Reference no: EM133617934

Assignment

Welcome to the Mitten Trauma Center! You are one of many registered nurses in the Emergency Department. While you have been a nurse for seven years, you are relatively new (< 1 year) to the emergency department. On this day, you are working the 7a - 7 pm shift. Shortly after lunch, you are assigned to care for a patient that just arrived. Let's go meet him!

Justin Hawkins is a 30-year-old Caucasian male who was brought to the emergency department by the police after being involved in an altercation at the gym. The police report indicates that they were called when Justin engaged in a verbal tirade with another customer. When the customer didn't respond the way that Justin desired, he shoved her, and she fell over the treadmill. As he continued to threaten customers and staff, the police were called.

After arrival at the ED, Justin continues to be agitated with the staff. He is pacing furiously and speaking very fast. His speech is loud, difficult to understand and he doesn't allow others time to respond when asking questions. Justin indicates that he was diagnosed with schizophrenia when he was 18 years old. When questioned about his medication use, Justin replied, "I stopped taking it two weeks ago as Big Pharma is just trying to control me!"

As Justin's behavior is frightening the other patients in the waiting room, he is asked by the police officer to sit down. He responds by kicking the officer repeatedly. Hospital security is telephoned for assistance because the registration clerk, who is new, didn't know about the panic button located on the underside of the desk. While waiting for security, Justin shoves the officer several times. When the triage nurse attempts to intervene, he pushes her, and she falls striking her head on a chair back.

As Justin continues to behave aggressively towards others, several physicians, nurses, and security officers assist in restraining him so that Haldol and Ativan can be administered IM. As this is done, Justin screams "Help" repeatedly which upsets the other patients and families in the ER. After the medications take effect, Justin is calmer and more cooperative, so the following assessment is performed:

Physical Assessment:

Appearance: Hair is greasy and uncombed. Clothes are stained and appear to have been slept in. A strong body odor is detected.

Cardiac: S1 & S2 noted. Regular. Regular, strong, and equal radial pulses. Brisk capillary refill.

GI: Abdomen flat, soft/nontender, positive bowel sounds in all four quadrants

GU: urine clear/yellow, unable to determine an amount as Justin flushed it so "you can't use it against me".

Respiratory: Breath sounds are clear and equal bilaterally, non-labored respirations

Skin: No open areas noted in exposed skin, skin turgor elastic. Pink, warm and dry. No visible edema noted of the hands. Unable to assess feet/ankles currently.

Mental Health:

Cognition: Alert & oriented to person & place. Unable to determine orientation to time and situation. Linear but an irrational thought process. Angrily states that "Big Pharma" and his father are trying to control him through his medication. Poor insight into the reason for ED visit. Poor judgment as indicated by his aggression in the gym and ED. While Justin denies any suicidal thoughts or thoughts of self-harm, he indicates a desire to teach his father and the gym "a lesson".

Motor behavior: Justin is pacing furiously around the room; agitation increases if the staff approaches him. No abnormal muscle movements noted.

Mood: Justin indicates that he feels very upset and angry as "no one is listening to me".

Speech: Rapid speech pattern. Incoherent at times. As agitation increases, the volume of speech rises. Often repeats words and phrases that others say. Frequently mutters to himself regarding how everyone is "out to get him".

Affect: Guarded in his responses. Becomes suspicious of the reason for "all these questions". Increased agitation noted when discussing his father and recent breakup with his girlfriend.

Employment:

Justin indicates that he is training to be an electrical journeyman. Despite working towards this goal since his early 20's, he remains an electrical apprentice. When questioned regarding this, Justin angrily retorts that this is just another way that "the man" holds him down.

Home Situation/Support System:

Justin reports living at home with his father and that his mother died 15 years ago from breast cancer. He indicates that he broke up with his girlfriend recently as she was trying to poison him.

Upon arrival to the emergency department, Justin's father is called. He arrives shortly after Justin has been calmed and assessed. Mr. Hawkins explains to Justin that he "just can't take these outbreaks anymore and that Justin can no longer live at the house." Mr. Hawkins apologizes to the staff for his son's behavior and notes that Justin had not been consistently taking his medication despite Mr. Hawkins' efforts to monitor and support medication compliance. Mr. Hawkins also tells his son that "you have dragged me down for so long that I'm exhausted and done." Mr. Hawkins, visibly upset and sad, leaves the emergency room.

Task

Question I. Describe 3 measures the hospital could implement to reduce the risk of violence?

Question II. Discuss at least 2 system changes at the national level that could be implemented to provide better care for Justin.

Question III. Caregiver burden happens frequently in those who care for individuals with a chronic illness. What can we, as nurses, do to help prepare caregivers for the role in general?

Question IV. Discuss 4 coping strategies for caregivers to help minimize caregiver fatigue.