2809Nrs Mental Health Nursing Practice Assessment Answers
Questions:
This assignment aims to help you to begin to use your professional and clinical judgement and to think like nurses working in a mental health settings and/or in relation to the mental health needs of people regardless of the setting. Go through the case scenario below of a person who is experiencing difficulties related to a mental health disorder.
Case scenario: Jayan-Risk of suicide
Description
Related to the person in your case scenario your assignment will demonstrate your understanding of the following:
- Mental Status Examination (MSE)
- A clinical formulation including biopsyhosocial history and your own MSE observations leading to the clinical formulation
- A nursing orientated handover
- Recognising and responding to the mental health needs of the identified person by identifying best practice nursing interventions
- How to engage a person in a therapeutic relationship
- The application of cultural safety
- The application of the recovery model/philosophy You will need to justify your assignment points with reference to relevant literature. Students, who plan to do well in this assignment, will read and use the unit readings as well as additional relevant evidence based practice resources.
Please follow the steps outlined below to answer this assignment question.
PART 1: Holistic assessment and planning:
This part does not always require full paragraphs. Use appropriate templates/tables to set out the MSE and 5Ps. For Part 1 there is no need for an introduction or conclusion sections.
The Mental Status Examination
- Using the MSE format from your weekly tutorial guide, provide a complete Mental Status Examination (MSE) of the person.
- Use specific examples from the case study materials to illustrate each part of the MSE .
- You must use health terms accurately (e.g. Instead of ‘talks fast’, use the correct term ‘pressure of speech’ and cite your sources)
Clinical Formulation Table
Use information gathered from the MSE and the biopsychosocial assessment (history of presenting complaint, family and social history, current living situation, the person’s strengths and coping strategies, medical history) to complete a table under the headings of presenting, precipitating, predisposing, perpetuating and protective factors (5Ps) relevant to the clinical presentation of the person described in your case study.
Plan for Nursing Care
- Identify two (2) high priority problems /issues for the person and briefly justify why each is a high priority
- Outline one (1) nursing intervention for each of the identified problems/issues and briefly explain how each is likely to positively contribute to care of the person with reference to relevant literature. Interventions must be nursing related, detailed, practical and within your scope of practice.
Clinical handover
- Synthesise the results of your MSE and clinical formulation to construct a paragraph describing the person and their main concerns that you could present at a clinical handover.
Part 2: Therapeutic engagement and clinical interpretation:
Part 2 builds on your work in Part 1. Use academic writing style for this section. Sub-heading is permitted.
The Therapeutic Relationship
- Explain how and why a therapeutic relationship will be established with the person in your care. This must not be a general description of therapeutic relationships but demonstrate that you are applying therapeutic skills to this selected case and person. Then describe at least one (1) specific strategy appropriate for the development of a therapeutic relationship with this specific person and how it was applied in the nursing care interventions you described in Part 1
Cultural Safety
- Describe the first step you would take to ensure that you deliver culturally safe care to this person. Then identify and describe one (1) issue that working with this person might present for you. Describe which of the principles of cultural safety you used in applying cultural safety in the nursing care interventions you described in Part1.
Recovery-oriented Nursing Care
- Consider the nursing interventions you developed in Step 1. Describe how these nursing interventions take the principles of the Recovery Model/Philosophy into account and relate these to your specific person’s recovery process.
Answers:
Part1: Holistic Assessment and Planning.
The Mental Status Examination for Risk of suicide case.
Mental Status Examination
|
· Appearance & behavior
|
On admission, Jayan 27-year-old aboriginal male, appears wearing dusty jeans, grubby long sleeved shirt, worn out riding boots and a cowboy hat. He is thin and appears much younger than stated age with long shaggy dark hair. Has tattooed fingers. Quiet and tearful. Restrictive to answer at first during interview. Cooperative and open. |
|
· Speech Form · Rate · Volume · Quantity of information · Speech Content · Disturbance of meaning · Disturbance of language |
Slow (he speaks quietly). Soft. (Quietly speaks). Monosyllabic and expansive. No disturbance of meaning or language. |
|
· Mood and Affect · Mood · Affect · Congruency |
Depressed, sad and hopeless (Indicators of suicidal thinking) tearful, anxious. Affect: Flat Appropriate congruency. |
|
· Form of Thought
|
Linear flow of ideas. No disturbance of language or meaning. |
|
· Content of Thought
|
Paranoia-Jealous about who his girlfriend. (relationship). Hopeless. Suicidal ideation- intent to harm self. Preoccupations, fear and obsession. |
|
· Perception
|
No hallucination No illusions. Decreased care to self. |
|
· Sensorium and Cognition
|
Conscious (concentrates with ability to focus and shift attention.) Memory not assessed but Recalls past events. Attentive throughout the interview |
|
· Insight & Judgment
|
Has low insight towards his mental health state. Impaired judgment as his ability to make positive decision is compromised. He engages in risky behaviors such as excessive drinking. |
|
· Risk Assessment |
Plan to harm self (as evident by suicidal ideation.). No harm to others Family history of harm to self. Vulnerable to access to high means of harm self (ropes and bush). |
Table1: The Mental Status Examination for Risk of suicide case.
Clinical Formulation Table.
|
Presenting factors |
Anxious and worried. Dramatic changes in moods (moody). Member of minority group(Aboriginal) Hopelessness-The client is hopeless about present and future. Love-The client is seemingly in love as evident by the tattoos engraved with the word ‘LOVE’ (Bolton,2015) (Turecki, & Brent,2016) |
|
Precipitating factors |
Illness- concurrent mental health disorder (depression). Age and gender-more vulnerable to suicidal plan completion in regards to age and gender factors. Stressing events-The client is worried and concern about his girlfriend. Poor appetite-lack of appetite leading to being physically thin. Recent interpersonal crisis- especially rejection Work place-can have access to lone places like forest. Recent relationship distress. (Inder et al.,2014) |
|
Predisposing factors |
School distressing events at early age Personality-stressful, the client is worried and concern about his girlfriend. Recent interpersonal crisis- Excessive alcohol drinking. Modelling- family suicidal history. Long distance relationship leading to distress. |
|
Perpetuating factors |
Genetic disposition- suicidal family history (Michel). Hopeless-feeling worthless. Self-neglected. Self-rejection-sense of self-disregard (Turecki, & Brent,2016) |
|
Protective factors |
Physical health- The client’s physical health is good. Responsive-Respond to inquiries during the clinical interview. Conscious- Awake hence can response during assessment Employment-The client loves his job. Social support-The client’s mother is concern and supportive. (Inder et al.,2014) (Fernando &Cohen, 2014). |
Table 2: showing representation of clinical for depression case.
Plans for Nursing Care
The first priority issue is managing accompanying depressive mental health disorder. Depression can increase the intensity of risk suicidal attempt ( Miché et al., 2018).Since some suicidal risk factors such as depression are amenable to intervention, I would manage the client’s current level of depression. Educating the client on mental health disorder and the appropriate care process required will empower him to actively get involved in his care, promotes the client’s sense of self-regard and help speed up the recovery process (Wilson, Crowe, Scott & Lacey, 2018). I would also ensure close observation and effective collaboration with client’s and other healthcare providers by developing effective working relations to enable gaining of pertinent information (Stovell, Morrison, Panayiotou, & Hutton, 2016.
Multiple risk factors of suicide is another issue. Many risk factors present in my client increases the chances of suicide attempts (Choi, Lee, Yoon, Won, & Kim,2017) hence assessment of all the risks in regards to my client will help in alleviating the risk of suicide such as access to means to carry out a plan, in a patient-centered care manner (Epner& Baile, 2012). ). Promoting the clients’ self-control, coping and problem-solving is a crucial intervention. Suicidality can be understood as an attempt by the client to solve a problem he finds overwhelming. I would as a nurse be nonjudgmental and work with the client using good communication skills to develop alternative solutions to the problems leading to the suicidal thought, intent and behavior. These includes talking to the client to minimize discomfort or feeling of rejection by loved one (Tess). I would watch my emotions and ensure that those around him too monitor their emotions hence contributing positively to his case.
Clinical Handover
Quality clinical handover is important for ensuring flow of information to other care providers responsible for Jayan when my shift ends (Siefferman, Lin & Fine, 2012). Mental related illnesses require clinical handover like other illness diagnosed by physicians for patient management (Malla, 2015). It is my professional responsibility to provide safe handover and ensures my client’s safety (Merten, van Galen & Wagner, 2017). The synthesized report for my case would be as follow:
Jayan is 27 years old male appearing much younger than his age. His symptoms on admission are; quiet, low-mood, anxious and flat. His speech is monosyllabic at the time of interview with frequent tearful emotions. He has a reported history of depression mental disorder by a community nurse. His loss of appetite has been reported and a personality change, low self-control and excessive alcohol drinking. His physical health is good and responsive during the assessment. He seems suicidal due to self-neglect felling by a loved one and hopelessness with a family history of suicide. His coping strategies are his good physical health, good employment and love to his girlfriend. He is distressed by relationship difficulties with thought of rejection and frequent suicidal ideation. He seems motivated to carry out suicidal plan in modeling and reference to family history of self-harm as a way of solving seemingly overwhelming problem. He is more vulnerable risk of suicide hence requires immediate alleviation of risk factors to reduce the propensity for engaging in suicidal behaviors.
Part 2 Therapeutic engagement and clinical Interpretation
The Therapeutic Relationship
A therapeutic relationship with my client will be a based on professional code of conduct in such setting and mutual trust (Unhjem, Vatne, & Hem, 2018) and a caring relationship develops when we come together with my client, resulting in harmony and healing (Unhjem et al., 2018). The strategy I would use to establish good relationship with my client is engaging and building good rapport, being empathic and identify with his situation. This will foster the therapeutic alliance. I will ensure the client get involved more in his care process to achieve wellness with respect to professional best practices and boundaries (Valente, 2017). During provision of care for my client, his privacy is important. Professional code of conducts and boundaries adherence underpinned by the standards of practice will be an important aspect of the relationship (Australian College of Mental Health Nurses, 2010; Nursing and Midwifery Council, 2015)). I would also create insight on my client on his state of mental health and professionally make him more involved on the care process and oriented towards recovery (Crane & Ward, 2016). I would implement self-care strategies to mitigate the effects of the work, and to have sustainable working experience with my client (Hunter, 2016).
Cultural Safety
Culturally safe care provision by incorporating culturally appropriate assessment of suicide risk and appropriate intervention is important. Cultural factors such as self-coping and help seeking behavior that are safe and can positively affect my client will be encouraged (Walls,Hautala, & Hurley, 2014). Understanding my client’s culture is a step in championing culturally safe care. The issue worth identifying is stigmatization in relation to mental illness (Rossler, 2016). Discrimination in all levels should be discouraged and awareness created to those involved in my client’s care process. I will focus on recognizing and responding professionally to my client’s deterioration in her mental state with reference to culturally safe care provisions and good practices (Australian Commission on Safety and Quality in Health Care, 2017). I will enlighten my client and involve his family and those around him to culturally impact on his care positively (Silbersweig, 2015). I will work together with the other team to discourage any form of labeling and modelling on my client in his social space and create awareness to reduce its impact on my client’s mental health and risk of self-harm. I will also consider my client’s pertinent cultural beliefs that may be the root cause of the suicidal ideation and help him have information on cultural norms and beliefs that may pose threat to his care.
Recovery-Oriented Nursing Care
Recovery is an individual process that cannot be controlled but can be supported and facilitated at various levels (Schon, Svedberg & Rosenberg, 2015). I will professionally offer care that support quicker recovery for my client. A step forward will be understanding process of recovery, then provide professional support to ensure recovery through clinical interventions. A recovery process that focus on my client and not just symptoms will be ensured as suggested by studies (Jacob, 2015). Providing safe care, maintaining favorable nurse-client relationship, patient-centered care and evidence base care will speed up recovery process. A guiding principle to recovery that emphasize on hope and a strong belief that develops enhancing environment for quick recovery is my central focus (Jacob, 2015). I will use both traditional and recovery models to ensure my client recovers quickly from the mental illness (Snow et al., 2014). Understanding the client’s lived experience with shared decision making make him the expert in his own care and make it possible to tame behaviors undermining recovery process, such as worries of impeding relationship difficulties. Using multiple approaches on recovery will ensure that the client’s diagnosis, compliance, reducing risks and a focus on the client’s lived experiences, choices and self-determination to positively cope will be employed (Snow et al., 2014). The practice of my professionalism the case will be based on dignity and respect for the patient under my care. It will recognize the possibility of recovery and wellness, self-determination and self-management of mental health and also helps the family to understand and support their loved one (Cavanaugh, 2018). The recovery approach acknowledges that individual expectations have strong influence on behavior and outcomes hence worth applying in respect to my client to maximize recovery oriented care.
References
Australian Commission on Safety and Quality in Health Care. (2017).National Consensus Statement: Essential elements for recognizing and responding to deterioration in a person’s mental state. Sydney, ACSQHC.
Bolton, J.W. (2015).How to integrate biological, psychological, and sociological knowledge in psychiatric education: A case formulation seminar series. Acad Psychiatry, 39(1), 699-702.doi.https://doi.org/10.1007/s40596-014-0223-7
Cavanaugh, S. (2018). Recovery-Oriented Practice. Journal of Mental Health and Addiction Nursing, 2(1), 28-30. doi: 10.22374/jmhan.v2i1.27
Choi, S. B., Lee, W., Yoon, J.-H., Won, J.-U., & Kim, D. W. (2017). Risk factors of suicide attempt among people with suicidal ideation in South Korea: a cross-sectional study. BMC Public Health, 17, 579. https://doi.org/10.1186/s12889-017-4491-5
Crane, P.J., &Ward, S.F. (2016).Self-Healing and Self-Care for Nurses.AORN Journal, 104(5), 386-400.doi:doi:10.1016/j.aorn.2016.09.007
Epner, D.E., Baile, W.F. (2012).Patient-centered care: the key to cultural competence.
Annals of Oncology, 23(3), 3–42.doi:https://doi.org/10.1093/annonc/mds086
Fernando, I., Cohen, M. (2014).Case formulation and management using pattern-based formulation (PBF) methodology: Clinical Case 1.Australas Psychiatry, 22(1), 32-40.doi: https://doi.org/10.1177/1039856218789785
Hunter,L.(2016).Making time and space: the impact of mindfulness training on nursing and midwifery practice. A critical interpretative synthesis. Journal of Clinical Nursing, 25(7-8), 918-929. doi:doi:10.1111/jocn.13164
Inder, K. J., Handley, T. E., Johnston, A., Weaver, N., Coleman, C., Lewin, T. J.,… Kelly, B. J. (2014). Determinants of suicidal ideation and suicide attempts: parallel cross-sectional analyses examining geographical location. BMC Psychiatry, 14, 208. https://doi.org/10.1186/1471-244X-14-208
Jacob, K.S. (2015).Recovery Model of Mental Illness: A Complementary Approach to Psychiatric Care. Indian J Psychol Med, 37(2), 117-119.doi:10.4103/0253-7176.155605
Malla, A. (2015).Mental illness is like any other medical illness: A critical examination of the statement and its impact on patients care and society. Journal of Psychiatry and Neuroscience, 40(3), 147-150.doi:https://ispub.com/ljANP/1011/7218
Merten, H., van Galen, L. S., & Wagner, C.(2017). Safe handover. BMJ, 359, j4328. https://doi.org/10.1136/bmj.j4328
Miché, M., Hofer, P. D., Voss, C., Meyer, A. H., Gloster, A. T., Beesdo-Baum, K., & Lieb, R. (2018). Mental disorders and the risk for the subsequent first suicide attempt: Results of a community study on adolescents and young adults. European Child & Adolescent Psychiatry, 27(7), 839–848. https://doi.org/10.1007/s00787-017-1060-5
Rossler, W. (2016).The Stigma of Mental Disorder: A millennium-long history of social exclusion and prejudices. EMBO rep, 17(9), 1250-1253.doi:10.15252/embr.201643041
Schon, U.K., Svedberg, P., & Rosenberg. (2015). Evaluating the INSPIRE measure of staff support for personal recovery in a Swedish Psychiatric context. Nordic Journal of Psychiatry, 69(4), 275-281.doi:10.3109/08039488.2014.972453
Silbersweig, D.A. (2015). Bridging the brain-mind divide in psychiatric education: The neuro-bio-psycho socialformulation.
AsianJPsychiatr,17(1),122-123.doi:https://doi.org/10.1016/j.ajp.2015.08.020
Siefferman, J., Lin, E., & Fine, J. (2012). Patient Safety at Handoff in Rehabilitation Medicine. Physical Medicine and Rehabilitation Clinics Of North America, 23(2), 241-257. doi: 10.1016/j.pmr.2012.02.003
Stovell, D., Morrison, A., Panayiotou, M., & Hutton, P. (2016). Shared treatment decision-making and empowerment related outcomes in psychosis: Systematic review and meta-analysis. British Journal of Psychiatry, 209(01), 23-28. doi: 10.1192/bjp.bp.114.158931
Snow,N.,Meadus,R.,Marie,A.A.,Budden,F.,Kirby,B.,Reid,A.(2014).The Benefit of Using an Interprofessional Education Model in an undergraduate Mental Health Course, Canadian Collaborative Mental Health Care Conference,retrieved from https://www.shared-care.ca/files/1J_-_Benefits-of-Using-an-Interprofessional-education_(Snow).pdf
Unhjem, J.V., Vatne, S., & Hem, M.H. (2018).Transforming nurse-patient relationships-A qualitative study of nurse self-disclosure in mental health care. Journal of Clinical Nursing, 27(5-6), e798-e807.doi:doi:10.1111/jocn.14191
Valente, S.M. (2017). Managing Professional and Nurse-Patient Relationship Boundaries in Mental Health. Journal of Psychosocial Nursing & Mental Health Services, 55(1), 45-51.doi:https://dx.org/10.3928/02793695-20170119-09
National Suicide Prevention Lifeline. (2015).Youth. Accessed September 25, 2018, at https://suicidepreventionlifeline.org/help-yourself/youth/
Nursing and Midwifery Council. (2015) .The Code: Professional standards of practice and behaviour for nurses and midwives. Accessed September 30, 2018, at https://www.nmc.org.uk/globalassets/ sitedocuments/nmc-publications/nmc-code.pdf
Walls, M. L., Hautala, D., & Hurley, J. (2014). “Rebuilding our community”: Hearing silenced voices on Aboriginal youth suicide. Transcultural Psychiatry, 51(1), 47–72. https://doi.org/10.1177/1363461513506458
Wilson, L., Crowe, M., Scott,A., Lacey,C.(2018).Self-management for bipolar disorder and the construction of the ethical self. Wiley Online Library, 25(3):e12232. doi: https://doi.org/10.1111/nin.12232
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