HLT54115 - Mr Jeremy Black Case Study - Electro Convulsive Therapy - Nursing Assignment Help

Assignment Task :

Case Study :
Mr. Jeremy Black is a 37-year-old architect who has been an inpatient on a mood disorders unit for the last 20 days. His current presentation is calm, with the appearance of a resolution towards his life and problems. This is in contrast to his clinical presentation 2 days ago when he was anxious, unable to concentrate, and worried about everything in his life.  
Jeremy is casually dressed. He has early morning wakening and difficulty going to sleep which is reflected in his presentation. He sits in a relaxed unguarded position. He doesn’t initiate conversation but is pleasant and replies when spoken to. Conversation is slow to begin with Jeremy answering initially in a relaxed nonchalant manner. As the conversation expands Jeremy becomes more engaged but remains relaxed with an unusual degree of composure.   
 

Background  
Previous admissions have involved Electro Convulsive Therapy (ECT) as a treatment strategy in combination with antidepressant medication. Since his last admission Jeremy has been receiving maintenance ECT every 2 weeks, however, there has been a gradual decline in Jeremy’s mood and functioning. During this admission, Jeremy has had a review of his antidepressant medication and has attended group therapy as appropriate, together with receiving ECT three times a week.  
 

Current Medication 
Jeremy is taking Duloxetine hydrochloride commonly known as Cymbalta 120mg which consists of 2 x 60mg blue/green pellets, taken once a day with or without food.  
He has been taking this medication for some time and is experiencing a few side effects i.e. dry mouth; orthostatic hypotension (drops in blood pressure when changing position from sitting to standing and dizziness). 
Cymbalta side effects may also include suicidality (Jeremy’s suicidal thoughts may/may not be related to his medication) raised blood pressure; withdrawal symptoms; palpitations; gastrointestinal upset; chills; musculoskeletal pain; muscle spasms; lethargy; somnolence; paraesthesia (loss of sensation); anxiety; sleep disorder; agitation; micturition abnormality (problems with urination); yawning; oropharyngeal pain (pain in face, jaw & neck); pruritus (itching sensation); mania; hypomania; very rarely, serotonin syndrome; hyperprolactinemia; hypersensitivity.  
 

Current treatment 
ECT is quite well tolerated by Jeremy with the most frequently reported side effects being a headache, which resolves within a couple of hours, and short term memory loss which can resolve over a variable time frame. The benefits of ECT is an increase in the patient’s level of motivation. However, this can also increase the risk of self-harm, etc.  
 

Presentation on admission  
On admission, Jeremy was noted as being low in mood with increased level of anxiety when contemplating everyday activities e.g. grocery shopping, collecting his children from school each day, etc.  
Jeremy reported a lack of motivation for social activities e.g. going out with his wife (Judy) to a restaurant, visiting relatives, going to the park with his children; he is unable to think about work at present. Jeremy has expressed worries that his manager is questioning his ability to do his job, also verbalizing that he frequently feels distraught and panicked i.e. pressured; shaking; dry mouth; sweating; feeling sick when he thinks about his life situation, stating that he “can’t see a way out”.  
 

Current Presentation at Interview  
Jeremy is pale and appears tired which is a consistent presentation for poor sleep patterns including early morning wakening. Jeremy’s appetite is poor and he has recently lost weight. 
Jeremy’s presentation in the last 2 days is that of calm resolution. He describes his previous concerns and worries as “under control” but when asked about this he is unable to outline what has changed. This might account for his current relaxed state.  
Jeremy is quiet, presenting as relaxed, sitting comfortably in the chair with his arms unfolded, legs uncrossed.
 

Social History 
Jeremy has been married for 10 years to Judy who is 35 years old. Jeremy describes his marital relationship as “on the rocks” and getting worse. Judy, a home maker, has threatened to take the children to her parents if Jeremy doesn’t “do something to make things better”. 
Jeremy has 2 children; Jodie aged 5 and Marcus aged 9. His parents both live in Perth and he has a married sister living in Japan with her husband and their 2 children.  
Jeremy feels isolated from friends, has no hobbies or pastimes and smokes a packet of cigarettes per day.
He has work stress and feels pressured to return to work as the mortgage has not been paid for months and he fears the bank will foreclose. 
Jeremy described feeling depressed at age 20 years when at university, recounting that his girlfriend, whom he described as “the love of his life” died from a drug overdose. Sometimes Jeremy uses drugs as an escape mechanism as he feels that life is such a struggle. 
Jeremy reports that his cousin, who lives in Perth, killed himself a month ago and that this has increased Jeremy’s anxiety and feelings of hopelessness. Jeremy says his cousin was more “capable, mature, and responsible” than Jeremy is and yet he killed himself. This event has caused Jeremy to also think about his girlfriend’s death. 
 

Past Life Events of Note 
Girlfriend’s death 17 years ago – drug overdose  
Recognizing feelings of depression at age 20 years  
Married at age 27 years 
Cousin in Perth committed suicide 1 month ago 
 

Behaviour, Affect and Mannerisms  
In the last two days, nursing staff have reported that Jeremy appears unusually calm in his manner, being noticeably brighter in mood. When asked what has caused this change in his approach to life Jeremy replies that he simply feels in control of his life, but when asked to explain how Jeremy offers no information. 
Jeremy has been spending quite a lot of time in his room, writing letters and notes which he says helps him plan what he needs to do. He continues to avoid interacting with other patients choosing to sit quietly on a seat in the garden area outside the ward. 
 

Ideas 
Although Jeremy has consistently expressed anxiety about performing everyday activities and when thinking about his life, he does not appear to have these concerns at present. Jeremy is not verbalizing any reasons for this change. He also appears unconcerned about the possibility of his house being repossessed or that he might lose his job.
Jeremy is reconciled to take action if his wife takes the children away from him, but he is not willing to disclose what action this might be.  
He is looking forward to catching up with friends from Perth when they visit Sydney as he feels he may not see them again for some time. He is also really pleased to be planning some time with his children.  
 

Suicide Plan
Research indicates that males choose a method with high lethality e.g. hanging. However, Jeremy’s plan involves the opportunity to meet up with friends to say goodbye, without letting them know what he is planning, and then to take his life by jumping off a well-known bridge. 
Jeremy views his life as overwhelming, and out of control. He understands how his capable, mature cousin took control of his life by killing himself. Given the pressures from his manager, the fact he could lose his home and his wife, and that she is threatening to take away his children, the best option, as he sees it, is to take back control and reduce the pressure i.e. by killing himself. His suicide plan is imminent given his arrangements to meet with friends. He does not want to divulge his plan because he knows the nurse will take steps to prevent him from enacting his plan, but with careful questioning, by a skilled clinician, Jeremy will hint at his plan, but be guarded in the information he supplies, trying to divert the conversation away from the plan, leaving the clinician with a high level of suspicion of risk of injury or harm. 

Questions based on the above case study :

1. Using the following list of factors that may be impacting on Jeremy’s life, list how these biopsychological effects of mental health affect his ideas, decision-making and his recovery. 

2. Perform a risk assessment on Jeremy using the table below. How would the interdisciplinary health care team use this information to develop a plan of care for the person and how would you in your role as an enrolled nurse participate in this care planning?
3. Tell us how you would explain (using plain English) to Jeremy the administration method of his Cymbalta medication, possible effects of this medication and known specific adverse effects. 
4. What can nurses do to support Jeremy, as a valued member of the community to build on his own strengths and to take as much responsibility as possible for decisions that affect his life and the life of his family? 

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