Discuss with consumers to set up goals to improve daily living skills. For example, preparing of shopping list, developing financial and budgeting skills.

Mrs S is suffering with auditory hallucination; she hears her mother’s voice and other voices to harm herself. The consumer is non-compliant with her medication because the voices tell her not to take the medication. Due to this, she was admitted several times to Hornsby Acute Mental Health Unit. Mrs S had a referral to Assertive Outreach Residential Support (AORS) for follow up regarding her recovery since 2009. Mrs S is unemployed; she is on a disability pension. She lives with her partner who has dialysis 3 times a week. However, he is independent with daily activities. Mrs S has a daughter who also suffers from auditory hallucination, her daughter is currently studying.

Medical History
Schizophrenia with negative symptom such as depressive mood, auditory hallucination since 1989
Type 2 Diabetes
Obesity
Hypercholesterolaemia
Hypertension
High risk of falls- last admission from mechanical fall in 21/4/2015

Diagnostic test

Blood test every fortnight for monitoring WCC due to clozapine prescription. Her recent blood test is on 26/5/2015. It shows that her WCC count is elevated and Neutrophils is also out of normal range.
Currently once every fortnightly Electroconvulsive Therapy (ECT).
Mrs S stated that it relieves her psychotic symptom. This type of therapy is a form of medical treatment for schizophrenia, severe depression, bipolar disorder and other psychotic illnesses. Clinical evidence showed that ECT is effective in relieving depressive and psychotic symptoms. The common side effect is memory impairment. This procedure needs to have consent and it has to be under supervision of a psychiatrist, an anaesthetist (Sane Australia 2014).

Mental Health Assessment

Appearance – lack of personal hygiene, messy hair and strong odour from the cloth.
Behaviour- pleasant, maintain eye contact during conversation.
Orientation- alert and oriented to place and time.
Moods – withdrawal, lack of motivation.
Affect – Flatten affect, dull tone of voice.
Speech – normal speech.
Perception –appropriate emotional response, continuing of auditory hallucination.

Risk assessment

Mrs S is rated as a high risk due to periodic thought of suicide. Also, depressive symptom appears to be increasing because she neglects her personal hygiene and her physical illness. For example, her blood sugar level monitoring and healthy eating. The consumer has social vulnerabilities relating to financial difficulty and recently finding a new rental property. These issues potentially impact her mental illness symptom.

Nursing Intervention

Goal: Improving the psychotic and depressive symptoms.

Strategies
• Supervise self administration of medication by visiting and telephoning a consumer.
• Ensure consumer follow up with GP and Psychiatrist appointments.
• Encourage a consumer to discuss about the voices that she has heard and her general health concerns.
• Promoting distraction technique to reduce the hearing voices symptom such as listening to the music, going out with friend and family.
• Referral to Recovery Pathway Unit for assisting in moving to a new house.

Goal: Reducing the risk of fall and improving mobility.

Strategies
• Educating of side effect of antipsychotic medication such as drowsiness and suitable time to take the medication.
• Monitoring any changes in mobility after anti psychotic dose adjustment.
• Referral to physiotherapy for mobility assessment and encourage a consumer to participate in fall prevention program.
• Once a week regular monitoring of postural blood pressure.

Goal: Maintaining the appropriate range of blood sugar level.

Strategies
• Monitoring a consumer for regular blood glucose check at home and record the result before meal and 2 hours after meal with insulin treatment.
• Educating a consumer and her family of type 2 diabetes treatment in case of emergency due to hypoglycaemia .Also, promoting good preventative foot care.
• Promoting healthy diet and exercise such as walking. Mrs S has obesity which is a high risk of cardiovascular disease.
• Encourage a consumer for a blood test every 3-6 months of HbA1C.

Goal: Increase social activities and promoting independency.

Strategies
• Involving a consumer in setting up a goal for a care plan such as studying, hobby.
• Monitoring a consumer to maintain personal hygiene. Discussing of showering products that a consumer likes to use.
• Engage a consumer in the recreation activities such as crafting, painting. Mrs S is encouraged to go to knitting class.
• Referral to Housing Accommodating Support Initiative (HASI) for social activities service. Mrs S likes to go out for with a HASI staff for a milk shake and movie.

Patient Medication

Clozapine 300 mg nocte
The medication is for resistant Schizophrenia. Other antipsychotic drugs have not had any effect on consumer’s condition. This medication can elevate WCC. Therefore, blood test needs to be monitor weekly prior commencing and continuing this treatment. Therapeutic dose range is between 200-450mg a day with dividing dose. Large doses are recommended taking at night time.

Aripiprazole 30mg daily
It is used for atypical antipsychotic, schizophrenia and bipolar disorder. It is not for dementia and Alzheimer treatment. This medication can cause leucopenia and neutropenia. FBC needs to be monitored. Maintenance dose is between 10-30 mg.

Escitalopram 20mg daily
It is Selective Serotonin Reuptake Inhibitor (SSRI) for treating moderate and severe depression and social anxiety disorder. It is for a person who is assessed with GP and a psychiatrist as part of mental health care plan. The therapeutic dose is between 10-20 mg.

Atorvastatin 40mg nocte
The medication is for hypercholesterolaemia in conjunction with healthy diet. It is recommended reducing risk of stroke in a person with hypertension. The common side effect of the medication is the elevation of liver function. Individual dose is between 10-80 mg.

Metformin 1 g twice a day
It is a treatment for uncontrolled type 2 diabetes with diet and exercise. It can be used together with insulin dependent diabetes. Regular blood sugar test is needed as this medication can cause hypoglycaemia. Moreover, lactic acidosis can occur due to accumulation of metformin. The risk factor is renal function impairment in high doses above 2 g per day. Mrs S is on 2 gram with dividing dose at meal time.

Novomix 30 12 unit twice a day
It is a DNA synthesis of human insulin; it is a rapid, onset medication to reduce hyperglycaemia. Individual dose is various. It is administered into subcutaneous tissue such as abdominal wall, thigh, Deltoid and gluteal. It should be injected immediately before meal. The injection site needs to be rotated due to high risk of lidodytrophy and hypersensitivity on the injection site.

According to Mrs S medication adjustment, a neurologist gradually reduced the dose of clozapine from 500 mg to 425mg in 2014 and 300 mg in 2015 due to numerous falls. After that, sodium valporate was ceased after medication review in the last admission from mechanical fall in 21/4/2015. Mrs S stated that she did not have any fall since she stopped taking sodium valporate.

On 16/06/2015, a psychiatrist reviewed her new medication regime. Sodium Valporate was prescribed for mood stability. Therefore, there might be a fluctuation in consumer’s mood in the next few months. It is essential to monitor any changes in her temperament.

Reflection on the role of registered nurse in Assertive Outreach Service (AORS)

• Providing medication education and management both oral and injection.
• Closely observing and assessing any changes holistically.
• Monitoring both physical and mentally condition in relation to the anti psychotic medication.
• Assisting consumers to maintain personal hygiene and management of clothing.
• Offering transport to dependent consumers to health care facilities.
• Continuing to maintain stability of serious illness consumers in the community as long as possible.
• Collaborating with multidisciplinary team to facilitate daily life activities skills such as cleaning and household maintenance.
• Promoting independency and quality of life to consumers who have serious mental illnesses.

Reflection on multidisciplinary team in Assertive Outreach Service (AORS)

Occupational Therapy

• Helping consumers to achieve daily life skills such as cooking and household cleaning.
• Attaining occupational and vocational skills
• Assessing physical safety environment to consumer with disability.
• Discuss with consumers to set up goals to improve daily living skills. For example, preparing of shopping list, developing financial and budgeting skills.
• Associating with other multidisciplinary team in relation to consumer needs.
• Monitoring and reporting any changes in both physically and mentally to other multidisciplinary team such as registered nurse, social worker.
• Promoting independency such as bus travelling training.