Mental_Health

Introduction The aim of this assignment is to display the authors understanding of the principles of assessment and formulation when working with a person dealing with schizophrenia and to demonstrate the knowledge supporting the authors practice. The history of the person will be obtained, and then constructed into a care plan. In exercising my accountability I must follow The Nursing and Midwifery Council (NMC, 2008), Code of Conduct requires that I must protect the clients dignity, being confidential at all times, and only with the resident’s consent to disclose relevant information with others. For this reason in this report I will refer to the client as Sarah. Client History Sarah is early 30’s and has come to a rehabilitation setting where individuals have some dependency of washing their own laundry, rehabilitation cooking and learning they once had or are regaining. Sarah has a history of grandiose delusions and currently believes she is an ‘angel’, she used recreational drugs since the age of 13 and lost touch with reality when in school. Suffering from auditory hallucinations hearing voices which she is responding to, Sarah believes these are the voices of the angels. She was hospitalized in 2000 for a year and has lived with schizophrenia since being diagnosed at 19yrs old. Sarah has now relapsed as she is dealing with immense fear of the future and despair over her own capabilities with removing herself from an abusive relationship, with support form both parents, She is an only child. Sarah is also noticed weight gain and sweating, this could be from her anxieties or side effects from her medication, she has not experienced these effects before, metabolic changes associated with atypical medications increase the lifelong risk of additional morbidity and morality, especially cardiovascular disease and type 2 diabetes (McEnany 2007). Current Medication Olanzapine 20mgs . More so, looking at Sarah’ antipsychotic medication could be a positive reflection. The history of a patient can trigger warning signs reducing the possibility and relapse in an individual, furthermore increasing knowledge of how the person has reacted to previous interventions (Royal College of Nursing RCN, 2009). Having access to Sarah’s file created facts including history from family members that are confirmed and relevant to use at present. Engagement I spoke with Sarah informally over a number of days in an attempt to build a rapport with her, before asking her if she would agree to be assessed. Cutcliffe and Barker (2002 cited in Harris et al, 2009 p:156) identified effective nursing is predicted on effective engagement with the person. Only through engaging with the person will the nurse come to understand the nature of the persons needs, and what might need to be offered to address them. I outlined the potential side effects of Sarah’s medication and the fact there are medications to counteract them. Hopefully this would increase the probability of Sarah co-operating with the Lunsers assessment. As nursing is a social activity, the very heart of nursing assessment involves asking questions – trying to find out what has happened to the person, and what the person is experiencing now, so that we might begin to work out what needs to be done in the name of care that is appropriate to this particular person at this time (Barker, 2009 p, 67). Assessment tool The Liverpool University Neuroleptic Side Effect Rating Scale (LUNERS) developed by Day et al (1995), is a 51 item closed response, self rating instrument which requires patients to specify how often they have experienced each of the side effects in the proceeding month. The scale consists of seven clusters: these include extra pyramidal (7items), antcholinergic (5items), autonomic (5items), psychic (10items), and allergic (4items). There is a 5point scale that rates from 0-4, 0 being not at all and 4 being very much. In addition the LUNSERS contain 10 ‘Red Herring’ (RH) items which are not recognized side effects of antipsychotics. These items are generally used as an internal suggestion for consistency to detect possible false positive responses. This scale assesses the prevalence and intensity of neuroleptic side effects. In result the tool in assessment will enable to look at any changes that may occur in the individual’s medication, consequently acting upon this will hopefully reduce any unwanted side effects in the future. It was designed to enable clients to report their experiences of side effects. In short the LUNSERS may be a useful tool for systematically eliciting side effect information from patients and as brief and cost effective measure of side effects in research studies (Day et al., 1995, p653). The assessment tool allows patients to tick off how much they experienced the symptoms over the past month for each of the LUNSERS item. This may provide nurses with appropriate method for assessing side effects. It is also in keeping with approaches to care which acknowledged and give credence to the subjective responses expressed by patients (Award, 1993). Using the LUNSERS tool will provide a structure for assessing side effects and help raise awareness of the problems and the extent to which they impinge in patient’s lives. Morrison et al (2000) pointed out that even one side effect may seriously damage interpersonal relationships or reduce the ability to find employment. Scales such as the LUNSERS also provide a benchmark to determine the effectiveness of any proposed changes in treatment (Gray and Howard, 1997, p: 225). Assessment and Process Conducting an assessment in nursing can prove vital to an individual, progressing all the way through successfully into the final stages of discharge. Problems can only be tackled effectively if they are identified in a clear and concise manner. Showing many skills are needed in the initial assessment such as not complicating questions that are asked as this can possibly damage the individuals concept of receiving care in the first place, making the individual feel comfortable moving forwards towards the potential plan of action. Lasalvia, (2008) recognised that, it is important that there is good therapeutic alliance between service user and the practitioner as this will provide more accurate assessments, and improved agreement between staff and service users which lead to improved clinical outcomes. Barker et al, 1999 agreed with Lasalvia describing this as ‘translation dimension’ of mental health nursing. Nurses were valued by service users for ‘telling the truth’ about medication rather than ‘what the doctor wanted them to hear’. This suggests that nurses may be considering alterative views within the therapeutic relationship. One of the roles of the nurse was seen both by other mental health team professionals and services users as a “go between”, bridging the lay world of the person and family, and the professional world of the psychiatric team ( p, 280). As the assessment took place an appropriate site was chosen to ensure everyone was feeling relaxed, (Sarah, my Mentor and I), Refreshments were available and other staff members were aware of our location. Sarah was reassured that this assessment can terminate at any time and can continue another day, this was done to minimise any anxieties that Sarah may have been experiencing during the interview process. Barker concluded that an individual with a ‘separation anxiety’ shall feel the absence of support or reassurance – from partner or ‘significant other’ (nurse or family member). The restoration of the ‘support or reassurance’ eliminates the anxiety and without the reassurance given through a relationship the sense of self is threatened (2004). Sarah was also made aware that she could examine the assessment documentation at any time the author positioned herself next to Sarah so she could actually see what was being written down. To achieve the goal of assessment nurses must work in partnership with the individual, family and all multidisciplinary team members, alongside organisations outside the service. The Department of Health (DH) stated that ‘Mental health practitioners need a wide range of skills, including basic therapeutic attributes such as empathy, acceptance and mutual affirmation. In recovery – orientated service, they need to be able to work with the service user and others to formulate a shared understanding of the problem and a positive, forward – looking care plan, with a clear, structured feedback on progress’ (2009). This continued further as I asked Sarah questions that included lack or loss of energy, changes in behaviour, emotions and feelings. Due to Sarah’s mental health state all these observations will be relevant to develop a supportive relationship and minimise risks. Sarah was informed that other assessments might come from this initial one such as physical; Sarah agreed and understood all possible outcomes. During the assessment I asked Sarah if she was experiencing any of the symptoms that were written down on the LUNSERS reminding Sarah what 0 to 4 meant. I could see some anxieties from Sarah as she kept looking out of the window, so before moving forward I mentioned that if Sarah gave an open response even though some questions might seem unnecessary to her I was there with my mentor to help her overcome these symptoms she is not happy with. The assessment continued on a comfortable mutual understanding. Burnard (1997) Mc Cabe and Timmins, (2006) both recognize that effective listening is essential between the carer and patient as this entails a positive trusting relationship which constantly continues to grow throughout the patient care and that essential communication skills in nursing are identified as listening and attending, empathy, information giving and supporting the context of a therapeutic nurse-patient relationship. I stopped the assessment half way through to ask if Sarah was ok, but Sarah was keen to push on as she felt more at ease knowing that we were doing this to benefit her. We finished the assessment and Sarah was happy with what she had answered. I also explained that we will do another one of these very soon to compare it to this one and see if any symptoms have changed then to show these results in a review as Sarah is not happy about her weight gain and sweating. Sarah’s results were: Nursing skills In nursing we come across many barriers, therefore using are skills can prevent misinterpretation between the patients and other colleagues. Recognisably communication is a way of forming a bond between others whether it just a simple question of ‘How are you today'’, or ‘Good morning’, these generalised questions can show patients that their presence is not only acknowledged but also to establish that there is no awkwardness. Everyday conversation can be known as ‘Phatic’ speech simply meaning that it is not the context that matters but the understanding by saying these questions to bond with another. Burnard indicates that while the formal part of mental health nursing work is concerned with maintaining the health of the patient, they might often also serve as ‘friends’ to them, thus the phatic part of exchanges is important in the meeting and greeting of clients on an everyday basis (2003). Using this form of communication can have its advantages as it can be used in a reassuring way to ease a patient’s worries, or be building blocks leading into a more formative discussion, but the use of too much of this skill can enable nurses to miss assessing their patient fully. Non verbal communication is just as important this can include body language, facial expressions sign language and the use of touch. Touch is not mentioned much in mental health nursing probably due to most patients being independent, but when engaging with a patient who may need comfort touch can be expressed variously giving empathy, compassion understanding, reassurance and thoughtfulness which can be used tactfully in nursing not unnecessarily. Nurse’s should know how the use the effect of touch without invading one’s privacy. In 2005, Salzmann – Erikson and Erikkson explored the use of touch between four clients (2 male and 2 female). They described physical touch as a ‘need’ for comfort, support and to feel connected. When a good nurse-patient relationship existed touch was described as ‘real’ and ‘compassionate’ and done in a manner that communicated a feeling of ‘serenity’ and ‘security’. (Salzmann – Erikson and Erikkson 2005, p: 849). Conclusion References Awad, A. G. (1993). Subjective response to neroleptics in schizophrenia. Schizophrenia Bulletin 19, Pg:609-618. Barker, P. (2002). cited in Harris, N., Baker, J., Gray, R. (2009). Engagment and working collaboratively with service users .Medicines management in mental health. John Wiley and sons Ltd, Chinchester. p: 156. Barker, P. (2004). In search of the whole person. Assessment in Psychiatric and Mental Health Nursing Barker, P. (2009) Assessment: The Foundation of Practice. Psychiatric and Mental Health Nursing ‘ The Craft of Caring’. 2nd ed, Arnold, p: 67. Burnard, P. (1997) Effective Communication Skills for Healthcare Professionals. 2nd ed. Nelson Thornes Ltd, Cheltenham. Burnard, P. (2003) Ordinary chat and therapeutic conversation: Phatic communication and mental health nursing. British Journal of Psychiatry and Mental Health Nursing 10, pp: 678-682 Day, J. C., Wood, G., Dewey, M. and Bentall, R. (1995). A self rating scale for measuring neuroleptic side effects. Validation in a group of schizophrenic patients. British Journal Of Psychiatry 166, pp: 650-653. Gray, R. and Howard, A. (1997). The Maudsley medication review clinic. Journal of Psychiatric and Mental Health Nursing 4, pg: 225-226. Mc Cabe, C., Timmins, F. (2006) Communication skills for Nursing practice. Basingstoke, Palgrave McEnany G.P (2007) Psychopharmacologic strategies and associated challeges in the long term treatment of schizophrenia. Journal of the American Psychiatric Nurses Association 13(5) 6-15 Morrison P., Gaskill D., Meehan T., Lunney P., Lawrence G., and Collings P., (2000) The use of the Liverpool University neuroleptic side effect rating scale (LUNSERS) in Clinical Practice Australian and New Zealand Journal of Mental Health Nursing 9, pg: 166-176 Royal college of Nursing (2009) Mental Health Nursing of Adults with Learning Disabilities. [ online ] www.rcn.org.uk/__data/assets/pdf_file/0006/78765/003184.pdf [ Accessed on 10th May 2010 ]. Salzmann – Erikson, M., and Erikkson H., (2005) Encountering Touch: A path to affinity in psychiatric care. Issues In Mental Health Nursing 26, pp:843-852 Schultz, J. M., and Videbeck, S. L., (2008) Lippincott’s Manual of Psychiatric Care Plans ‘Strategies for promoting the use of written care plans’. 8th ed, Lippincott, Williams and Wilkins p: 5.