INP drama case scenario - Mental Disorder (Bulimia, Bipolar Disorder, Paranoid Schizophrenia)

1. Name: Dave Jay Manriquez (INPCase Drama Scenario)
Scenario 1
Sarah
- 42 yrs old
- Bulimiafor 12 yrs
- Traumaticdivorce
- Highlyanxious
- Substance use (alcohol)
1. How will you open the conversation with Sarah and create a therapeutic environment for
assessment?
- Ask person’s name, and use it during conversation.
- Build rapport and trust using simple conversationtechniques, such as: speakingslowly and calmly, use
of simple concrete language, and reducing unnecessary stimuli.
- Create a safe space for your safety and not to intimidate the patient.
- Be patient for her response.
- Show empathy toward her emotion, listen, and validate response
- Do not invade personal space or touch without permission.
- Be aware of own feelings and don’t judge.
2. What will you assess in order of PRIORITY? Include the questions you will ask and the physical,
emotional and behavioral symptoms you will assess for. What tools will you use?
PRIORITY:
a. QPA
b. Vital Signs
c. Weight
d. Mental health status
Possible questions to ask:
1. Is this your first time to visit the clinic?
2. Have you been diagnose before of such condition’s, and are taking any medications?
3. Do you have any allergies to any medication?
4. Have you been treated with your condition before by another doctor or clinic?
5. Are you craving for so much food and feel guilty after eating?
6. Are you still drinking alcohol as of lately.
Physical effectswhich include:
 Shortnessof breath
 ChestPain
 Heart palpitations
 Headaches
 Sweating
 Muscle weakness
Emotional Effectsinclude:
 Irritability

2.  Restlessness
 Feelingsof tensionordread
Behavioral Effectsinclude:
 Nervoushabits
 Binge eating
 Purging
Assessment Tools:
a. CAGE – cutting down, annoyed, guilt, eye opener
b. CIWA – Alcohol Withdrawal Assessment Scoring Guidelines
c. Life change Index Scale (The Stress Test)
d. The nurse’s global assessment of suicide risk tool
e. The Holmes-Rahe Life Stress Inventory
f. Mental Status Examination – general appearance, psychomotor behavior, mood and affect,
speech, cognition, thought patterns level of consciousness
g. Anxiety Scale
3. Whatquestionsmay you ask to explore hercurrent mental healthstatus? Whatsigns and symptoms
of anxiety are you watching for and how will you address anxiety in Sarah? Describe fully?
Questions that can be ask to a Bulimic patient:
 Are you obsessedwithyourbodyandyourweight?
 Doesfoodand dietingdominateyourlife?
 Are you afraidthat whenyoustart eating,youwon’tbe able tostop?
 Do youevereat until youfeel sick?
 Do youfeel guilty,ashamed,ordepressedafteryoueat?
 Do youvomitor take laxativestocontrol yourweight?
AnxietySignsand Symptoms
Physical effectswhichinclude:
 Shortnessof breath
 ChestPain
 Heart palpitations
 Headaches
 Sweating
 Muscle weakness
Emotional Effectsinclude:
 Irritability
 Restlessness
 Feelingsof tensionordread
Behavioral Effectsinclude:
 Nervoushabits
 Binge eating
 Purging
Cognitive Effectsinclude:
 Persistentthoughtsregardingallegeddangers

3.  Obsessive thoughtsaboutperceivedfears
 Her anxietyiscause bya resultof a traumaticlife eventinherlife withpreviousdivorce.
Treatment of Anxietyand Eating Disorders
It is crucial that anxietyistreatedinconjunctionwith treatmentof aneatingdisorder;particularlyasthe
two are closelyrelatedandcommonissuesare addressedtoheal fromthe underlyingfactorsassociated
with both disorders. Comprehensive treatment considerations for an individual suffering from both
anxietyandan eatingdisorderare cognitive-behavioral therapy (CBT), psychotherapy,support groups,
and some medications that can be helpful in managing anxiety and separating feelings from food.
Learning healthier coping mechanisms for managing anxiety are also the focus of treatment.
4. Sarah has a history of alcohol use. Describe what questions you will ask and indicate the tools for
assessmentyouwill be using.Whatwouldyoudoand/ or say? WhatstressorsinSarah’s life maytrigger
a relapse into this method of coping?
Possible questionforalcohol addiction:
1. Do youlose time fromworkdue to yourdrinking?
2. Is drinkingmakingyourhome life unhappy?
3. Is drinkingaffectingyourreputation?
4. Have youeverfeltremorse afterdrinking?
5. Have yougottenintofinancial difficultiesasaresultof your drinking?
6. Do youturn to lowercompanionsandaninferiorenvironmentwhendrinking?
7. Does yourdrinkingmake youcarelessof yourfamily'swelfare?
8. Has yourambitiondecreasedsincedrinking?
9. Do you crave a drinkat a definite timedaily?
10. Do youwant a drinkthe nextmorning?
11. Doesdrinkingcause youto have difficultyinsleeping?
12. Has your efficiencydecreasedsincedrinking?
13. Is drinkingjeopardizingyourjoborbusiness?
14. Do you drinkto escape fromworriesor troubles?
15. Do youdrinkalone?
16. Have you everhada complete lossof memoryasa resultof your drinking?
17. Has your physicianevertreatedyoufordrinking?
18. Do youdrinkto buildupyour self-confidence?
19. Have you everbeeninahospital or institutiononaccountof drinking?
What to say to the patient:
1. Everythingwe have discussedwill be keptconfidential.Informationwill onlybe sharedto
the members of the health care team that will assess you with your addiction.
Assessment Tools:
a. CAGE – cutting down, annoyed, guilt, eye opener
b. CIWA – Alcohol Withdrawal Assessment Scoring Guidelines

4.  Her past traumaticlife eventinherlife withpreviousdivorce thatresultedherinsubstance
misuse (alcohol).
Scenario 2
Lisa
- 35 yrs old
- admitted to an acute mental health unit for stabilization and medication review
- history of bipolar disorder, two manic breaks with psychosis in the past 4 months
- divorced and has a difficult relationship with her ex-husband
- twodaughtersinsharedcustody,doesn’twant their current house, spend weekend on father’s place
- recentlysell townhouseandcurrentlyliving in assisted living housing
1. How will youopenthe conversationwithLisa and create a therapeuticenvironmentforassessment?
Consider how you would best approach and interact with someone exhibiting both hypomania and
hypermania psychosis?
- Ask person’s name, and use it during conversation.
- Build rapport and trust using simple conversation techniques, such as: speakingslowly and calmly, use
of simple concrete language, and reducing unnecessary stimuli.
- Create a safe space for your safety and not to intimidate the patient.
- Be patient for her response.
- Show empathy toward her emotion, listen, and validate response.
- Use a supportive, caring approach.
- Match tone and rate of speech.
- Encourage self-care and normal routines.
- Ask how you can help, and know if she is receiving any supports from family members.
- Knowsuicide risk factorsandwarningsigns,andif possible ask if she has plan to harm self and others.
2. What will you assess in order of PRIORITY? Include the questions you will ask and the physical,
emotional and behavioral symptoms you will assess for. What tools will you use?
Priority to assess:
a. Safety (for patient and the care provider) – hold for observation
b. QPA;Vital Signs
c. Ask if religiouslytakingmedicationsorhave takingothersubstance.
d. Mental status assessment –General appearance suchasgrooming
Possible questionstobe asked:
1. What is goingon foryou?What bringyouhere tonight?
2. What you are feelingisimportanttoyou?Thusthisfeelingbotheringyou?
Sign and Symptoms to assess:
Physical
a. Increase motoractivity
b. Bizarre dressandaccessories

5. c. Poor hygiene
d. Excessive energy
Emotional
a. Inflatedself-esteemorgrandiosity
Behavioral
a. Extreme euphoria
b. Talkative withrapid,racingspeech
c. Flightof ideas
d. Decreased needforsleep
e.Easilydistracted
f.Extreme irritabilityandmoodiness
g. Recklessandimpulsive behaviors
h. Lack of judgment
i.Irresponsiblebuyingspreesorbusinessdeals
j. Sexual indiscretions
k. Delusionsof grandeurorpersecution
l.Auditoryandvisual hallucination
Assessment Tools:
a. Beck’s Depression Scale
b. Quick Depression Assessment Checklist
c. DSM-IV Criteria for Diagnosis of Depression
d. Life change Index Scale (The Stress Test)
e. The Holmes-Rahe Life Stress Inventory
f. Mental Status Examination – general appearance, psychomotor behavior, mood and affect,
speech, cognition, thought patterns level of consciousness
g. Anxiety Scale
3. Whatquestionsmay you ask to explore hercurrent mental healthstatus? Whatsigns and symptoms
are you watching for and how will you address these concerns. Describe fully.
Possible questions to ask:
 Whendidyou or yourlovedonesfirstbeginnoticingyoursymptomsof depression,maniaor
hypomania?
 How frequentlydoyourmoodschange?
 Do youeverhave suicidal thoughtswhenyou're feelingdown?
 Do your symptomsinterfere withyourdailylifeorrelationships?
 Do youhave any bloodrelativeswithbipolardisorderordepression?
 What othermental or physical healthconditionsdoyouhave?
 Do youdrinkalcohol,smoke cigarettesoruse streetdrugs?
 How muchdo you sleepatnight?Doesitchange overtime?
 Do yougo through periodswhenyoutake risksthatyouwouldn'tnormallytake,suchasunsafe sex
or unwise,spontaneousfinancialdecisions?
 What, if anything,seemstoimprove yoursymptoms?
 What, if anything,appearstoworsenyoursymptoms?

6.  Refer sign and symptoms on answer no. 2
Addressing the behavior:
- Constant Monitoring; need to be held
- Giving of medication: Antidepressants; Antianxiety
- Promote rest, reduce environmental stimuli. Make sure patient have eaten.
- Call for support groups to assess the person.
Scenario 3
Rhonda
- 23 yrs old
- history of paranoid schizophrenia
- admitted for a risk assessment for suicidal ideation
- underobservation afterbeingfoundstandingatthe edge of a new Port Mann Bridge threateningtokill
herself
- forced to drop out first year engineering at UBC
- had alcoholic mother who was verbally and physically abusive
- living alone in a basement with no window
- loves to read books
- has a supportive father
1. How will you open the conversation with Rhonda and create a therapeutic environment for
assessment?
- Ask person’s name, and use it during conversation.
- Build rapport and trust using simple conversationtechniques, such as: speakingslowly and calmly, use
of simple concrete language
- Do not argue or try to convince the person the hallucinations is not real.
- Focus and validate the feelings not the content.
- Listen carefully and decrease stimuli.
- Create a safe space for your safety and not to intimidate the patient.
- Be patient for her response.
- Be aware of own feelings and don’t judge.
2. What might you expect and how will you manage a client who is out of touch with reality? Explain
your interventions and provide rationales?
> Since psychosis has no cure only intervention can be done to prevent self-harm or hurting others. As
care providerfocuson emotion.Donot argue or try to convince the personthat what he isseeingisnot
true. Instead re-direct him to the present situation or the reality.
> Try to ask questions to explore more on the feelings, be empathetic, and validate response.
3. What will you assess in order of PRIORITY? Include the questions you will ask and the physical,
emotional and behavioral symptoms you will assess for. What tools will you use?
Priority to assess:
a. Safety (for patient and the care provider) – hold for observation
b. QPA;Vital Signs

7. c. Ask if religiouslytakingmedicationsorhave takingothersubstance.
d. Mental status assessment
Possible questionstobe asked:
1. What is goingon foryou?What bringyouhere tonight?
2. What you are feelingisimportanttoyou?Thusthisfeelingbotheringyou?
Symptoms of Paranoid Schizophrenia:
Physical
a. Aggression and violence
b. Quarrels
Emotion
a. Anger
b. Detachment
Behavioral
a. Auditory hallucinations
b. Delusions
c. Anxiety
d. Condescension
e. Suicidal thoughts and behavior
 Becomingsociallywithdrawn
 Mood swings - however,mooddisordersand problemswiththinkingare lesscommoninthistype of
schizophrenia
 Beingobsessedwithdeath,dyingorviolence
 Feelingtrappedordesperate
 Increasedconsumptionof drugs(includingillegal ones) andalcohol
 Changingeatingorsleepingpatterns
 Startingto gettheiraffairsinorderand givingawaybelongings
 Sayinggoodbye topeople inaspecificway(asif theyare nevergoingto see themagain).
Assessment Tools:
a. Life change Index Scale (The Stress Test)
b. The nurse’s global assessment of suicide risk tool
c. The Holmes-Rahe Life Stress Inventory
d. Mental Status Examination – general appearance, psychomotor behavior, mood and affect, speech,
cognition, thought patterns level of consciousness
4. What questions may you ask to explore her current mental health status? What signs and symptoms
are you watching for and how will you address these concerns. Describe fully.
Possible questions to ask:
1. When did you first notice the symptoms?
2. Have symptoms been continuous or occasional?
3. Do you have a plan to commit suicide or harm others?
4. Are you functioning in your daily life — are you eating regularly, going to work or school, bathing
regularly?
5. Have you been diagnosed with any other medical conditions?

8. 6. Are you currently taking medication?
 Refer sign and symptoms on answer no. 2
Addressing the behavior:
- Constant Monitoring; need to be held
- Giving of medication: Antipsychotic
- Promote rest, reduce environmental stimuli.
- Call for support groups to assess the person.
5. Rhonda has a significantlife stressors.Describe whatquestionsyouwill askand indicate the tools for
assessmentyou will be using. What wouldyou do and say? What stressorsin Rhonda’s life may trigger
a manic-psychotic episode?
Possible questions to ask:
1. Do you feel threatened and alone?
2. Do you have circle of friends to socialize?
3. Do your father continuously giving you financial and emotional support?
4. How is your relationship with your mom?
5. How do you feel being drop out from school?
6. Do you have plan going back to school?
7. Are you getting enough rest?
8. Have you spoke to someone or reach someone for help?
Say to her:
 Everythingbeingdiscussedisconfidential notsharedto the public,onlyto the healthcare team
that will be assessing you.
The following may trigger Rhonda manic-psychotic episodes:
- forced to drop out first year engineering at UBC
- had alcoholic mother who was verbally and physically abusive
- living alone in a basement with no window
Assessment tool to use:
a. Mental Status Examination – general appearance, psychomotor behavior, mood and affect, speech,
cognition, thought patterns level of consciousness
b. Beck’s Depression Scale
6. How will you explore Rhonda’s strengthsand ability to achieve wellness?Whatquestionsmightyou
ask? What might you say to help her see her strengths? Explain.
 Since Rhonda loves reading book and has a supportive father but live long distance, start from
there by asking question to explore her feeling on those.Focus more on her positive attributes
than the negative happeningsin her life. By focussing on her strengths and good happenings, it
will give herarenewedperspective onviewinglifethatmaysave herfromher currentcondition.
 Sample questions:

9. a. Is your father still keeponcommunicatingwith you?What usuallythe thingsthat bothof you
are discussing?
b. Are you sharing your problems to your father? Is your father giving you advice?
c. Aside from the book that you love to read, do you have other interest that inspire you?