THE ASSESSMENT AND CARE PLANNING OF CARE IN MENTAL HEALTH NURSING
Table of Contents
INTRODUCTION 2
BIOGRAPHY: 3
ASSESSMENT: 4
- Mobility: 10
- Maintaining Safe Environment: 11
REFERENCES: 14
Appendix: 17
INTRODUCTION
The nursing process is a structural outline for nursing practice. It involves all the stages undertaken by the nurses in carrying outpatients’ care and provides a useful basis for setting progress goals and care delivery. It embraces assessment, care planning, implementing, evaluation (APIE). Lately, diagnosis is an additional stage that can sometimes be identified between assessment and care planning (Wrycraft, 2015). However, in this essay, the holistic assessment and planning of care of a service user, that I was involved in her care in mental health ward, where I undertook my last placement will be discussed using a nursing model. Holistic originates from a Greek word holos, which means whole or complete rather than some part of something. In the assessment, holistic approach is gaining comprehensive information through assessing different specific areas and making use of these to plan care (Walker, Carpenter and Middlewick, 2013). Holistic approach in care addresses the connection between the spirit, soul, body, social/cultural, emotions, relationships, context, and environment. The collaboration of all these features help with healing, as holistic nurses look towards every aspects and the way they affect the health and well-being of a patient (Nursing theory, 2019)
Firstly, the biography will be briefly explained. Secondly, activities of living (AL) model developed by Roper Logan and Tierney, (RLT) nursing model will be used and analyze critically in carrying out assessment and care planning. Further reference to sociocultural, biological, environmental, politico-economic and psychological factors affecting the service user’s health will be examined. In addition to these, the role played by the professional skills in relating to this assessment and investigation of care planning will be carried out. Kim is a pseudonym used for my service user according to the Nurses and Midwifery Council (NMC) code of conduct 2018 in prioritizing people through providing respect of their privacy right as well as by maintaining their confidentiality.
BIOGRAPHY:
My last placement was in an acute mental health unit, the service provides care for patient’s age 18 to 75 years, who are suffering from symptoms associated with mental health illness and need hospital admission for assessment, planning, and evaluation of their care. The ward team comprised of nurses, students, support workers, psychiatric doctors, psychologist, discharge coordinator, occupational and physiotherapist, ward clerk.
Kim was brought in by police under section 136 of the mental health act 1983 due to the recent history of suicide ideation and self-harm by cutting herself. She became mentally unwell and started showing symptoms of depression since her husband died 5 years ago. Due to this, she has been in and out of the hospital, stop working and unable to keep up with her bills. She is already recognized by the units of in-patient as well as units of mental health including the community team as she has been unwell for the period of five years. According to Kim, she was experiencing sleepless nights, low mood, loss of appetite, avoiding social events and self-neglect in carrying out personal care. These symptoms became worse and she started cutting herself and thinking of taking her life. Her daughter has been supporting her with her activities of daily living as she loses interest in doing things for herself, she suffers from poor concentration and has a retarded thought process.
The 64 years old lady lived together with one of her daughters in a two-bedroom council house. She has two older sisters who are both also living with depression and one younger brother, they both grew up happily together in a small village in southeast England. Kim moved to southwest England immediately after marriage and had two daughters but only get along with one. She went to a college and finished with national vocational qualification level 2 in administration and use to work as a cashier in her local post office. Kim also worked for the local charity as a volunteer every Saturday but became mentally unwell and started showing symptoms of depression since her husband died 5 years ago. Due to this, she has been in and out of the hospital, stop working and unable to keep up with her bills.
Kim’s enjoys going out to the club every Friday night when her dad was alive and loves shopping. Kim was a very happy person, very hard working and always ready to help others. She also loves dancing and uses to go with her family to different dance show and movies, she is very religious and attended the Church of England a few meters away from her house. Kim registered with the local General Practitioner whom she has been visiting for physical health checks as she suffers from postural hypotension. Kim had a dog which has been given back to royal society for the prevention of cruelty to animals (RSPCA) due to her incapability of taking care of the dog. She was infected by scabies from the dog and visited physical health hospital for investigation and treatment of skin rash and infection. I choose to be involved in Kim’s assessment and care plan because my mentor was her named nurse. Throughout her stay in the ward, I worked mostly with my mentor to support and care Kim.
ASSESSMENT:
Over the past thirty years, the value of pigeon-holding people within different diagnostic categories has been considerably questioned. It appears that people are living with certain problems which can be mild or severe, nevertheless, such people have strength and resources which are helpful in resolving these problems, this then gave birth to traditional assessment (Barker, 2014).
According to Nick Wrycraft 2015, assessment is the purposeful collection of important facts to form a complete understanding of individual psychology, physical and sociological health. Chris Hart 2014 stated that assessment in mental health setting is a way of assembling and examining data from many and different sources, including interviewing the individual in developing the understanding as well as evaluating the possible mental health problem. It is an opportunity to understand our service user’s story of their illness rather imposing our view and understanding of their illness. It is a continuing process used to classify needs, strength, skills, capacities, and right coping approaches of a patient in order to plan their care and not just their negative effects of mental ill health. (Nick, 2015).
Likewise, assessment is considered as an important phase as professionals of healthcare are required to understand the cognitive functioning of a patient, there process of thinking, emotions, values and beliefs as well as the next step the patients are going to take which includes suicide attempt and in the worst scenario serious self-harm (Barker, 2009). Assessment is found to be an important phase in patient care and it is the first phase in the whole procedure of individualized as well as holistic care in nursing furthermore, providing information which is important to develop an action plan which improves the status of personal health. Expanding further, Trenoweth and Moone (2017) suggested that assessment should cover biopsychosocial functioning, the risks to the mentally ill person and risks to others, previous record of violence or criminal activity, needs that arises due to comorbidity as well as personal circumstances such as family, financial and occupational status as well as needs of physical health.
In mental health context during the assessment, risk assessment is vital as risk is the possible occurrence of a behaviour that may be harmful or beneficial to someone or others. Risk assessment involves analysing the possible outcomes of such behaviour and set up a plan to reduce the harm that can be caused (Hart 2014). It is a complete process that covers several areas and must be approached from a multi-disciplinary view. In in-patient care, the contributions of all services that have contact with the service user are important, Information must be collated and shared among these services so that decisions about management are optimally informed. Clearly bearing in mind service users’ confidentiality and protecting their privacy to achieve the safest possible care standard (Newell and Gournay 2009).
The nurse assessing a patient must be careful of not imposing their expectation, values or assumptions and identify diversity and individual choice of service users when collecting or interpreting data (NMC 2018). Before the assessment is undertaken, the nurse have the responsibility of explaining when and why the assessment will be carried out and allow enough time to assess the needs of the service user. In addition to this, confidentiality should be considered, ensure the environment is conducive, considered. Assessment is beneficial for the patient as it allows service user’s needs to be recognized, however, it might create a feeling of intimidation or embarrassment, hence the nurse require to develop a good relationship.
Assessment has two stages of collection and interpretation of information from the service user’s experience and life event. It can be classified into three classes of approaches. Firstly, a full interview which can be formal or informal and cover all aspect of biology, psychology and sociology functioning, commonly used for service user admitted onto the ward. During this interview, a formal meeting is held to discuss service users background history and detailed physical health check will also be carried out by a doctor. Secondly, observation where service user’s actions, behaviour, the speech will be assessed while her mood will be assessed on regular basis. Lastly, intensive assessment tools are used which has some fixed questions to score service user’s responses at that time (Nick, 2015).
In the ward where I did my placement, the Roper, Logan and Tierney model of nursing care based on the twelve activities of living is used to assess how service user’s life has changed because of their illness and ways to plan their care as well as promoting independence.
Holland et al 2003 stated that the RTL model was originally created to be used as an educational tool for the new students of nursing and is being used ever since as a framework to care, practical application, to teach and for learning. For these reasons, I developed an interest in RTL nursing model as a student for service users’ assessment and my own learning. Furthermore, RTL also helps to move the attention of nursing from ill-health to health, facilitates health promotions and changes in individual lifestyle (Roper et al 2000). It is widely taught and used in the United Kingdom nursing schools and other countries worldwide. This model is flexible and broad allowing it to be used in any nursing practice.
Therefore, it is understood that there is a presence of a solid connection among the RLT nursing model as well as the process. Roper, Logan, and Tierney (2008) portrayed the nursing procedure a straightforward technique for sensible reasoning. There are five interrelated perceptions of RTL which are: – Activities of living, Lifespan, Dependence/ independence continuum, Factors affecting activities of living and lastly, individuality in living. This model of nursing has been used in conjunction with the nursing process, health practice, care planning and help to teach service users relatives and aides how to individualize nursing care. However, the ALS themselves are often misinterpreted or are presumed to have restricted possibility, leading to dissatisfaction with the model when one neglects to recognize that the ALs are more unpredictable than the title would believe. In the United Kingdom, where the model is predominant, it has been reduced to being used just as a checklist, often used to assess how the life of a patient has changed due to sickness, injury, or admission to a hospital rather than as a technique of planning for increasing individuality and quality of life.
Kim assessment was carried out in the multi-disciplinary team (MDT) room located at the rear of the ward, away from ward noise and activities as chose by her. It is a conducive environment set up to allow relaxation of both patient and professionals. Present in the room were Kim, her daughter, me, my mentor, the ward manager, named psychiatrist, and Kim’s key worker usually a support worker on the ward. The MDT room was set up in a way to allow good eye contact, chairs were arranged around a big table encouraging sitting squarely with an open posture.
Assessment in mental health requires the ability to communicate effectively. In fact, poor communication and lack of self-awareness can result in misinterpretation of service user experiences (Trenoweth and Moone 2017). In view of this, a semi-structured interview was used during the assessment, this includes structured and unstructured interview method. This help interviewer to understand and evaluate possible mental health problems through planned and prepared question combined with interviewing according to service user’s style (Hart, 2014).
Prior to Kim’s assessment, verbal consent was gained from her for effectiveness, plans and preparation were made for her and her daughter’s convenience and a date were agreed on and documented. This is in accordance with NMC code 2018 which states that, before carrying out any action on service users, we must make sure that we seek appropriate informed consent and document it.
Kim assessment was led by my mentor who asked everyone present to introduce themselves. Good rapport was established through explanation of the purpose of the assessment, maintaining privacy, encouraging open communication, acknowledging and validate her concerns (NMC, 2018). Kim added during interview that her symptoms are accompanied by serious headache and dizziness. She appears to be shaky, her eyes were swollen, and she was yawned several times during the meeting. Physical and neurological observation were carried out as her baseline has already known and documented prior to the assessment. Result shows that Kim’s blood pressure was a little bit high. During Kim’s interview, non-verbal communication combined with observation was used. This include making good eye contact as our faces and bodies are very communicative especially in non-verbal communication. Able to show effective communication skills including active listening, summarising, paraphrasing, and questioning. Ability to identifies certain non-verbal skills summarised in SOLER acronym in sitting squarely, adopting open posture with uncrossed arms and legs, leaning always towards the person, maintaining good eye contact without staring and in a relaxed posture can help mental health nurses to create the therapeutic space and tune in service user’s story (Morrissey and Callaghan 2011).
Every individual has several factors in their lives influencing their performance in terms of everyday living activities. According to Roper et al. (2008), the list of the activities of daily living is quite long and hence, are arranged in the form of potential factors to make use of the Roper Logan and Tierney model with fewer complications. The potential factors are categorized into 5 namely, “biological, psychological, socio-cultural, environmental, as well as politico-economic”. These 5 potential factors provide the light to every activity of daily living. The biological factor consists of all the physical characteristics as well as the overall genetic base of an individual. Similarly, the psychological factor consists of factors related to emotions and intellect whereas, the socio-cultural factors include cultural background, and factors associated with philosophy, religion, spirituality and the role played by them within society. The environmental factor consists of the environment which is built naturally for the patient’s living, particle atmosphere including both organic and inorganic and the waves as well such as light, sound, etc. The politico-economic consists of factors related to law and the economy. The application of the following five factors to every activity of daily living tend to highlight a person’s individuality (Roper et al. 2008).
As cited by Dorrett (2011) the practice theories are explained in terms of actions which are oriented to meet a specific goal. However, Barrett et al. (2009) suggested that the RLT model is a type of aid that helps to assist and measure the overall ability of patients like Mrs Kim to get independent with every stage of the care provided. The activities of daily living are 12 in number according to the RLT model. They are “safe environment maintenance, communication, Proper breathing, Eat and drink, elimination, personal cleansing as well as dressing, body temperature control, mobility, work and play, expressing sexuality, sleep and death. All the 12 activities of daily living are used as a framework to assess, plan, implement and evaluate in the care provision Barrett et al. (2009).
The activities help to relate to patient care. As used by Mlinac & Feng (2016) in their study to depict the use of care setting as a chance on how individual human rights can be simply changed. According to the NMC (2018), no person should be subjected to any kind of torture, treating in an inhuman way or shall be punished which reflects the fact that the atmosphere or an environment in which the patient is provided care should be kept in a maintained way to make sure that the well being of patient (i.e., physical, mental as well as psychological) should be kept in mind along with minimizing the infection related risks. Therefore, the Roper et al. (2008) model of care is an important tool to make sure that all the requirements of the patient are kept in mind. However, care of the internal environment i.e., at a cellular level should also be maintained according to Mlinac & Feng (2016). This part help in forming a highly important phase of the recovery process for the patients like Mrs Kim.
The Care Framework for the Activities Of Daily Living :
It is argued by Akinsanya (2008) that the action of a nurse tend to help in improving the overall experience of the patient with the help of his/her theory based knowledge or awareness in specific conditions or situations, hence, helping to dislodge a patient’s fears regarding specific conditions which are witnessed by the patient for the first time (Akinsanya, 2008).
The handover of Mrs. Kim explained her sleep patterns all night; it also stated the medicines prescribed to her for depression as well as for pain, discussed mobility, as well as interventions, wound care discussed where she tried to self-harm by cutting herself observed and stated dressing of her wound to be changed. However, Mrs Kim assessment was obtained through a secondary source, the care of the patient is still required to be assessed for establishing the priority of care for her. Hence, the assessment is considered as the initial stage in the procedure where the nurse makes use of their communication skills for gathering to initiate the care planning for the patient. The RLT model is important to use as an individual perform various essential activities of daily living to maintain their health and physical well being. These activities are found to be in close relation as well as commonly practised in daily living by the individuals as part of their lives. In order to establish such activities during different stages of life, an individual should have a continuum which ranges from being dependent towards being completely independent, possibly depicting variations while performing few activities. The RLT model consists of different phases of the assistance methodology such as evaluating the activities of daily living, planning care, selecting the interventions for implementation, as well as consequent assessment. The following biopsychosocial issue has been identified affecting my assessment and care planning in which the major recognised areas are sleep, maintaining safe environment, mobility and personal hygiene (Roper, Logan and Tierney 2008).
Mobility:
As per Okumi & Koyama (2014) mobility is found to be effected through several events as well as interventions of nursing which will help in improving the overall function of the body as well as the recovering ability. The clinical guidelines of NICE (2018) stated that mobility is important for patients like Mrs Kim to encourage the level of hydration and for the reduction of risk related to clotting in veins due to non-physical movements. The clinical team have prescribed some painkillers to treat the wound caused due to cut. However, Mrs Kim refused to take those medicines and has a right to do as per their choice. According to NMC (2018) advised that an individual have the choice and the right to refuse any treatment on their own choice.
The assessment of Mrs Kim stated that no specific barriers to mobility are observed as well as different types of improvements are observed in her condition however, the understanding and information of psychological issues are required to be diagnosed in Mrs Kim condition. The communication skills when used for the formation of therapeutic relationship which is considered as an intervention, Mrs Kim revealed that she is unable to focus and concentrate on her daily activities, but her daughter who takes care of her helped her with her daily activities. She later began to mobilise on her own. Another intervention that was practised on Mrs. Kim to aid her in mobilising is through the administration of medicines to manage her depression and the effects of the cut caused due to the wound.
- Maintaining Safe Environment:
Mrs Kim is dependent on staff for her to be safe as she is suffering from depression and has a retarded thought process. She also tends to exhibit some bodily movements that are interfering with her normal habits of eating and drinking. During several occasions, her erratic movements are very extreme which increases the risk factors of physical injury and self-harm. Mrs Kim can harm herself by cutting herself on hand, wrist, face due to her extreme mental conditions. Such type of extreme conditions might put her at high risk of physical damage as well as mental damage. This uncontrolled state can also hinder her medication routine which is however very important for her physical well being (Dorrett, 2011).
- Personal Cleansing and Dressing:
Mrs Kim is not able to do her personal hygiene on her own as she has complex needs of health. Due to her retarded state of a mind she cannot be asked to clean herself conventionally. She recently has had infected by scabies from the dog. Currently, Mrs Kim is in state of self-neglect and avoid taking baths however, she has been recently provided with the bed bath using an aqueous cream. Mrs Kim is also not able to independently manage her requirements of oral hygiene and needed support to manage her oral hygiene for maintaining healthy teeth gums. Mrs Kim’s oral hygiene is tried to be maintained on a daily basis. She is tried to be kept focused and to concentrate on the activity she is doing to minimize the retarded thought process and self-neglect state of her mind (Roper et al. 2008).
- Sleeping:
Mrs. Kim is given time between her sessions to rest either in her bed or chair. However, her depression is causing a lack of sleep and during several times she takes longer time to go to sleep during night and observed to have many interruptions during her sleep. In terms of the activity sleeping, it is observed that the factors which are mostly compromising this activity are the changes in terms of periods with in the position of supine, overall quality of the mattress and pillows being used by the patient, Medicines prescribed, depression, etc. The sleepless nights can decompensate Mrs Kim and will expose her to several other mental diseases other than depression. This activity is found to be largely affected by the biopsychosocial aspects which tend to influence the sleeping activity of daily living. The diagnosis which is elected for the sleeping activity is the disturbed sleep patterns as observed in Mrs Kim. Hence, it is required to develop care plan which consists of influential elements which will offer viable and valid solutions for improving the sleeping problem in Mrs Kim (Roper, Logan and Tierney 2008).
According to Snowden (2012) ‘The patient should be a part in the care planning’ and specific goals which are set for the patient are required to be taken consent from the nursing staff, the patient himself, relatives of the patient. The evidence based perspective of potential risk factors at the Roper, Logan, Tierney model is that the model particularly concentrates on physical aspects of the care provided to Kim. However, another factor recognised is the issue of interpretation, AL should be based on physiology and required wider aspect of psychosocial perspectives (Williams, 2015).
Roper et al. (2000), also stated that core care plan can be used efficiently only for post-operative care. However, it is recognized as a limitation to provide care at individual level as it takes a lot of time to write a care plan hence a core care plan is used to avoid this limitation. Furthermore, the use of core care plans require not to standardize care as it has been found that different patient react in a different way to diseases as well as treatments (Moura et al., 2015). When assessing the requirements of care for patients like Kim consideration should be given to the biological factors such as the physical ability as it shows variation as per age and in older patients like Kim it is less efficient. RLT model (2008) states that evaluation should not be a basic goal with respect to a particular problem. Other factors include not setting a measurable or achievable goals depicting unsuccessful nature of the nursing interventions. Peate (2010) states that new goals are required to be set if they are not measurable or achievable. Legal and ethical issues were not recognised as potential risk factors impacting the care and planning of Kim as verbal consent was gained from her for effectiveness, plans and preparation. The Nursing and Midwifery Council states to obtain a consent before giving away any treatment or any type of care (NMC 2018).
In summary, it is necessary to appreciate that communication includes the exchange of information and messages between the patient (i.e., Kim) and my mentor. There might be several factors among both my mentor and Kim to receive different messages sent by both the parties. Such situations can be avoided by learning to read the non-verbal language as well as my mentor being aware of the non-verbal messages that according to them will be beneficial for an effective communication.
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