Friday, 1 August 2014

The Observed

16 Feb 2014, 00.53

Patient "J" arrived on the unit at around 07:00 as an informal patient, escorted by the Crisis Team. She is 10 days postpartum. I approached her to introduce myself with another member of staff. She presented as very labile in her mood, at times becoming irritable and tearful. Despite various attempts to discuss her care and inform her of her informal rights, staff were unable to interrupt her conversation due to the extent of her pressured speech and her refusal to allow staff to speak. She repetitively stated that staff were not listening to her, when staff had been reduced to silence. She became increasingly distressed when staff attempted to answer her questions, making it impossible to have any meaningful conversations with her. She would at times say she was in her "safe place" and that she "loved staff", but this would change quickly when again staff made attempts to engage with her.

Patient J was seen by Duty Drs. During this time she became increasingly hostile and aggressively asked them to leave the ward. She followed the Drs. out of the room and appeared to make an attempt to grab them, but staff intervened and were able to prevent this happening without the use of any form of restraint techniques. She then became tearful stating that the Drs. had spoken about medication and the need to sleep while they were both sat on her bed. She felt they were preventing her from sleep and she felt as though they were trying to enforce medication on her. I remained with Patient J for 3 hours following this and made various attempts to disengage due to the repetitiveness of the conversation and the continued unwillingness to listen to me or other staff when attempting to speak with her. She then went on to say she had not been given food as promised and hadn't been offered a shower/bath. I attempted to explain that I had made various attempts to go and get her food/fluid and towels to have a bath, but that she would not allow me to leave the room to complete these tasks. She repetitively spoke about a "spasm" that we would cause her if she was interrupted and if we left the room without her "permission", which was granted in the form of a finger being placed on our mouths. I stated that I had to leave the room to speak with another service user as there were both staff nurses within her bedroom and I needed to complete other tasks. She became increasing hostile and aggressive towards myself, stating our "trust" had gone and that she did not wish to speak with me again today, subsequently slamming her bedroom door.

Attempts made to engage with her husband independently to inform him of the importance of medication and the possibility of being placed on a Section if she continued to refuse her oral medication. Patient J became distressed when she was not with her husband, making it impossible to have a 1-1 with him.

T/C (Telephone Call) with Dr. around 15:00. He was informed of Patient J's refusal of her medication and her unwillingness to consider medication.

T/C from Dr. at 18:15. Informed of continual refusal of medication and chaotic presentation. She has agreed to place Patient J on a Section 5(2) and has completed a capacity and consent to treatment form, highlighting that she is unable to retain information, unable to understand information and unable to weigh information as part of the decision process.

16 Feb 2014, 01:08

New Admission.

Entered room, patient is operating a system of sign language and is very particular about "her safe place", people speaking when permitted and listening to her. She uses the sign language she has come up with to show this.

She was using her husband to speak for her, as she could only whisper.

Feels she has postpartum psychosis. Doesn't know how long she has been in, but feels scared, smelly and degraded. Embarrassed. Stated she was initially happy to take advice and try "whatever medications as you are the experts."

Vey labile in mood, tearful, aggressive and very irritable at times, calm at others, pleasant, joking. First became irritable when we suggested she should "calm down" then later if we could discuss medication. "I don't want any medication from you"

"I am a lioness protecting my husband and cubs"

Would not let us leave the room without her permission, kept on wanting to tell us the rules but never got round to them.  
"If you don't calm me down I will have a spasm in 10 seconds"
"All I need is sleep and food, no one has bought me food. You must be thick if you think I need medication before these things"

Suggested medication could help her sleep "Shut the f-up"

Appearance and behaviour: casually dressed, tired looking, calm at times, joking, then irritable and both verbally and physically aggressive. Overfamiliar. Overstaring wide eye contact, made physical contact and squeezed both Drs. hands when upset. Wanted full control of the interview.

Mood: Subj: "exhausted, tired, scared, degraded" Obj: irritable, labile.

Speech: Pressured, formal thought disorder, flight of ideas. Whispering at first, then shouting when irritated.

Thought: Not able to assess as wouldn't let us talk.

Perception: Not able to assess as wouldn't let us talk.

Imp - postpartum psychosis, manic episode.

16 Feb 2014, 15:27

To be put on 1:1 observation today

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