Study: Presentation Challenges in Detecting Mental Illnesses (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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