A Mental Health Nursing Case Study

Introduction

Mental health nursing is a crucial element in the provision of healthcare. Patients with mental health conditions exhibit different complications that significantly hamper their functionality. Dementia is one of the main conditions of the mental disorders that affect a significant number of people. A mental health practitioner plays a crucial role in providing care to patients of dementia. In this study, the assessment of dementia will be covered as well as a discussion of the care plan that was developed to manage the condition of the patient. Among others, the study appreciates the person-centred care and the interpersonal theory in nursing as key enablers of the assessments and care plans for the patients with dementia and will be demonstrated in this assignment. This assignment is focused on the case study of a patient suffering from dementia. However, the assignment adopts a pseudonym for the patient. This is in accordance with NMC (2018) that discouraged from disclosing vital information of the patients assessed to the public domain in order to maintain the confidentiality of the information, which is one of the core aspects of the nursing practice.

Biography

I was attached to the hospital in the clinical assessment department where part of my duties included providing the first point of contact to the patients seeking mental health assessment and recommending the patients to the doctors for further diagnosis depending on the result of the assessment. In the course of discharging my duties, I met numerous mental health patients who were seeking various clinical assessment services. Having served for over 3 years in the hospital, my experience in the clinical assessments had significantly grown and I could pinpoint most of the symptoms of various mental health conditions.

As I was working, I met with a male patient whom I will give the name Daniel. Daniel was a Black British male aged 32 years old. He was born and raised up in a family that was of a low social class depicting a struggling childhood that he experienced. As a child, Daniel revealed that he experienced frequent fights between his parents which occasionally resulted in numerous injuries with the mother bearing most of these injuries. His father worked as a carpenter in the nearby town centre and he was an accustomed alcohol consumer and would become violent after consuming alcohol.

Daniel suffered numerous domestic violence episodes that were displayed towards him by the father at first and later his mother. When his father could come home drunk, he could beat him up on no grounds at all and when he reached 9 years of age, his mother too showed aggression towards him especially after domestic fights with his father. Thus, Daniel endured resentment from his parents. A year later, one evening his father cam e home drunk and a domestic quarrel ensued which resulted in his father stabbing his wife with a knife as Daniel was observing. Helpless, Daniel’s mother succumbed to the knife stab. A week later, as the police were still investigating the matter and pursuing Daniel’s father who was on the run after murdering Daniel’s mother, his father came home one evening drunk, he bound Daniel and tied him onto the chair, beat him up and sodomised him.

Daniel revealed that from these experiences, he has always grappled with mental disorders at the recall of the traumatic events and childhood. This resulted into his habit of excessive drinking of alcohol in a bid to forget the horrific childhood memories. Till then, Daniel was not married, and was generally introvert and spent most of his time in isolation.

Assessment

In the field of mental health, clinical examination is a crucial aspect in the practice due to identified benefits to the patient and the nursing practitioner (Brown 2015). The purpose of clinical assessments of mental health patients is to acquire a wide-ranging cross-sectional description of the patient's mental state (NICE 2019). During the assessment of Daniel, I obtained help from my mentor who played a crucial role in directing me through the assessment period to ensure a comprehensive assessment is conducted. A comprehensive assessment enables the nurse to understand the patient’s condition in detail as well as expose their objectives, aspirations and dreams when seeking medical assistance.

The assessment was conducted in a room which was closed to enhance confidentiality of the information we discussed during the assessment. Considering the sensitive case of Daniel, the room would offer him comfort and allow him feel at ease to talk to us and disclose his experiences and this was effective. I welcomed Daniel into the assessment room, introduced him to my mentor whom I explained to Daniel about his role during the assessment session and in designing the care plan that would enable him feel better and Daniel agreed to have my mentor stay in the room.

There is a framework for understanding and adopting the approach to clinical assessment of mental health patients (Pressman and miller 2014). In a professional manner I ushered Daniel to the seat of his choice in order to ensure that he felt at ease and that his autonomy to decide and act as he pleases was upheld and respected. Having settled down, I initiated general questions about how he was feeling about his experience at the hospital and the room, his general perception about his life, and what he liked to do most of the times. Such exploratory questions were aimed at creating a therapeutic relationship between Daniel and I which is emphasized in the interpersonal relationship model in nursing assessment and care which I relied upon. This model emphasized on the need to create a rapport between the patient and the health practitioner as this will enhance the reception of the patient to the therapy and enables the nurse to gain a deeper insight in the patient’s experiences (Harris et al 2013). Additionally, Harris et al (2013) explain that it is common for the nursing practitioners to form stereotypes and assumptions prior to assessment of the patients. Such assumptions inhibit the nurse’s ability to examine all the patient’s experiences and adopt a patient-focused approach in the assessment and care provision but instead encourage a paternalistic approach where the nurse makes the decisions and the patients are obliged to follow.

Having created comfort and established the rapport, I slowly narrowed down to asking Daniel about his experience regarding the mental disorders. My mentor directed me during the initiation of the assessment questioning by encouraging me to use open ended questions and allow Daniel to answer the questions without interruption. One of the key pillars of interpersonal relations is emphasis on the freedom and time to speak during conversations. Therefore, Daniel was allowed time to narrate his story, exposing all the experienced he went through as a child as has been elaborated in the biography section above. For instance, Daniel spoke the struggles he had as a child, the anger he felt towards his parents following their resentment and apparent neglect towards him and the sadness as well as anger he felt during the murder of his mother by his very own father. In fact, Daniel remarked “I couldn’t believe my eyes! I was so sad and troubled to lose my mother at the hands my very own father. From then, I hated him with passion. Sometimes I even thought of kill him as well”.

Regarding his experiences after the traumatic events, Daniel revealed a great deal of discomfort, lack of sleep and was always troubled when recalling the horrific events that had occurred to him. It was apparent that the murder of his mother and his subsequent ordeal when his father sodomised him were causing him more trauma and stress. This is evidenced by his remarks “each time I recalled my mother’s death and that cruelty of my father towards me, I feel resistant urge to drink away my sorrow. One day I even attempted to pickpocket two people in the streets in order to get money for alcohol. I was so broke, but I have never repeated that”

However, to understand and fully conduct a mental health assessment, the mental health nurse should possess the core skills necessary for the evaluations (McKhann et al 2011). This assessment adopts a systematic data collection that is pegged on the observation of the behaviour of the patient while the patient is at the hospital under the view and observation of the mental health nurse. This allows the nurse to acquire an insight that is based on the evidence on the symptoms and signs of the mental health disorder, common among them being presenting the potential of being a danger to self and others that are present at the time of the interview (Ruscovky et al 2011). Furthermore, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. Mental health assessments are generally carried out in the manner of an informal inquiry by using a combination of both open and closed questions. I relied on the effective communication skills and the interview session allowed me to observe both the verbal and non-verbal cues exhibited by Daniel during the assessment. According to NICE (2019), assessments that adopt effective communication skills allows the nurse to fully understand their patient which is helpful planning and delivering tailored care. My mentor therefore encouraged me to empathize with Daniel as he was telling us his experiences during the assessment. Empathy is another core skill for effective assessment of the patient and elicits feelings of understanding of the patient’s situation and encourages the patient to open up and disclose sensitive information (Brown 2015; Harris et al 2013).

The focus on the patient during the assessment is crucial in the diagnosis of the condition of the patient (Pressman and Miller 2014). The information presented by Daniel during the assessment was necessary as it pointed out the core causes and manifestations of the mental health disorder he was experiencing. Thus, I explained to Daniel that assessment notes would be taken in the course of our interactions during the assessment sessions. Since Daniel was not under the influence of alcohol during the assessment session, my mentor sought to obtained a verbal consent from Daniel to allow us to make some clinical notes from the information he would give us. And when asked, Daniel replied “It’s okay, I have no problem with that. You can go ahead. After all, you are here to help me recover” informed consent is a crucial aspect in the nursing practice and allows the nurse to conduct their obligatory duties be it during clinical assessments, diagnosis, care planning of medication delivery with full support and participation from the patient. According to the mental capacity Act (2005) all the patients are considered mentally capable of making decisions on the treatment and care accorded to them in the hospital (McKhann et al 2011). This aims at protecting the patients from being treated without their approval and fights the health malpractices and litigations that would otherwise occur in the absence of the consent. Since Daniel was of sound mind and sober at the time of assessment, a verbal consent was sufficient and thus a written consent was not necessary, neither was it necessary to request Daniel to provide another person such as relative to offer informed consent on his behalf (McKhann et al 2011).

In the course of clinical assessment however, I relied on core values of the nursing practice to enhance the patient’s feeling of comfort during the assessment. In this case, I adopted a patient centred approach in the assessment where I considered the patient’s concerns throughout the assessment phase. I sought to establish an interpersonal rapport with the patient and I realized that in the presence of rapport, we could communicate easily and the patient was relaxed and interested in the assessment process. To achieve this, I relied on respect, preservation of dignity and human rights as key values in the clinical assessment phase. These values are concomitant with the patient-centred care model (NICE 2019) and also blend with the interpersonal relations model which I relied upon in establishing rapport, and questioning Daniel to obtain information about his experiences. At the end of the assessment session, which took over one hour, Daniel felt more relieved to have shared his story and his slim smile portrayed the hope he had in recovering from the stress disorders he was experiencing. From this interaction, with the help of my mentor, we managed to determine that Daniel was suffering from post-traumatic related stress disorders which stemmed from his childhood experiences as he was growing up. Therefore, the care plan needed to focus on tackling the mental disorder of the patients and other aggravating factors such as alcohol consumption since they were both related.

Care planning

The nursing care plan is crucial in the provision of the services and the framework for evidence based, standardized and holistic care (Lovell and Yates 2014). The care plan depicts the type of nursing care that the patient may need. For many years, nursing care plans have been used to manage different human purposes and in recent years, the care plans have increasingly been formalised to ensure that effective care is documented to enhance the quality of services accorded to the patients (Ke et al 2015).

Bearing in mind that in recent years, there has been a continued influx of patients seeking medical health services, it is difficult for the nurses to provide care to all the patients without any documentation. Thus, the care plan documents the type and the level of care that should be accorded to the patients (Stewart 2011). Patients with mental health conditions require more focused care due to the many needs that the patients may be presenting (Exley et al 2009). Daniel for instance exhibited multiple needs that required attention in the creation of the care plan that would help alleviate his condition.

Ideally, the construction of care planning is aimed at identifying problems and coming up with solutions to reduce or remove the problems (Black et al 2009). The documentation of the care plans allows the nurses and the patients to understand what exactly the care will be covering and how it will be offered to the patient. Care plans make it possible for interventions to be recorded and their effectiveness assessed (Lorenz et al 2008). Nursing care plans provide continuity of care, safety, quality care, and compliance. Quite important to note is the fact that nursing care plans can be relied upon for the reimbursement purposed by health insurance plans such as Medicare (Vandervoort et al 2012).

The construction and generation of the clinical care plan, which can be equally referred to as the patient’s profile is the nurse's responsibility. The nurse is the only person who has the ability to inscribe on the care plan and re-evaluate the course of treatment of the patient. Based on the above case study relied upon in this paper, following the assessment of Mr D, I discovered that the patient had cognitive functioning problems as a result of this dementia conditions. Specifically, the patient had difficulties communicating and the memory was deteriorating as time was passing by. This is evidenced by the fact that after assessment, Mr D had difficulties recounting the activities that occurred in the earlier sessions of assessment. The quality of a care plan depends on the precision of the assessment conducted by the nurse and the information gathered by the nurse about the condition of dementia.

Care planning is designed to ensure that tailored intervention is delivered to the patient. In this case, while there may be two patients suffering from dementia, there are two different types of needs presented by individual patient and thus, relying on the clinical care plan of one patient to provide care to the other patient will be unprofessional and unproductive (Dickson et al 2013).

There are common benefits and expected outcomes of the clinical nursing plans. To begin with, clinical care planning seeks to promote evidence-based nursing care by providing comfortable and familiar conditions at the hospitals (Van der Steen et al 2014). This evidence-based care is in line with the person-centred care which was crucial in the assessment of Mr D, a patient with the dementia condition. With the plan in place, Mr D would be more at ease at the hospital as he will be aware of the specificities of the care provided to them and the documentation of the same ensures that the patient is informed of the entire care.

Nursing care plans help to provide holistic care to patients with different medical conditions. This means that the entire aspects of the patients including the physical, psychological, social and spiritual in relation to management and prevention of the disease (Sampson et al 2010). This holistic care can be detailed in the care plan and following through the plan will ensure that the patient is effectively managed and recovery is achieved in due time.

In most instances, the patient’s needs may require multidisciplinary effort in the provision of care for the patient. The team efforts will benefit from the care plans which enable the team effort to come to a consensus regarding standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease (Burla et al 2014).

Psychological support and reduction of stress and anxiety to the patient are some of the core objectives of developing a nursing care plan. A well-documented plan details the approach adopted by the nurse in providing care (Burla et al 2014). As listed above, a clinical nursing plan is developed with a focus on the crucial elements that should be contained in the healthcare plan. As highlighted in the assessment section above, interpersonal theory of nursing was relied upon in the assessment of Daniel and the care planning. This theory explains interpersonal relationships and social experiences in regards to the shaping of personalities, as well as the importance of life events to psychopathology. In this case, the patient’s behaviour depicts a need to have his needs met which can be achieved through interpersonal interactions (Gerand et al 2011). In this theory of nursing, therefore, the establishment of a solid relationship between the nurse and the patient is the determinant of the success of the care provided to the patient. In fact, regardless of the comprehensive nature of the nursing care plan, the absence of the interpersonal relationships denies the patient an opportunity to access quality care from the nursing staff as well as hampers the team effort that is crucial in the care provided to the patient.

Following the assessment of Daniel, I identified two main themes that required care. My mentor played a crucial role during the collation of the information and analysis of the clinical notes we had taken during the assessment in order to identify the two main aspects that our care would be focused upon. However, I also noted that due to the reduction in the cognitive functioning of the patient, there were associated physical pains such as continuous fever stemming from feelings of frustrations and stress. I believe that the care plan tailored at enhancing the communication and the memory aspects of the patient would effectively enhance the cognitive functioning of the patient and this will enhance the quality of life experienced by Daniel.

In developing the care plan, I first established that it was not necessary for the patient to be admitted to the hospital for the care of dementia. Thus, a home care would be effective to manage the patient, though I would make continuous follow-ups of the patient’s progress and recommend the care to the patient as well as assess whether the patient would be responding to care and following the assessments, Daniel would be required to visit the hospital from time to time depending on their response to the healthcare.

I developed a care plan that was focused on managing the post-traumatic stress disorder that Daniel was evidently suffering from. Appendix 1 details the care plan that I developed, with assistance of my mentor. To effectively manage the traumatic stress disorders, I relied upon the services from other healthcare professionals who provided inputs on the management of Daniel’s condition (Robinson et al 2012). The doctor provided the prescriptions and this was included in the care.

The care also focused on the alcohol consumption problem that Daniel was grappling with. In this case, recommendations from the counselling psychologists were integrated into the care. These recommendations were focused on the strategies that could be relied upon to enhance Daniel’s recovery from alcoholism (Gerand et al 2011). In the plan, I also recommended that support groups such as alcohol anonymous would be of benefit to Daniel on his journey to recovery from alcoholism condition. From the assessment, it appeared that Daniel was not yet addicted to alcoholism, but that is beyond my jurisdiction as a student nurse to decide and thus the psychologist would be in a better position to help Daniel address his alcoholism condition. I additionally provided my contact to the carer so that we could keep communicating and as stated in the plan, I committed to providing weekly visits to monitor Daniel’s condition since he would be at home and their commitment to implementing the nursing care plan.

Conclusion

The role of mental health nursing is curial in enhancing the healthcare of the patients with various mental health conditions. This paper has detailed an assessment and nursing care planning for the patient with dementia, one of the pronounced mental health conditions. From the assessments, it is clear that interpersonal theory and person-centred care is crucial in the conduction of the assessments and care planning for patients with various mental health complications. I have learned that each individual presents unique needs that should be considered for effective care provided to the patient.

Furthermore, a care plan is a crucial tool for providing quality and tailored care to patients. To maximize the benefits of the care plan, it is crucial that the plan is informed by the outcome of the assessments and that the main needs should be the core focus of the nursing care plan. The nurse plays a crucial role in ensuring the effective implementation of the care plan. The inputs form other healthcare practitioners should be sought and integrated into care provision. Furthermore, a mental health nursing plan for Daniel should be continuously evaluated and as detailed in the appendix section, the assessment of the nursing plan helps to understand the whether the therapeutics and palliative care interventions documented in the plan achieved the desired outcomes which are equally documented. This will also help the nurse to evaluate whether the patient is responding to the nursing plan.

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