My marijuana dependency, total brain injury from a motorcycle


My patient that I chose
to do my analysis on was a 60-year-old male that was admitted with the
diagnosis of disruptive mood dysregulation disorder. He was admitted on 1/4/17
from a correctional facility after assaulting a fellow resident in the nursing
home. He has a history of seizures, his first presenting at a very young age,
which appeared to make him decline ever since. Some of his other diagnoses are
alcohol and marijuana dependency, total brain injury from a motorcycle accident
which left him in a coma for one year, seizures, DVT, hypertension, and
sebhorric dermatitis. Some of the main concepts affected with this rationale
would be safety, mood and affect, cognition, and coping. His general appearance
appeared to be appropriate for age and appropriately matched. This client’s
illness appears to be a chronic one spreading out over the length of twenty-one
years. The patient’s acuity level is yellow, which allows the patient grounds
access with the accompany of a staff member.

The patient appears to
like staying to himself, but will answer questions and interact if the
opportunity presents itself. He stated, “I don’t really talk or like to talk to
these people.” For family issues, he stated that he does not have any family,
though the chart indicated that he grew up with his mom and stepdad, is still
currently married and that no divorce papers were ever filed. For his
spirituality, it was documented in the chart the he was “doing what God is
telling him to do and he is reading his bible.” The presenting attributes and
antecedents pertaining to the patient’s diagnoses are chronic cognitive
impairment related to total brain injury. This diagnosis also contributed to
his admitting diagnosis as he presented with disordered and pressured speech,
odd interactions, shuffling gait, lack of hygiene, and was noted to wear many
clothes in warm weather. For his diagnosis of sebhorric dermatitis, he appears
to have very edematous and red skin periorbitally.  Though his seizures appear to be under
control, his history of seizures had made him decline cognitively. Seizure and
fall precautions are initiated for this patient at all times. He also has a
history of alcohol abuse as well as use of marijuana.

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Compare and contrast attributes and antecedents

Upon conducting the
abnormal involuntary movement scale (AIMS), the patients presented with  no awareness on the muscles of facial expression.
There was no indication of frowning, blinking, smiling or grimacing. The score
was also the same in the areas of lips and periorbital area, jaw, upper body
and lower body for extremity movements, trunk movements, and global judgments.
This score of a zero indicates that this patient does not present with abnormal
movements. He also does not have problems with his teeth and does not wear
dentures. He is able to eat solid foods with no complications, allowing for
adequate intake of nutritional needs.

The clinical goal of the
patient’s treatment is control of manic/mood symptoms. This is being treated
with medication therapy and group therapy, although the patient states “I don’t
go to my therapy even though I probably should.” A safety plan has been initiated
to keep the patient and other patient safe from self-mutilation and assault
since the patient’s diagnosis can contribute to violent behavior. The patient
will also practice deep breathing and relaxation techniques since upon
admission and follow up visits the patient reports “I don’t know what calms me
down.” Per patient’s chart. A decrease in the level of substance abuse will be
attained. This goal is currently being met by the patient remaining at Terrell
State Hospital for over a year now. One of the most important goals is that the
client will maintain stable neurological function. This goal unfortunately, is
not being met since there has been a notable decline in cognition since
admission in January two thousand seventeen. The patient has been moved to a
different unit than when he was initially admitted indicating that he is
regressing cognitively and needs extra attention by the staff. The patient’s
perception of perception of his own goals are that in three months, he wants to
“get out and have fun.” In one year, he “wants to get a job so he has money”
and then in five years he wants to “go to social security and get community

Although some of his
goals are realistic, there are several factors that hinder his personal goals.
Though he is physically fit without any hinderances, he does not have the
emotional, social, financial and lifestyle choices in place that will be able
to help him meet such goals. Since he came from a nursing home, it is apparent
that he needs help with care. Financially I believe he does receive social
security and compensation from the VA in Dallas, TX. Since he is considered
incompetent to stand trial for the three aggravated assault charges pending
against him, is appears that even if he were to leave Terrell State in the
future, he would serve time in a county jail for these charges. Some of the
more realistic goals that were proposed was that he should attend therapy so
that he could have better coping skills. He said “I know I need to because I
get angry, but I don’t want to.”

For the
psychopharmalogical treatments, this patient is taking the following
medications to aid in managing his diagnosis of disruptive mood dysregulation
disorder: He is taking levetiracetam Keppra 500 mg twice daily by mouth, which is
an anticonvulsant by class. This medication “may inhibit nerve impulses by
limiting influx of sodium ions across cell membrane in motor cortex.” The
nursing implications that need to be addressed so that the medication is
therapeutic is to “monitor BUN, seizure activity, blood studies such as RBC,
Hct, Hgb, and assessing mental status such as behavioral changes and suicidal
thoughts.” Side effects include: psychosis, suicidal
ideation, decreased Hct, Hg, RBC, infection, and abdominal pain. A contraindication
is hypersensitivity. Pertinent lab values are BUN, Hct, Hgb, and RBCs.” (Mosby’s Drug Guide for Nurses, 2011) This patient is also taking Lorazepam, Ativan 1 mg
orally at bedtime. This medication has a “functional class of a
sedative/hypnotic, antianxiety agent and a chemical class of benzodiazepine.
The action is potentiates the actions of GABA, an inhibitory neurotransmitter
which depresses the CNS. Nursing implications are: assess degree of anxiety, assess
for alcohol withdrawal symptoms, monitor CBC and hepatic studies, monitor
seizure control and assess mental status. Pertinent adverse effects are
tachycardia, cardiac arrest, and apnea. Contraindications include: pregnancy,
hypersensitivity, closed-angle glaucoma, psychosis, history of drug abuse,
COPD, and sleep apnea. Pertinent lab values are CBC and hepatic studies.” (Mosby’s Drug Guide for Nurses, 2011) Lastly, the patient
is also taking risperidone 4 mg po twice daily. ” It is in the antipsychotic
class. The action is that it may be mediated through dopamine type 2 and
serotonin type 2 antagonism. The nursing implications are assess mental status,
monitor I, monitor bilirubin,, CBC, liver function tests monthly, and
identify for neuroleptic malignant syndrome. The side effects are tachycardia,
heart failure, seizures, and renal artery disease. Contraindications for
risperidone are breast feeding, hypersensitivity and seizure disorders. Labs
that should be evaluated for this drug are: prolactin levels, CBC, and liver
function tests.

When comparing the
patient’s diagnosis of disruptive mood dysregulation disorder (DMDD), I find
that it is a very interesting diagnosis. There is still a lot to be learned
about this particular diagnosis in that there is still no specific treatment
regimen for it. There have been ongoing studies since the 1990’s when this
disorder was recognized, but no sure set of medications and therapies has been
100% effective. Documented from a journal article, apparently there has been
some success by using  “An open-label trial using low doses of
risperidone in youth with SMD showed significant reductions in irritability scores (Krieger et
al., 2011). It is important to emphasize that there
have been no pharmacological studies on DMDD, and extrapolating data from SMD
may be problematic given that there is surprisingly little overlap between the
two conditions.” (Psychiatr, 2015)(Krieger et al., 2011). In a different journal article it also presented evidence that
risperidone is effective for this particular diagnosis by stating: “Risperidone
and aripiprazole are FDA approved for the treatment of irritability (including
aggression, temper tantrums, self-injurious behaviour, and quickly-changing
moods) associated with autistic disorder in children and adolescents.
Pappadopulos and colleagues identified nine RCTs of aggressive children and
adolescents being treated with risperidone. All nine of these studies showed
greater reductions in aggression with risperidone compared to placebo in
subjects with CD, ODD, ADHD, autism, and MR/ intellectual disability (ID). The
overall effect size of risperidone was quite high (0.9)” (Tourian, 2015) By using these two sources of
information, it matches up with the current care that the patient is receiving
at Terrell State Hospital since one of his medications is in fact Risperidone.
In the instance of patient/family education, and referrals, there does not seem
to be a plan in place for theses at Terrell State Hospital. It could be
indication that the patient does not have any family on file to be contacted
and also that he came from the forensic unit and is there because he is
incompetent cognitively to stand trial. For psychotherapies and support groups,
though, the patient appears to have everything in place at Terrell State. There
are therapy sessions scheduled during the week that the patient can choose to
go to where they can aid the patient and encourage effective coping mechanisms
for his anger. These therapy sessions are known as group psychotherapies which
“is often done in conjunction with with individual psychotherapy as part of an
ongoing plan of feedback in which intense one-to-one work is interspersed with
opportunities to relive and work through early life experiences in a supportive
group.” (Halter, 2014) Five evidence-based nursing
interventions that would be appropriate for this patient are “empowering the
patient by involving him in goal setting and treatment planning: this increases
the treatment adherence and improves treatment outcomes, developing and
maintaining sustained therapeutic relationships; trust in providers is key to
achieving treatment adherence, Safety is of utmost importance not only for the
patients, but for other patients and staff as well. Providing supportive psychotherapy,
focusing on the here and now; this aids in maintain rapport and positive
self-esteem and reduces maladaptive coping. Caring for the person as a whole
due to the lack of poor hygiene and health practices” (Halter, 2014) is very important
not only for health reasons, but also for the dignity of the patient.

The evaluation of the
effectiveness of current treatment and nursing interventions is a positive one
in most aspects such as being able to keep the patients moods stable, adequate nutrition
and hygiene status, and also the patient having therapeutic levels of his antipsychotic
medications. I enjoyed getting to see the psychiatric side of nursing in that it
gave me exposure to certain situations that nurses are put in and the overall job
of the nurse in this field. Unfortunately, I believe that the patient’s prognosis
is that he is cognitively declining as evidenced by charted documentation that the
client has appeared to be regressing since he had a seizure when he was young followed
by a TBI. He was also switched to a different unit so that he could be helped more.
When asking the client questions, he would respond to some questions, but not all.
I believe that this patient will remain in Terrell State Hospital unless notable
cognitive advancement is made in the future.