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Introduction: NUR20158 mental health nursing

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JJKD was a 34 years old mental patient of the “Acute Care Team” since 2008. He was a patient with “bipolar affective disorder” and “schizoaffective disorder”. He has been admitted to the local hospital several times due to depressive episodes and many health conditions breakdown. Also several times he has attempted suicide and was admitted to the hospital due to that. He was currently under the medication of “quetiapine” and “lithium”. And previously he was under the treatment of “Sertraline (antidepressant)”, “Sodium valproate (antipsychotic agent)” and “Risperidone (antipsychotic agent)” he was under the care of “Continuing Care Team” from May 2009 to August 2013. He was last seen on 31st December 2015 at around 6:00 am by a fisherman (Fernandes et al. 2018). He was standing on a surfing board at that time. But there were large and dangerous waves on the sea. When the fisherman lost sight of him, the fisherman called triple 0, and the next morning the Volunteer Marine Rescue team recovered him at around 10:26 am on 1st January 2016. 

1. Develop a timeline of JFK's involvement in the mental health service 

  • He was under the care of the Community Continuing Care Team (CCT) from May 2009 till August 2013. Then he was again readmitted due to non-compliance, cannabis use, and not attending the sessions of his consulting psychiatrist. He was advised to be treated with lithium and olanzapine.
  • Between October 2013 and April 2014 he was under the Psychiatrist, Dr. IP and according to him JJKD was mentally more stable than before and residual symptoms promoted a change to clozapine
  • From 7 April to 1 May 2014 he was admitted to an ITO for clozapine therapy.
  • JJKD’s case manager was Nurse Gk from October 2013 to her death (Ayayd?n et al. 2019).
  • After discharge JJKD was attending clozapine clinic appointments since 23 June 2014. regularly. He has been prescribed 300 mg of clozapine and in that time, his clozapine level was recorded as between 70 to 450 ug/L.
  • Between March 2015 to July 2015, JJKD maintain a daily intake of clozapine as the clozapine dose level was found to be between 90 and 150 ug/L and on 18 august 2015 his dose is increased to 400 mg.
  • They came to know that he stopped taking all his medications and he wanted to find employment and get off his disability support pension.

2. Review of psychotropic medication prescribes to the patient:

The following psychotropic medication was prescribed to JJKD which has been identified from the provided Coroner’s case study-

“Sertraline”- when JJKD has bipolar affective disorder sertraline is used to treat his depression (Ganguly et al. 2018)

“Sodium valproate”- Sodium Valproate used for bipolar symptoms (Hendouei et al. 2018)

“Risperidone”- Risperidone was used for manic episodes which occur in JJKD’s bipolar affective disorder (Dodsworth et al. 2018)

“Quetiapine”- when the schizoaffective disorder has been diagnosed for JJKD quetiapine was given to treat schizophrenia (Fernandes et al. 2018).

“Lithium”- lithium was given to control the bipolar symptoms (Ganguly et al. 2018).

“Clozapine”- when the deterioration in the mental health of JJKD happens Clozapine was given (Dodsworth et al. 2018)

The metabolic pathways

Sodium valproate- the metabolic pathway of sodium valproate is eliminated via glucuronidation and mitochondrial beta-oxidation pathways and CYP enzymes are metabolized at about 15-20%. On the other side, adult valproate metabolism is shifted towards the CYP- dependent route (Brakoulias et al. 2019). 

Clozapine- “clozapine” is a “psychotropic medication” that belongs to the chemical class of benzisoxazole and this drug is being used for the treatment of schizophrenia. Clozapine is mainly metabolized in the liver by CYP450 (Ayayd?n et al. 2019). The primary metabolic steps are the demethylation of clozapine and forms nor clozapine and oxidation to clozapine n-oxide (Galbally et al. 2020). Other major enzymes CYP3A4 and CYP1A2 play a major role and CYP2D6 plays a minor role in clozapine demethylation.

Risperidone- risperidone is mainly metabolized in the liver. For risperidone, the main metabolic pathway is with the help of enzyme 2D6 hydroxylation of risperidone to 9- hydroxyrisperidone (Rostama et al. 2020).

Quetiapine- quetiapine is also very much metabolized in the liver. The main metabolic pathway of Quetiapine is to produce two metabolites from sulfoxidation, one is oxidation parent acid metabolite and the other is sulfoxide metabolite (Le Daré et al. 2020).

Lithium- there are two metabolic pathways for the lithium enzyme. One is inositol monophosphatase within the phosphatidylinositol signaling pathways and the other is protein kinase glycogen synthetic kinase (Shakoor et al. 2022).

Matters of Concern aboutthe Prescribed Medications

JJKD was a 34 years old man who was suffering from mental illness for some time and he was under several medications to cure his mental illness. JJKD was admitted to the “Acute adult mental health unit” of a public hospital from 17th September 2008 to 30th September 2008. He got admitted with manic and depression-related problems. JJKD was prescribed different medicines to cure his illness “sertraline”, “sodium valproate” and “risperidone”.

JJKD was suffering from his depressive mood he was treated with “sertraline” which is well-known as an antidepressant agent. This medicine has several side effects which should be taken as a serious matter to fight those side effects Hwang et al., (2021). A major side effect of this drug is patients can face problems with sleep and this cause’s anxiety disorder along with the brain could not function properly (Wartko et al. 2019). Therefore, the nurses should treat JJKD with another antidepressant rather than “sertraline” to avoid such problems. Also nurses could have followed a better monitoring process to treat JJKD.

Another drug “sodium valproate” was prescribed to him to treat his “Bipolar affective disorder” as “sodium valproate” has an antipsychotic agent. This drug has a key side effect which is it can cause severe and long-lasting nausea and it can harm the pancreas (Banawalikar et al., 2021). So, the nurses should recommend other medicine instead of “sodium valproate” to overcome the above-mentioned problem.

JJKD was treated with “risperidone” also, as this was given to him to overcome his maniac episodes. This drug is also prescribed for its antipsychotic agent (Beaucheminet al., 2020). This drug has a severe side effect in that patient could face a fast heartbeat which can lead to cardiac arrest.

“Schizoaffective disorder” was another problem with JJKD, and he was given “Quetiapine” and “Lithium”. “Quetiapine” was prescribed to him for Schizophrenia and “Lithium” was used to control his bipolar symptoms and depression. “Quetiapine” can cause trouble while controlling the movements of the body, and “Lithium” can cause severe hand trembling along with severe vision changes Campbell et al., (2019). The nurses of JJKD needed to take the side effects of these medicines as a matter of concern so that the problems could not appear.

Early Warning Signs of Adverse Reactions to the Medication

JJKD was a mental health patient who was under treatment for a short-term period to treat his illness, but several early warning signs had been avoided by the nurses so his mental health could not be recovered and he died by drowning.

JJKD was recommended to take 300 mg of “Clozapine” and he was under the CCT case manager but he started to attendthe“Public Clozapine Clinic” on himself 23rd June 2014. In 2015, he was found to take a lower amount of “Clozapine” which caused several complications also he was taking alcohol and cannabis and this was identified by CCT and after his discharge, the level of the drug increased to 400 mg.

After a month when JJKD was attended CCT manager again, he was found to have taken 150 mg of the drug which was majorly low against the prescribed quantity. As stated by Hartley et al.,(2020), Nurses are responsible to development of a schedule of proper follow up monitor the patients’ health condition. However, in this case nurses has neglected their responsibilities while continues to administer this drug. Poor judgment is responsible for the deterioration of JJKD’s mental health which led him to cut his wrist reported by his mother to the CCT manager. After that, he was taken to “Emergency Treatment” and “McDonald’s”were the early warning signs which were left unnoticed, and of this, his mental health could not be recovered at a proper time. If effectiveness in the diagnosis had been shown, then JJKD’s health could be improved and his death could not occur Johnson et al., (2018). The early wring signs have been identified in this report to rectify the future treatment of these mental health issues with other mental health patients. 

Advanced Clinical Nursing Interventions that should have been utilised Concerning Adverse Reactions.

A mental health nurse should assess and evaluate the patient's mental health, a proper care plan should be developed, should consult with other health professionals about the diagnosis plan and also should maintain the medical records. Nursing interventions should be taken for “Clozapine” which was used for the improvement of JJKD’s mental health as it has antipsychotic agents (Maben & Bridges, 2020). The nurses should educate the patient about the risks of hypersensitiveness which includes “agranulocytosis” and “myocarditis” when “Clozapine” was used. In order to treat the adverse reactions related to “Clozapine”.

The nurse should have given proper education to JJKD with the use of “Clozapine” and a huge lack has been identified in his case study regarding this use of “Clozapine”. “Myocarditis”is a hypersensitivity reaction which comes with the use of “Clozapine” which occurred during the therapy the third week. The patient’s “troponin”, “ECG” and “CRP” are needed to be checked while the treatment is happening. Another hypersensitivity reaction had occurred in JJKD’s case was “agranulocytosis”, here neutrophil count is reduced and an increased level of white blood cell count can be found which can lead to high infection in the patient. The nurses should incorporate laboratory testing to detect cell counts (Pirozziet al., 2020). A shred of limited evidence and insufficient documentation has been found in the JJKD’s treatment about the education of medicines and regular monitoring and diagnosis. Therefore, the level of “Clozapine” was found to be regularly subtherapeutic and it ranged between 90 to 150 micrograms/liter.

According to Lally et al., (2021), nurses should be provided with an effective intervention through a “meta-analysis” and “randomized controlled trials” (RCT). Another case study has been reported of a young female who was suffering from TRS explained by Agugliaet al., (2022) studied that after two weeks “Clozapine” was stopped and the follow-up scans of the chest showed a complete suspension of pulmonary conditions (Aguglia et al., 2022). In comparison with this case study, the nurses of the JJKD case have been advised in this report that regular follow-ups are very important to maintain the proper diagnosis and if this was done, the patient’s health could have improved.

3. UtilizingAppropriate Literature, Examine Issues Relating to the Concurrent Use ofthe Medications Prescribed

Different issues have been identified with the constant use of the drugs which had been prescribed to JJKD for the improvement of his mental illness. Lally et al., (2021) have mentioned several points about the constant use of “Clozapine” which can create adverse situations in a patient’s treatment. When the “Clozapine” drug has been given to a patient regular check-up is recommended to detect the use of this drug and it can be also detected whether any side effects are occurring or not. The author has submitted a report in the study that 32 patients who are under regular check-ups have responded favourably, on the other hand, 30% of patients were re-hospitalized because of the irregular follow-ups during the treatments.

Hwang et al., (2021), has mentioned in the report that “Cellular MAPT” occurred when the “HEK293-derived cell line” was used and this created high levels of the central nervous system. Also, the effects of “sertraline” on Tauopathy were examined to discover its prospective as an “Autophagy therapeutic agent”. “Sertraline” could be a part of the “antidepressant effects” occurring in a living body. Pirozzi et al., (2020) have explained in the report that “sodium valproate” is an antiepileptic drug, which could be responsible for time and dose-dependent hepatoxicity. The study also supported the effective perspective of Sodiumbyurate on VPA-convinced liver injury and also indicated a reasonable therapeutic submission in preventing the common side effects of VPA chronic treatment. Beauchemin et al., (2020), has reported in the study that “risperidone” can cause body weight gain also obesity is variable and is associated with notable gender and effects of the dosage.


In comparison to JJKD's case study, the nurses of mental health treatment are recommended to do regular follow-ups for the patients who are under the medication of “Clozapine” so that, proper and timely initiatives can be taken if any side effects arise. Efficient monitoring could help the nurses to monitor early warning signs of any drug. All the family members of any mental health patient are recommended to give mental support to the patient which is a crucial matter. The families should have to build up effective communication; learning about mental health could give proper recovery to a patient from psyeducation perspective.


It can be concluded as per the JJKD's case study that irritated treatment several times due to depressive and manic episodes are the major symptoms of schizoaffective disorder. Different barriers had risen when JJKD had been diagnosed with a major mental illness with particular characteristics. However, opposed to the care and treatment he had gotten from the community and private doctors led to the deterioration of his mental health. The early warning signs could not be recognized by the doctor and the nurses who led JJKD to his death. A different situation could have been created if the mental health nurses could create the diagnosis with empathy and authenticity by understanding the early warning signs.


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