Many teenagers are exposed to various traumas that can have long-lasting consequences, such as eating disorder, self-injury, depression, and anxiety. The professional assessment of trauma and its outcomes is key to making the best management strategy and treatment interventions. The given essay discusses Miriam Rosen case study from the perspective of a psychiatric nurse practitioner, including interview questions, suggested care plan, lab analyses, psychotherapy, and medication.
To determine an eating disorder, a nurse practitioner should ask Miriam the following questions. Do you worry you have lost control over how much you eat? Have you recently lost more than 15 pounds in a 3 month period? Have you taken laxatives to control your weight? How many periods have you missed over the past 3 months? What is the date of your last period? To diagnose self-mutilation, the following questions should be asked.
How often have you harmed yourself in the past 6 months? If you harm yourself, what do you do and in which part of your body? Could you describe why you chose this form of self-harm and this part of your body? To identify sexual assault, the following questions should be asked. Do you feel safe from violence at school? Has anyone ever forced you to do something sexually that you did not want to do?
Care plan includes the diagnoses, the anticipated outcome, and nursing interventions. The diagnose is an eating disorder with self-mutilation and depression as a result of sexual assault. The anticipated outcome is a fully normal individualized weight restoration, normal eating behavior, stopping self-harm, and acquisition of stress management techniques. The first intervention necessarily involves safety, which means the correction of medical abnormalities, including urgent immediate medical abnormalities, self-improving symptoms or signs of starvation (Mehler & Andersen, 2017).
The best management strategy is tertiary outpatient care for Miriam including selective psychopharmacology and psychotherapy, motivational interviewing, psychosocial support for the quality of life, nutritional education, and family-based therapy.
Several lab tests may be needed to assess the appropriate level of care for Miriam. CBC test should be ordered to identify infection, inflammation, or trauma to tissue (WBC count), fluid loss due to dehydration or diarrhea (RBC count), and anemia (HGB, HCT, MCV). CMP measures a variety of factors related to overall health, including kidney and liver function as these organs may suffer damage due to an eating disorder. Abnormal levels of Calcium, Sodium, Potassium, Bicarbonate, and Chloride can cause serious medical complications. As eating disorders affect endocrine systems, TSH, T3, and T4 levels should be measured to determine whether hyper- or hypothyroidism is present.
Urine toxicology can determine the presence of ketones and the urine specific gravity, that can assess dehydration and fluid intake. Vitamin D should be measured to assess the risk of osteoporosis, cessation of estrogen, and increased cortisol levels, all of which contribute to bone loss. HIV testing should be ordered to identify whether Miriam has HIV. A pregnancy test should be ordered to exclude the possibility of Miriam’s pregnancy.
Even though antidepressants for the treatment of eating disorders have limited effectiveness, they offer a benefit when there is co-morbid depression (Hay, 2013). I suggest taking Fluoxetine 10 mg qAM with a gradual increase to 20 mg. Like other SSRI drugs, it helps recover from depression, and it has fewer unwanted effects than older antidepressants. Fluoxetine helps to increase the concentration of serotonin in the brain structures, that increases the duration of the stimulating effect of serotonin on the nervous system. By increasing serotonergic transmission, a negative feedback mechanism inhibits the neurotransmitter metabolism. The drug is metabolized primarily in the liver and excreted by kidneys; its half-life is of 2 to 4 days. Side effects of the drug include nervousness, insomnia, headache, and nausea.
Fluoxetine has serious interactions with at least a hundred different drugs including goserelin, isocarboxazid, and leuprolide. Taking MAO inhibitors with Fluoxetine may cause serious consequences that may even be fatal. Therefore, it is recommended to take MAO inhibitors 2 weeks before and 5 weeks after treatment with Fluoxetine. Simultaneous treatment with Fluoxetine and alcohol is not recommended as it may cause severe side-effects.
Identifying a Case Conceptualization
Case conceptualization is a process aimed at guiding therapy to relieve patient distress and build client resilience. At the age of 15, Miriam was forced to have sex with two boys (ORIGINS). As a result, Miriam learned the schemas “I am defective, I was used by those boys. My parents won’t understand it and will criticize me” (MECHANISMS), that were followed by experienced depression (SYMPTOMS). To get temporarily release from this thoughts, Miriam began eating less than usual being obsessed with losing weight and cutting herself (PROBLEM).
Cognitive Behavioral Therapy
I would recommend cognitive behavioral therapy as cognitive behavioral approaches have been proven to be the most efficacious in treating people with eating disorders and depression (Peterson, Becker, Treasure, Shafran, & Bryant-Waugh, 2016). CBT corrects dysfunctional perceptions and maladaptive information processing and thus reduces depression and the possibility symptom return. CBT techniques include behavioral, cognitive, and physical interventions aimed at social skills training, thought monitoring, cognitive restructuring, mindfulness, and psycho-education. Apart from CBT, art therapy may also be considered as it may help Miriam explore her emotions, improve self-esteem, and relieve stress (BJC HealthCare, 2010). It may be of help in overcoming the psychological consequences of sexual assault.
Ethical and Legal Implications of the Case
From the ethical perspective, nurses have to be advocates for their patients, which means acting to protect or support them in situations of assault. Under this principle, nurses have to treat people with compassion and respect the inherent worth and dignity of each individual. When providing services to victims of sexual assault, the following principles should be considered as fundamental: autonomy, non-maleficence, and fairness.
Nurses may be required to report abuse and sexual assault involving the dependent adult, older adult, and the vulnerable adult to adult protective services and police (Oldham & Symonds, 2015). Healthcare professionals who don’t meet their mandatory reporting requirements can be exposing themselves to fines and loss of license. Therefore, the first thing the nurse practitioner should do is to report sexual assault to Miriam’s parents and then to the head physician.
To sum up, Miriam Rosen case study has been thoroughly discussed from the perspective of the psychiatric nurse practitioner. Interview questions for determining an eating disorder, self-mutilation, and sexual assault were chosen. Care plan that included an appropriate level of care, safety measures, and best management strategy has been suggested, as well as laboratory tests to be ordered and medication to be taken. Case conceptualization has been identified alongside the recommended type of psychotherapy. Legal and ethical aspects of the case study have also been discussed alongside the best way for a nurse to proceed.
[BJC HealthCare]. (2010). [Video File]. Web.
Hay, P. J. (2013). Assessment and management of eating disorders: An update. Australian Prescriber,36(5), 154-157. Web.
Mehler, P. S., & Andersen, A. E. (2017). Eating disorders: A guide to medical care and complications. Baltimore, Maryland: Johns Hopkins University Press.
Oldham, J., & Symonds, A. (2015). Sexual assault can happen in your facility. Nursing, 45(3), 30-36. Web.
Peterson, C. B., Becker, C. B., Treasure, J., Shafran, R., & Bryant-Waugh, R. (2016). The three-legged stool of evidence-based practice in eating disorder treatment: Research, clinical, and patient perspectives. BMC Medicine, 14(1). Web.