This piece of work will demonstrate how care is delivered to a specific individual in an acute in-patient setting. This involves a holistic assessment of an individual’ needs which will then be met by various professionals who meet those needs. To this end, my objective in the clinical placement is utilising a care study in order to show how therapeutic interventions were planned based on a holistic assessment. The pseudonym of ‘Ann’, ‘patient’ or ‘individual’ will be used during this care study to protect individuals’ identity. I will not divulge any personal information related to his identity according to NMC Code of Professional Conduct (pp.2 2008) which clearly defined assurances of anonymity and confidentiality.
Furthermore, this work will explain how theoretical knowledge, local policies influences care delivery in practice, particularly when caring for Ann. Assessment is an ongoing process adapted to identify Ann’s needs and problems. It is the first stage of nursing process which is useful for my involvement and participation during the assessment of the Patient. The nursing process will present discussion on the assessment of tools used in partnership with a nurse, the patient and the multidisciplinary team. Implement the care plan, care co–ordination and review are the cornerstones of the Care Programme Approach (CPA). Adopting different approaches, this paper brings to light previously unexplored insights into the way nurses and others practitioners interact with Ann’s mental health problems. Drawing on Ann’s social interaction, this paper considers her bipolar disorder and associated problems.
Other Information will be obtain in direct manner (observation, interviews) and throughout interpersonal care with a combination of therapeutic method focusing on Ann’s person-centred approach. Specifically, the paper focuses on aspects of role performance during Ann’s assessment and her contribution into the care plan. Information collected by many members of the healthcare team, such as her biography, therapeutic interventions and consultations.
Ann’s psycho-biography
Ann is a 79 year old white English lady who was born in Hackney. She came informally admit on this acute elderly admission ward to focus on her functional illness. Due to Ann’s confused presentation, a collateral history of her biography was from her son, who accompanied her to the hospital. He reported that his mother has never had any mental problems and that was her first contact with a mental health services. Tony’s stated her mum spoke fondly of her youth: “Mum never met her father but her mother describes her dad as a compulsive gambler with a terrible temper, alternating with expansive grandiosity”. Since Ann’s father died before she was born and her mother worked irregular hours as a Nurse. When her mother remarried Ann spent much of her childhood and adolescence with various father and went to many school. When Ann met her husband she was engaged in a comfortable and constructive relationship; she gained benefit from sharing goals with at least one person she trusted. She gave birth to Tony (who is now 49 years old). But her life became tragic when Ann (33 years old) lost her husband on in a car accident; Tony was only 3 years old. And this experience of her life left her to face the world with constant struggle and some financial difficulty. Ann never remarried, she also raised her son and she was working in accountancy for a business company in London.
With regard to her social need and goal, Ann lives in a two bed room privately owned bungalow and they are no other family members or relatives. Her son stated that his mother was functioning well and was attending an elderly club, which she enjoyed. Tony was unable to identify any triggering factors or recent stressors that could explain his mum’s sudden illness. He became the main carer her mother who frequently finds it impossible to manage on his own. Tony felt unable to cope with his mother’s illness, stating that her sleep was disturbed. Her emotions were fluctuating and that she was becoming verbally aggressive, so he had taken her to the Accident and Emergency department. During a private life examination, Ann’s behaviour made her predisposed to sever depression. Ann was subsequently referred to psychiatric specialists on presentation of the following symptoms: elevated and irritable mood with feelings of decreased self-esteem. The primary care physician’s diagnoses Ann with manic depression, another name for bi-polar mood disorder.Schultz, Videbeck (2009) defined this illness as “abnormally and persistently elevated, expansive, or irritable mood” And Ann alternates between two states: a manic or high and a depressive or low. Information on Ann’s psychological historical analysis provided by her GP claimed that Tony’s statement is accurate. Ann’s has no previous mental illness.
Main body
Ann was encouraged to live her family and home for a long-stay inpatient admission of 4 months.
The ‘echoes of hope’ come from a collection of perceptions (Basset and Stickley 2010). Attempts have been designed to integrate method of systematic intervention during the nursing process (problem-solving). Leading to implement and evaluated Ann’s plan of care. The Health and Social Care Act (2008) place the needs, wishes and decisions of the person at the centre of assessment, planning and delivery of care.
Under supervision of the nurse, I was reviewing Ann’s chart, hearing the report on her, and discussing with the others practitioners before meeting her. I truly believe that Normal and Ryrie (2009) definition of ‘relationship forming skills’ attract Ann’s motivation to engage in psychological treatment, including a therapeutic relationship. Everyone faces serious challenges, at some stage point in their lives. Nobody has ever cried with Ann before. Ann’s journey to recovery is determined by the recovery model as a new way to explore her bio-psychosocial needs (Barker, Buchanan 2009). The process of applying these fluid’s skills is carried out under an umbrella of assessment (REF James, pp37).
An effective and valid assessment method was to monitor Ann through a detailed assessment to elucidate factors triggered her illness in the first place. Normal and Ryrie (pp130 2009) imposed initiating and promoting effective interpersonal communication involve nurses to employ cultural competencies and evidence-based clinical practice. The method of Ann’s informal assessment covered information collected data from objective (measurable and observable) and subjective (not measurable or observable) should be obtain from the patient’s behaviour. Her assessment covers all aspects of interrelationships between the social, behavioural, physiological, biological factors of Ann’s health. So the nurse and I focus on the individual’s thoughts, feelings and behaviour assumed to be Ann’s responses to her actual mental health problem. (Barker, pp.7:8 2009).
The need of honesty for mental health nurses is crucial. The legal and ethical contexts operate patient’s autonomy and freedom. Nurses maybe engaged to decisions-making achieved a fair balance between protecting, controlling and treat a person with mental disorder (Department of Health, 2008).
A holistic approach (means treating the whole aspect of care of a person). These present unique challenges for Ann’s diagnoses with bi-polar disorder (long-term illness). Her emotional problems may be vague, not visible like many physiological disruptions (Laidlaw et al.pp44 2003) Stages of treatment for Ann’s co-existing problems require drawing together a ‘stepped care’ approach on Ann’s mental health assessment (Baker, 2010). Ministry of Health (2010) highlights that individuals with co-existing problems have the right to high-quality, patient-focused and Integrated Solutions of care provides practical suggestions.
The care programme approach (CPA) is the statutory framework within which bio-psychosocial needs assessment is carried out. ‘CPA’ was introduced in England for people with a mental illness, published by the Department of Health in 1990 and effective from 1991. This framework will be used throughout Ann’s stay to provide a smooth transition between in-patient services and discharge back to the community (Hall et al., 2008). Ann was invited to sit in a waiting room with Tony before attending the CPA meeting. Assessment tool “Your Treatment and Care” questionnaire was provided for her/son to complete and sign (APPENDIX). Than Ann was escorted into a private interviewing room where her CPA take place for the maintenance of her confidentiality, dignity and privacy.
The powerful way to support change is to get people working together with Ann to make things happen. Valuing forms of therapeutic relationship between Ann and others mental health practitioners (constitute of a consultant, a psycho-geriatrician a physiotherapist and occupational therapist (O.T.) a dietician and a community psychiatric nurse). The continuous process of change seeks a new multi-dimensional approach (team work in practice). Consequently, to empower Ann to lead her own recovery rather than being directed by professionals. Incorporating the recovery approach into the aspect of Ann’s intimate care. Encompassing and promoting social inclusion foster a positive vision for the future (Repper and Perkins pp.77 2010).
Technique of therapeutic communication described by Piaget (Ref.) developed an approach “intellectual” of the interview. Under the Nurse’s supervision, I wanted some space; my key role is to encourage Ann to tell her story. I began to empathy (one’s ability to enter in Ann’s world and to reflect this understanding to her as the person). So reviewing her record before beginning the assessment prevents repeating questions that she has already been asked;
Ann’s journey beyond silence began with ideas infused:
Ann feels severely anxious (emotional state) every time she is about to go out or when she is out (occurrence) from fear of being going on her own at her local community she felt like stupid and people looking and laughing at her (cognitive experience). In response she is avoiding going out and will also stop going outside in her own garden (responses). Tim (her son) works far from home and she is rarely seeing him. Other people’s presence outside or in her local community could have been issued as a major problem. This make Ann feeling upset, miserable and isolated (response is unhelpful long term). At this point, Ann is a victim and not totally in controls of her life and feels the panic resulting from this realization -a very little confidence in her- (impact on self). Her life has been restricted as a victim, she may flail about emotionally, verbally, or even physically as she experience this lack of control (impact on life).
Rosenbluh (1981) point out to employ active element which reflect the understanding of Ann in a manner that generates warm, trust, and willingness to be open. The key to effective listening is accurately hearing the feeling and meaning the content of communication. Repeating key words or phrases that Ann used and I did not clearly understand. I focused attention on a particular thought or feeling and encourages Ann to ventilate her feelings in ways that are non destructive and acceptable to her. My body language provides cues to conversation: I did not cross arms or point fingers. I was using unfinished statements (paraphrasing). There are possibilities of compulsory for Ann’s treatment, the elimination of her level of mental illness. In collaboration with Ann and the multi-disciplinary team identify priorities and develop appropriate plan of care.
I started speaking in as structured, carefully chosen way (using non-confrontational approach). I made a psychosocial approach through her own conscious “social” conversations for the development of her personality. “Is anything happening at the moment that upsets you?” Ann’s statement “It was very noisy, I couldn’t sleep well”. Response -“You didn’t get a good night’s sleep. I tell Ann what she heard; it helps me to make sure it was what she meant. Ann says- “I’m worthless and isolated”, response- “You say that like you’re angry, isolated.” Ann states “I am usually treated by Robinson. He has been visited me several time and prescribed medications to cure my pain. He knows exactly what I want!” Doctor carried the interview to elicit information – “Ann we have done some research and we have no heard from any Dr Robinson practicing in this hospital”…
Social factor
The study begins from observing Ann’s behaviour and interaction with her son and others team members. A collaborative approach must be central to all decisions making. My role during Ann’s evaluation was accepting the challenge that the nurse has to value the effectiveness of intervention. Attaining the best possible level of health to form partnership of care between Ann (who receive services) and with the nurse and I (to provide services) and to combat discrimination and stigma (Newell Gournay, 2009). It was clear that I also have Ann’s consent for participation of the assessment of her needs. Consent form formalized by The Mental Capacity Act (2005) will assess whether the patient is mentally capable of making the decision, and the Mental Health Acts (1983 and amended in 2007) describe the very limited circumstances when a patient can be forced to be hospitalized for assessment and/or treatment against their wishes.
Behavioural assessment
Enhancing the engagement process (which more specific care is offered). A psychological treatment approach -as an umbrella term- it directly obtained through interviews, examination of Ann’s behaviour and her interactions with staffs, family and relatives (Brooking et al., pp.167 2000). Ann was presented with mood variation hence unpredictable. She was deeply sad and discouraged and likely to lose weight energy and have suicidal thoughts and feelings of self-reproach. Nurses must handle Ann’s feeling (as a victim).
Rosenblush (years) closely described facts pertinent to her problem needed an ‘emotional first aid’ treatment. Many people who suffer like Ann from anxiety disorder feel ‘on edge, excitable or restless’. This indicates that one’s physical health can influence after the emotional behavioural, psychological responses of individual (FRUDE pp. 35 Years). Before, Ann was non concordant with her medication and a mood stabilizer should be given when she is agitated. Many of these treatments caused controversy and arguments around the proposed therapeutic rationale of these drugs effectiveness (Healy, 2009).
Physiological assessment
The nurse and I used the following information Ann’s level of functioning -the biochemical level- to promote Ann’s independence and sense of self irrespective to her illness (Barker, pp.10 2009).
On Ann’s profile, her primary problem of manic depression is causing her disturbed sleep, as she always known it -subjective-self information- (Norman and Ryrie, pp.217 2009).
Ann has a poor nutritional intake stated not eating well. A cognitive-behavioural approach is a short-term applied to focus on her eating disorders which affect a chain of thinking, feeling and actions (Baker, pp.281 2009).
Ann also has phlebitis -inflammation of a vein, usually in a lower limb- (Tortora, pp.666 2009) (physical examination appendix.3). Her Mobility was assessed by the Physiotherapist for risks of falling.
Biological assessment
Ann was screened for potential biological causes of infection (objective-self data). Following the Doctor review, a urine sample was taken explaining sudden confusion, a full blood test and a Computed Tomography done prior to admission. Ann was hypertensive (high blood pressure). Johnstone, (2006) dominant psychiatric theory and practice in mental distress is best understood as medical illness upon a biomedical model. The doctor assessment included neurological assessment (appendix.5) on a MSE (Mental state examination score 22 out of 30). Newell, Gournay (2009) explain recent research on serious mood disorders demonstrated abnormalities of the neurotransmitter systems in the brain. Some areas of the brain are smaller in people with mood disorders.
Risk Assessment
Ann risk factors were associated with her mental illness that decreases her functionality and quality of life has making her self-neglected (lack of personal hygiene). In addition, a moving and handling risk assessment and infection risk screams to detect risk of deterioration in both her mental and physical state, and prior nutritional intake and sleep disturbances.
Ann was allocated a named-nurse responsible for coordinating her care and implementing the CPA process. As soon as Ann’s problems are identified, nursing care begins by determining priorities, setting goals. The dynamic care plan (as legal documents, a copy of the care plan should be kept by Ann, the nurse or multidisciplinary notes) was also implemented. The evidence-based practice and intervention are now framed within a recovery-oriented approach. I contributed to a tool of recovery action plans of wellness to promote self-discovery (Hall et al. pp.146 2008).
Ann’s short-term goal requires a home visit planned (within four days) for her functional assessment to discharge planning.
Organization of Ann’s home based on Roper’s Activity of Daily Living (Appendix)
On the journey to her home Ann was able to identify local landmarks and roads. Ann was orientated to her bungalow, she manoeuvre safely around the property. She demonstrated good bed mobility she was independently able to complete bed transfer. However risk of falling in the shower room. Ann was referring to social worker for care package. Emergency access will be arranged to allow carers to visit her (soon being discharged); assisting her personal care, medication administration and meal preparation. Refer to day centre to maintain social skills and engage in leisure activities. Ann started going out with previous relatives at the local community just for the day.
Conclusion
My involvement and participation during Ann’s assessment presented discussion likely to favour more informal methods when studying Ann psychosocial needs. Ann’s progress was record to demonstrate her journey within this acute unit. CPA forms reset out as care plans for Ann’s mental health problems and complex needs.
The relationship between care plans and quality of care could be challenged on the basis that time spent writing the care plan can take away time spent with Ann. Care plans are often done for the patient rather than with the patient.
The concept of recovery in mental health is often influenced more by specific human values and beliefs, than scientific research and ‘evidence’.
After her interview, when I asked her how the interview had been for her, she told me that she had expected to be crucified and had been pleasantly surprised to find that I wasn’t. I could not judge use logic or give advice as Ann’s feelings must be legitimize.
If someone says something that is manifestly untrue then the person should be encouraged to see the error of their ways. But if this were true what would be the point of challenging delusions.
