Mental_Health_and_Therapeutic_Interventions

MENTAL HEALTH AND THERAPEUTIC INTERVENTIONS: INTRODUCTION: The assignment describes my involvement in the care of a patient whilst on my recent placement. This essay will focus on the nursing process of assessment and care planning in identifying the patient’s needs and formulating care plan. Following the guidelines of the Care Programme Approach (C.P.A.) and the National Service Framework for Older People (N.S.F.) Moreover, a model or framework utilised to aid the assessment process will be highlighted. In addition, the involvement by other professionals in the patients care will be mentioned, highlighting any legal and ethical issues that pertain to the patient. For the purpose of this assignment, Peplau's model of care (1988) in conjunction with the nursing process is used as framework in which the care is delivered. Finally a reflection of personal development would be drawn. Through the assignment I have change the client's name to (Jo) in order not to contravene the NMC (2000) code of professional conduct. It is important to know that I gained a verbal consent from Jo for the purpose of the assignment. Biography Jo is 73 years of age who was admitted into the ward under Section (3) of the Mental Health Act (1983), which allows compulsory admission and treatment (Sundeen 1997). Jo had previously been diagnosed with dementia three years ago. Jo is a widow and has a son who lives in France and hardly sees him. She lives in a two bed roomed house. Jo's memory has been bad for some time. She would find it hard to remember where she put things and becomes easily confused. When she was going out she would forget to turn the cooker off as well. Neighbours would have to call the Fire Brigade on several occasions. Her deterioration in mental state gradually culminates into verbal and physical aggression. Her deterioration in her mental state prompted her admission, which was facilitated by her community psychiatric nurse (CPN). ASSESSMENT: According to the Royal College of Nursing (RCN) 1993, assessment is considered to be the first step in the process of individualised nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status. It also decreases the potential for, or the severity of chronic conditions and helps the individual to gain control over their health through self-care. (RCN 1993) The Care Programme Approach (CPA 1991) states that, the purpose of an assessment are to evaluate the individual’s strengths, identify areas of need, and to identify the person’s CPA level of need and to determine whether intervention from mental health services is appropriate. As indicated by the Department of Health (2000) in the National Service Framework for older people (Standard 2), there is a requirement for a single assessment process across health and social care services by April 2004. This entails social care services treating older people as individuals and enabling them to make choices about their own care, which can be achieved through the single assessment process. It also requires agencies to work together so that assessment and subsequent care planning are person centred, effective and co-ordinated. (D.HO.H. 1991) Assessment always leads to a nursing diagnosis. 'Thus insufficient or incorrect assessment could lead to an incorrect nursing diagnosis, which could mean inappropriate planning, implementation and evaluation. (Kitwood1997) Alfaro 2002 believes that ‘assessment is necessary in order to help the patient and the nurse to identify together the function difficulty and also his area of ability’. The first step when assessing a patient with cognitive difficulties is to obtain a detailed history from the patient Brown and Hillam (2004). On our first day to see Jo as an in-patient, we had a goal of getting as much information as we could about the patient. Much of the assessment was elicited through careful history taking, using information from other members of the multi disciplinary team involved in her care. The first phase being orientation in the client nurse relationship according to Peplau (1993) is where the nurse and the client come together as strangers meeting for the first time and the development of trust and empowerment of the client becomes the primary considerations. Having been allocated to Jo as her associate worker, I was introduced to her by my mentor. After the introductions I explained my role and gained her consent to work with her for the period that I would be on the ward. To obtain a full picture of Jo and build a therapeutic relationship with her in assertion of Dexter et al (1999), I conducted an assessment of Jo with the help of my mentor. The day before the assessment I informed Jo about the process and outlined the purpose of the assessment and also stressed to her that the whole issue was a confidential one (Belsky). During the assessment, I conveyed to Jo an unconditional positive regard (Dexter et al, 1999). This was important to show Jo that I genuinely accept her as an individual in a non-judgemental manner. My Posture during the interaction with Jo was important, so I sat upright, slightly leaning forward and squarely close enough to Jo to demonstrate “psychological closeness” whilst maintaining good eye contact in a relaxed condition. These skills are an acronym by Egan (1982) as “SOLER”. Furthermore, I took into account that I needed to establish the right atmosphere for the creation of a therapeutic relationship. Wright (1994) believes that the therapeutic climate is fostered by relationship conditions of empathy, positive regard and genuineness offered by the nurse. Also Epp (2003) pointed that clients need to have your warmth transmitted to them. To achieve this I also conveyed friendliness and warmth by demonstrating good non-verbal communication such as a friendly eye contact and making it paramount to concentrate on listening effectively to Jo. I used opened-ended questions that would allow Jo to ventilate her feelings and expressed how she felt in her present condition. This rational is supported by Crowe, (2000) who asserts that verbalisation of feelings allows the client to begin to explore the origins of these feelings. During assessment Jo’s responses were often impulsive, disorientated and bizarre. For instance when I asked her what she would like to do in the next two years, she responded, “I would like to meet God, because I have not met him”. A further difficulty that arose was her lack of insight into any form of mental illness. I therefore explained to her the reasons and meanings of the Mental Health Act (1983) under which she is detained in hospital. It is significant to note that Jo’s views were taken into consideration during the assessment so that measurable and realistic attainable goals can be achieved (Dexter et al 1999). The assessment was also based on Roper et al (2000)’s daily activity of living highlighted four main areas of concern. These were Jo’s personal hygiene due to neglect and memory disturbance, poor nutritional intake, safe environment, and sleeping. She also presented grandiose ideas believing people want to kill his son. Information gathered during the history is supplemented by use of rating scales, physical examination and psychological examination by other professionals. On our next assessment, we used assessment tools, which included; mini mental state (MMS) Appendix 3, generic depression scale (GDS) Appendix 7, and the risk assessment. Various rating scales are used to help in the assessment of cognitive impairment. The (MMSE) assesses a wider range of cognitive function and is still very dependent on the patient’s ability to comprehend and respond to verbal instruction and is an easily administered scale with a high inter-ratter reliability. The down side of this is that it needs a patient who can co-operate and sustain a certain degree of concentration and effort. Some patients may get low marks not because they do not know but because they just do not want to answer to questions. The way the questions are asked and the environment also affects the result. Jo scored 20 out of 30, which is a good mark on this test . On the (GDS) She scored 4 out of 15, which indicate, that Jo appeared not depressed (see appendix 7). On the Clifton assessment procedure for the elderly she scored 5 out of 30 which gave an indication that she could still do things on her own but with a lot of prompting. We also looked at the risks that she has and found that she has a risk of falling, wandering, fire, suicide and can be aggressive at times (see appendix 1). The assessment process utilised above very much mirrors the requirements of the single assessment process, which was patient centred and involved other professionals from the multidisciplinary team and agencies. CARE PLANNING Planning is the second phase in the nursing process. The plan for providing care can be describe as the determination of what can be done to assist the client, and involves the mutual setting of goals and objectives, judging priorities, and designing methods to resolve actual or potential problems (George 1990). The second phase being identification, Peplau (1993) asserts that the client in relationship with the nurse identifies problems that require working on. To perform a holistic planning for Jo, issues raised from the assessment were considered. (See appendix 4) Clients are expected to contribute in their care plan therefore a realistic and achievable goal must be set with the patient (Belsky 1999). ‘Patients problems relating to the activities of living are identified during assessment and transferred to the plan of care. The goals agreed by the nurse and patient, using this model, must relate realistically to those implicit in the model’ (Pearson and Vaughan 1986). The degree of Jo’s mobility and safety was identified. The plan therefore was to provide a safe environment for Jo and allowed a one-one counselling session for her to ventilate and express her feelings. Due to her dementia she was to be assisted in her daily activities of living. Another stressor identified was Jo's lack of sleep. Her dementia has also led to memory disturbances and manifestations of confusions. As a result she had developed poor motivation to engage in things of interest and also having difficulty living independently. She was to be monitored on her medication and mental state in order for her to maintain optimum level of physical and mental well being. This was to include exercise, social group activities and a good balance of fluid and food intake. She was also to be encouraged and engage in social activities during the day to help her have adequate sleep during the night. The doctor, who is part of the multidisciplinary team and in charge of Jo’s medical treatment, prescribed Zopiclone 7.5mg nocte to help her sleep well at night, Amisulpride 25mg (mane), Tradodone 100mg (nocte) and Lorazepam 0.5 (PRN). With her poor mobility we referred Jo to the hospital’s physiotherapist who formulated programs that would facilitate her independence in mobilising. These include sessions on using the walking frame and weekly physical exercise on the ward. Having identified her poor nutritional intake during assessment, I also referred her to the hospital dietician who recommended a special diet, which included vegetables, fruits, fish and foods that are easily digestible. Indeed I spent a lot of time with Jo, which proved to build the therapeutic relationship we had. This became evident as Jo began to be more open to me and willingly to comply with treatment. James (2001) asserts that, observing patients is a very essential part of nursing especially in a psychiatric context. Occasionally I would observe that Jo would experience hallucinations, which make it difficult to converse with her. During such occasions she would be unwilling to engage with me or other members of staff, and would express herself as “hopeless”, “worthlessness”, and “undesirable”. Whenever this happened I ensured that I do not argue or challenge her behaviour but rather reassured her calmly but firmly that I and other members of staff were valuing her. CONCLUTION It is evident that I was able to reasonably achieve what I had set out to do from onset. I was able in collaboration with my mentor and other professionals to carry out a comprehensive assessment of the needs/problems of my chosen patient. Formulating a patient centred care plan specifically approach to assessment and care planning was very helpful as it develops teamwork and better communication. Jo no doubt would benefit and experience marked improvement with her problems she presented with, at the start of her admission, if the therapeutic interventions identified are carried through. At the end of the assignment, I was able to have a better understanding of the assessment tools used to assess elderly patients followed by subsequent care planning, Moreover, I was able to have better grasp of the importance of interpersonal relationship between a nurse and a patient, which is the primary instrument to change and engagement.