In this essay I will discuss a service user I encountered on recent practice placement who was referred to the hospital after she has been deteriorating in mental health and she has bipolar disorder. I am going to discuss the assessment and development of the care plan of the service user. The essay will also consist of a brief biography of the patient’s contributing factors towards her present mental health circumstances. The relevant culturally sensitive engagement and assessment skills used by the nurse in their relationships with the service user will be discussed. I will also explore legislative and nursing frameworks that influence and contribute to positive and hopeful service user’s care. The assignment will also explore the multi-disciplinary nature of mental health care delivery and discussion of the care planning of the service user.
The Nursing and Midwifery Council (NMC Code, 2008) states that it is the role of the nurse to maintain confidentiality of the patients and in line with the Data Protection Act(1998), in this essay I will change the name of the patient by giving her a name Alice. I will discuss three of the twelve Roper, Tierney and Logan’s Activities of Living (Roper et al, 1990) which are communication, maintaining a safe environment and mobilising. I will use the tidal model also known as recovery model which is a model for the promotion of mental health and recovery developed by Professor Phil Barker, Poppy Buchanan-Barker and their colleagues (Barker, 2001). Alice is an eighty two year old British lady admitted informally at the mental health ward. She is a widow who lives by herself in a bungalow and the husband passed away in 2005. She has got a daughter who immigrated to Australia, and she has a brother, nieces and nephews who live far away from her and they visit each other once or twice a year.
Alice is a catholic and she enjoys going to church. She has a good social network of friends and she likes going out for meals and shopping with friends but recently she has been isolating herself. Alice used to work in the police force and after she retired she had been doing a lot of charity works. The lady is known to services with a history of bipolar disorder. Alice has got a history of taking overdoses due to depressive illness. She had a fall at home sustaining a cut about ten centimetres on her head and stitched and Alice’s mental health had been deteriorating over the last two weeks following a suspected financial abuse from one of her neighbours whom she had a close relationship with. These two incidents made Alice to be quite low in mood with reduced motivation and also an effect on her confidence leaving her confided to her house and not going out as she used to. She felt sad and confused and she was brought to the ward by the community psychiatric nurse (CPN) and social worker. Alice used to go to the day centre every Thursday and she had not been going for the past two months.
Alice care is co-ordinated under a Care Programme Approach (CPA) and this is a particular way of assessing, planning and reviewing someone’s mental health care needs, and she should have a written care plan. A care plan is a written document that identifies the care to be given and a record that shows who planned and gave that care. It is a legal document and it should guide the work of others and be a basis of continuity of care. A care plan should also show a logical and systematic flow of idea through from the initial assessment to the final evaluation. The CPA was introduced by the Department of Health in 1991 to provide a framework for effective mental health care. It makes sure that people with mental health difficulties receive the care and support they need in a care package tailored for individuals (CPA & Care Standards, 2008).
The Department of Health (DOH) formed The National Service Framework (NSF) for Mental Health (1999) which sets national standards and defines service models for promoting mental health and treating mental illnesses in the five following areas: mental health promotion; primary care and access to services; effective services for people with severe mental illness; caring about carers; and preventing suicide. The Department of Healthy formed a National Service Frame for Older People (2001) which was established to look at the problems for the elderly people so they get the best quality of care. This helps to minimise age discrimination in elderly people and it promotes independence and provides person centred care. The framework has four underlying principles which are; respecting the individual, intermediate care, providing evidence based specialist care and promoting an active healthy life.
There is also National Care Standards which aims to improve the quality of life of the patients by the level of care and support provided. The frameworks and legislations help to guide Alice’s care. Alice needed an assessment of her needs and to have a care plan that is regularly reviewed by professionals. Assessment is the decision making process, based upon the collection of relevant information, using a format set of ethical criteria, that contributes to an overall estimation of a person and her circumstances (Barker, 2004). I was going to get most of the information from Alice. Barker (2009) suggests that wherever possible information should be obtained directly from the person, either in the form of some kind of self report or via observation. Good communication and a systematic approach to data collection are needed for a successful assessment. It is necessary to form an effective therapeutic relationship with a service user before carrying out an assessment.
The stages of therapeutic relationships are identified as developing, maintaining and ending therapeutic alliance (Callaghan and Waldock, 2006). I was going to start by carrying out a formal assessment so I took Alice to one of the quite rooms where I was going to interview her in the presence of a qualified nurse. We all sat on the chairs so that we would be on same level and that would make Alice feel comfortable and relax and offered Alice some drinks. Introductions were made to check the service user’s name and how she would like to be called. I introduced myself, the qualified nurse and our roles and the aim of the interview so that Alice would feel welcome and comfortable. I explained to Alice that the information she gave would be kept confidential and only to be shared with other professionals like doctors, occupational therapists, support workers and physiotherapists. This is supported by the NMC Code (2008) which states that professionals should maintain confidentiality and ensure individuals’ right to privacy, respect and dignity will be maintained at all times.
However confidentiality needs to be breached if there maybe harm to the service user or others. Alice indicated that she understood and agreed to be interviewed. During the interview Alice was asked about her past history as well as full details of her current problems and the reason why she was admitted. This information is taken to ensure that the help and support offered while in hospital is appropriate. Alice said that her mood had been fluctuating from quite low and tearful to quite happy. She felt she was only on the ward for respite and did not need a lot of input. Alice was asked if there had been any history of mental health problems in her family (Schultz and Videbeck, 2005) and she replied there was none she was aware of. I asked Alice some questions that would give me ideas if there was any history or present risk of harming herself. She denied having any suicidal feelings, thoughts or ideation. She is prone to falls due to unsteady gait and had stitches on her head when she arrived. As per trust policy I completed the 16 points screening tool which identifies risk factors for falling in older people (see appendix 3). During the interview Alice denied to have any risk of harm from others.
Alice’s property was checked if she was carrying any weapons that would be dangerous to her or other service users and medication. She did not have any weapons but had her medication which had been handed over by the CPN and the social worker of which I recorded. During the interview there were occasion Alice looked very depressed and she was putting her hands on the cheek and biting her mouth which indicated that there was a lot going on in her mind. May (2005) stated that after recording a number of behavioural incidents, it often becomes possible to see that certain antecedents consistently trigger the behaviour or particular consequences appear to be maintaining. Alice was also asked what she expected from the hospital and staff and she said she wanted to get better and her wound on the head to heal. I was prepared to listen to Alice by showing concentration and supported her to ventilate her feelings as it is healthy. It was vital that Alice’s baseline physical observations were taken and recorded to check if any observations were outside of normal parameters so that the doctor would be highlighted.
The other reason for baseline physical observations is to detect and identify any physical health problems. All the results were on the normal range (see appendix 4). Alice stated that her appetite and fluid intake had not been bad. I had also to assess if Alice was at risk of pressure sores by completing a Waterlow Risk Assessment Tool (see appendix 5) as it is a requirement by the placement trust, and was not at risk. Alice stated that she was able to assist herself with simple activities of daily living when asked and she did not have any incontinence issues. Alice smokes occasionally and does not take any drugs or alcohol. During the interview Alice was asked about her sleeping pattern and she said she sleeps well with the aid of sleeping medication. The reason for assessment was to find and identify the problems and strengths so that there will be a plan towards her treatment. Following an accurate assessment the next stage in the care process is care planning.
A care plan is a written account of how the service user’s needs are being met, and a well designed care plan should involve working together with service user so to agree the desired outcomes (Callaghan and Waldock, 2006). The care plan includes the agreements or actions agreed with the service user and interventions which are the pathway to a certain goal with the ultimate aim to reduce the symptoms, distress and/or disability associated with the problem (NICE, 1999). Following assessment, the main needs identified were Alice being in variable mood fluctuating from quite low and tearful to quite happy, have a medium risk to falls and have a cut on her head. Mental health care plays a vital role in keeping people safe and helping them achieve recovery.
The concept of recovery is about staying in control of life despite experiencing a mental health problem and a foundation of recovery is a journey and does not mean getting back where you where (Barker and Buchanan,2005). The professionals in the mental health sector often refer the recovery model to describe the way of thinking and the care plan is about the future and what the patient is saying. Since one of the problems identified on Alice was variable in mood, fluctuating from low and tearful to quite happy. The desired outcome was to return Alice’s mood to a stable level by using the appropriate interventions. Alice should continue taking her medication to keep her mood stable or to treat moods which she found distressing. Staff should administer the medication as prescribed, monitor any side effects, educating her and talking about the intended effects of the medication. When a side effect appears, the nurse should document the side effect and notify the prescriber so that further evaluation can be made (Boyd, 2008). A complete list of medication should be maintained and evaluated for any potential drug interaction.
Alice should be offered regular weekly reviews by the multi disciplinary team (MDT), the consultant and as and when required by ward doctor. The next need which was identified was Alice to join the occupational therapy groups. Occupational therapists are responsible for providing activities that help patients increase their attention span, improve their motor skills, and their ability to perform their daily activities (Fontaine, 2009). Alice was to be offered regular one to one session to enable her talk about her feelings. Staff should encourage Alice to be independent by letting her do things for herself which she is capable of doing. Alice was put on general observations and the level of observations to be reviewed and amended if needed. Staff should monitor and record her mood, behavior, how she is presenting herself and her whereabouts.
In line with Schultz and Videbeck (2009), Alice should also be provided with a safe environment and reassured that she is safe. Alice should be encouraged to attend ward meetings with other patients to talk about what she would like to spent her time doing during the day so that she can participate in the groups going on that day. According to James and Gilliland (2001) working with clients to formulate a plan gives the patient control of their lives and autonomy and the patient will feel that the nurses are not forcing their ideas to the patient. By encouraging Alice to join the groups would make her not to isolate herself, develop new skills, and share her feelings and thoughts in an open and honest manner. Alice will also provide support to other service users and receive from them.
Another identified problem was Alice is prone to falls due to unsteady gait and uses a stick. When Alice is walking staff should observe her and make sure she uses her stick at all times and encourage use of and compliance with hip protectors. For long distances a wheel chair should be used and when using a wheel chair staff should make sure Alice’s feet are on the footplates. If any faults found on the wheel chair this should be reported and it should not be used. Nursing staff to accompany or be within reach of Alice during high risk activities like showering and bathing. Staff should liaise with physiotherapists for safe mobility and should be encouraged to join exercise groups with the physiotherapist. Staff should also liaise with the district nurse to attend to the cut on her head. Any bleeding and concerns noticed on the head should be monitored and reported. Good communication skills are required during the nursing process of Alice, this is supported by Callaghan and Waldock (2006) who stated that effective communication is an essential feature of the mental health care of older people.
When talking to Alice staff should listen actively and that encourages the service user to describe all the relevant aspects of the problem. You also get and give accurate information and establish and maintain relationship with service users and their families. In every conversation staff should also check if Alice has understood, asking one question at a time and allowing her time to respond. When approaching Alice staff should make sure that they are not moving arms into her intimacy circle and keep their posture relaxed. It’s also nice to make sure that Alice is aware of your presence before touching her and not doing makes her frightened. Eye contact should be maintained whilst talking to Alice and have their eyes at the same level as hers when talking to her. When talking to service users you should keep your voice level, calm and even and ensure that you are demonstrating listening by head nodding and responses (Barker, 2009).
Good communication improves the service user’s satisfaction with the care given and reduces negative emotion and fear. Another aspect of Alice’s care was to consider risk of abuse during her stay in the ward from anyone. Abuse can be taken in many forms but is usually defined as physical, sexual, financial or psychological/emotional. ‘No Secrets’, published jointly by the Department of Health and the Home Office, set out a framework for safeguarding – keeping people safe from abuse and neglect. The Safeguarding Vulnerable Groups Act (2006) was passed to strengthen safeguarding arrangements for individuals in the workplace. One of its main points is to improve vetting procedures so that people who may present a danger to service users are identified and prevented from working in social care professions.
Alice should not be discriminated because of her age or her mental illness. If someone is in fear or feel disloyal to the organisations there are some organisations which can be notified like the social services and the Care Quality Commission (CQC). There is also whistle blowing policy which protects staff from losing their job or be victimised by the employer after reporting any wrong doing happening in the work place. Alice should have choices, dignity, respect, safety, realising potential, equality and diversity and should be treated individually. She should get the best quality of care and as a nurse it is our responsibility to keep it in practice to Alice’s recovery and, a good assessment and good care planning lead to Alice’s recovery. I have learnt that good communication between healthcare professionals and service users is essential.
Alice needs to be assessed regularly and as and when required and care plan to be amended during her care to establish a well structured routine. Although bipolar disorder tends to be a lifelong, recurrent illness, there are many things Alice can do to help herself. Besides the treatment Alice gets from her doctor or therapists, there are many things she can do to reduce her symptoms and stay on track, including educating herself about bipolar disorder, surrounding herself with people she can count on, and leading a healthy “wellness” lifestyle. She is not powerless when it comes to bipolar disorder and with good coping skills and a solid support system, she can live fully and productively and keep the symptoms of bipolar disorder in check.
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