Nursing Care Plan P.12-14 Essay Examples
Introduction p. 3
Part One p. 3-8
Part Two p. 8-12
Conclusion p. 14-15
Bibliography p. 16
This essay will discuss the role of a mental health nurse in risk assessment and management and developing recovery strategies for the patient, Hilary. Also, the relevant risks both psychologically and physically are identified during preparation for discharge by the role of the Community Psychiatric Nurse (CPN) and other professionals involved in her care. It will demonstrate a systematic understanding of the significance of mental health interventions in addressing the needs of people with mental health problems. It will go on to critically discuss a discharge package, community support services available, and nursing and psychosocial interventions on discharge. Treatment options for depression will also be discussed.
Two areas need to be addressed for the purpose of this essay. Initially, it is necessary to discover and critically analyze assessment strategies. Second, the nursing care and evidence-based interventions must be developed for patient assistance.
2. Part One:
People with depression are at significant risk for suicide. Research has identified several factors associated with an increased risk for depression including gender, age, stress, alcohol and social circumstances. Depression often runs in families, suggesting a genetic component. Disturbances in body chemistry are triggered by disease and illness, traumatic stressful events such as bereavement, retirement, work, relationship problems, or financial issues.
In Hilary’s case it is important to carry out a risk assessment of her clinical presentation. The first step in the risk assessment is in relation to her depression. By establishing her mental health history it is possible to determine the sources for her current depressive condition. Other risk issues for suicide have been recognized and should be considered when assessing depressed person. It should be noted that a family history of self-harm and/or suicide is significant. Hilary did relate to me that she had battled depression for years but felt she had made little progress. Her lack of expression except when crying a little substantiated this information. Hilary has no history of attempted suicide, but she spoke to me about being” so tired I just want to give up”.
When carrying out an assessment the nurse establishes a therapeutic relationship with Hilary by using informal interviews; the use of Core Communication Skills are helpful (Morrissey & Callaghan 2011). These include effective listening, paraphrasing and reflecting, summarizing, and effective questioning techniques; these are a choice of opened ended or closed questions. Egan (2006) identifies non-verbal skills in the acronym SOLER and states that using them can help the mental health nurse to make the therapeutic space and tune in to what the patient is saying. The acronyms stand for Sit, use an Open posture, Lean forward, make Eye contact, and Relax. These skills not only help create a relationship with the patient, it allows the nurse to be comfortable in the process. Many patients can sense when a healthcare professional is tense or lacks confidence and these skills can create confidence in the nurse. The author felt an ability to establish a modicum of a relationship with Hilary useing the steps, but she remained distant throughout the interview and did not respond in a positive manner to my attempts to smile or make eye contact.
The first task is to ask consent and tell her the reason of interview. The consent needs to be in the form of a written signature kept in the patient’s chart. Many times, psychiatric patients become paranoid and deny they gave permission for treatment. It may be wise to have another staff member initial the signature with the nurse to double-verify permission was granted. We also explain to Hilary that everything discussed is confidential and it will be only shared with health care professionals who are involved with her care. This will help with building confidence and create a comfortable environment where Hilary will feel less scared and observed.
When undertaking the risk assessments for Hilary there are numerous procedures, sources, diagnostic tools and methods that nurses use to gather information. In Hilary’s case, a nurse would use Beck’s Depression Inventory (Beck 1961) as a diagnostic tool to measure the severity of Hilary’s depression. It assesses the presence of depression signs, symptoms, and cognitions such as loss of loved ones, feelings of suicidal thoughts, hopelessness, physical symptoms of tiredness and weight gain, and loss of interest in social activities (WHO 2010). It is also important to ask Hilary to grade her mood using a Likert scale. On the scale of 1-10, 1 is low, 5 is average, and 10 is elated. The results of the evaluation should be carefully recorded in Hilary’s chart and compared with additional evaluations in the future. This is a good indicator of her mental state and can be correlated with any future problems that arise. For instance, if a family member reports Hilary is misusing medication, the results of the Likert scale should indicate changes in mood and serve as an indicator in the future that she is not compliant with her care plan.
Using tools such as these are beneficial because they serve as a reliable diagnostic measurement for depression severity. This evidences the presence of cognitive triad and allowing the nurse to analysis the link between Hilary’s depression severity and suicidal risk factors. These factors are historical (self-harm past and present) and the seriousness of the suicide attempts before admission. Hilary told the author her family does not have a history of suicide and, although she has thought about it, she has made no attempts at self-harm. However, when speaking with a family member, the author was informed her grandfather died in a manner that was suspicious of suicide.
Hilary admits to drinking more alcohol recently. The Department of Health (Gov.UK 2015) recommends women should not exceed the daily recommendation of 2-3 units of alcohol. It states drinking above this recommendation on a regular basis can significantly increase the risk of ill health. Furthermore, alcohol compromises decision-making and increases aggression and violent behavior. This contributes to risk-taking behavior. Barker and Buckley (2011) state alcohol ingestion frequently accompanies depressed behavior. There are also the withdrawal symptoms to contemplate. Severity can be mild, such as sleep disturbances or anxiety, or more severe. They can include life-threatening symptoms such as delirium, hallucinations and autonomic instability.
Considering this, a nurse is immediately concerned as to whether Hilary is suffering from alcohol withdrawal. If so, a nurse would first assess the severity of Hilary’s alcohol intake using “The Alcohol Use Disorders Identification Test – AUDIT” (Babor et al. 2001) to establish the severity and frequency of her alcohol consumption. The nurse would also use observational assessment skills to detect the presence of any primary alcohol withdrawal symptoms. These include shaking, sweating, and increased anxiety as well as complaints of headache, nausea, or vomiting. The use AUDIT is beneficial because it educates the patient of the risks associated with consuming alcohol as well as acting as a diagnostic tool. It may indicate the need for the patient to enter an alcohol detoxification program. Hilary told the author she does drink excessively on occasion and did so a little over a week ago. While she exhibits mild symptoms of withdrawal, she does not appear to be in delirium tremens.
A CPN noticed that Hilary has been difficulty of breathing and coughs a lot. She also has a history of heavy smoking. The Department of Health (Gov.UK 2015) states smoking cigarettes can have harmful effects for the body. Smoking cigarettes has become socially acceptable, but education in the effects of smoking is crucial for informed decisions by patients to continue.. Cigarettes contain 250 chemicals that are considered poisonous and 70 considered carcinogenic. Smokers have a risk 2 - 4 times higher than non-smokers for coronary heart disease and stroke, 23 times higher for lung cancer in men and 13 times higher for lung cancer in women, and 12 - 13 times higher for death related to congestive obstructive pulmonary disease. Addiction to smoking is indicated when the patient recognizes she needs to stop and would like to, but cannot. Programs are available free through government programs to assist patients to quit the tobacco habit.
Smoking in any form damages practically every organ in the body, leading to illness and reducing well-being. The physical effects of smoking include reduced lung function, permanent damage to the lungs, increased lung infections, coughing, irritation in the wind pipe and voice box, increased risks of heart attack due to blood supply blockage, reduced blood flow, reduced bone thickness, gum disease, and cancer (Mayo 1999)
It is crucial to obtain a complete medical and family history. During the history of her current illness Hilary presented with chest symptoms, difficulty of breathing, recurring respiratory infections, exercise intolerance and cough. Assessment of Hilary’s past history at attempting to stop smoking address the length of smoking cessation, difficulties with former attempts, number of previous attempts, and causes for relapse. Nurses should also include a physical health assessment as there may be serious concerns regarding her health. Collins et.al (2013) state that physical health assessment methods are a significant part of the risk assessment procedure.
There are numerous ways to monitor and observe Hilary’s physical health. The easiest process is physical tests; for example, measurement of vital signs, height, weight, and urinalysis (Collins et.al 2013). The rate, depth, and beat of the Hilary's breathing should be monitored. These are simple and useful methods of physical health assessment, providing a good understanding of Hilary’s wellbeing. For instance, monitoring blood pressure can make the nurse aware that Hilary may suffer from hypertension. Similarly, it ought to show valuable information to the Multi-disciplinary team (MDT) to establish baseline outcomes to monitor and observe for signs of worsening.
3. Part Two:
In expectation of Hilary’s discharge the nurse may look at her discharge folder as suggested by standard 4 of the National Service Framework (NSF). The NSF inspires the incorporation of care with other health care professionals and crisis resolution teams (Gov.UK 2015). According to the government care program approach (CPA) document (Gov.UK.org 2012), care plans for severely mentally ill service users ought to comprise urgent follow-up within the first week after hospital discharge. Consequently, prior to discharge the nurse needs to send information to Hilary’s general practitioner (GP) who will continue to see Hilary in the community.
Discharge should be included in the nursing care plan. The MDT needs to efficiently accomplish the switch from hospital to community, as this is a crucial period patients frequently find worrying and disturbing. Accordingly, the risk assessment needs to be performed again. To reduce risk and deliver continuity of care, the MDT needs to be mindful of the situation Hilary entering on discharge. This will involve the MDT making connections with community practitioners and involve Hilary and her family in planning future care and treatment.
Patients should be informed how best to contact them in between appointments should an emergency arise. The nurse should encourage them to let staff know if they feel worse or have increased urges to act upon their suicidal thoughts. Patients should also be given details of who to contact out of hours when staff are not available. Where appropriate, reception or administrative staff may need to be alerted that a patient should be prioritized if they make contact. When a patient is at risk of suicide this information should be recorded clearly in the patient’s notes. When the clinician is working as part of a team it is important to share awareness of risk with other team members. Out-of-hours emergency services need to be able to access information about risk easily. It is advisable to be open and honest with patients about concerns regarding the risk of suicide and to arrange timely follow-up contact in order to monitor their mental state and current circumstances.
The CPN should talk to Hilary and let her know about essential preventive measures to take to keep her safe and she should be involved in her care planning. This will build Hilary’s confident and control which is a significant part of recovery. This also shows the nurses’ importance and concern in her care and delivers a chance for nurses to encourage Hilary to express her feelings (Eby and Brown 2009). The CPN should encourage Hilary to carry out self-care and point out any improvements Hilary’s condition; for example, sleeping and eating patterns as she may be unable to recognize them. The CPN should encourage Hilary to take part in art, drama or occupational therapy liaises with fellow professionals in the community (RCP 2012).
Risk of suicide can fluctuate so the Community Mental Health Team (CMHT) needs to continually monitor records accurately and report any changes in Hilary’s mood and behavior. Immediate changes in behavior or mood such as withdrawal is linked with increased risk of suicidal thoughts. Likewise, the CMHT needs to be aware of behaviors; for instance, discussion about death, concealment of objects which could be used to self-harm, and decreased communication (verbal and non-verbal). These can indicate Hilary’s decision to commit suicide (Schultz and Videbeck 2013).
Hilary has lost interest in cooking, does not socialize with her friends, and admits to drinking more alcohol recently. Shephard (2002) states that an individual suffering from depression is likely to typically neglect their appearance or perhaps use illegal substances. She may show misuse withdrawal and inertia so the CPN needs to talk with Hilary and attempt to encourage her to find ways of increasing her activities of daily living. The CPN also need to make a care plan together with Hilary and encourage her to contribute to her activities of daily living. Author has had experience with patients suffering from depression frequently neglecting their appearance. However, with encouragement and reassurance they will attend to their personal care.
Hilary has a history of heavy smoking. The nurse needs to make sure Hilary is sufficiently supported in the community to help her smoking cessation, increase her understanding of the effects of smoking, provide her with up-to-date health and wellbeing educational literature, and give her advice to enable her to make informed decisions. The author has noted in the clinical setting that many patients suffering from depression neglect personal hygiene. However, with encouragement and reassurance, they may adjust their behavior.
Hilary has started drinking alcohol after discharge from the hospital. The Royal College of Psychiatric (RCP 2013) states alcohol abuse affects the chemistry of the brain and increases the risk of depression. The guidance suggests motivational interviewing (MI) (Miller and Rollnick 2002), twelve step facilitation therapy (Alcoholics Anonymous 2010), social behavior, network therapy, and coping and skills training as the key interventions. The nurse could have used MI to attempt to address any residual feelings about wanting to change her behavior as far as abstaining from alcohol when discharged and engage her regarding their social situation.
The National Institute for Clinical Excellence states that no drug treatment is suggested for mild depression as the individual frequently gets better without intervention (NICE.org.UK 2009). However, patients should be offered additional assessment. Healy (2005) proposes that structured routines and physical activity along with a healthy diet and ample amount of sleep might be enough to clear up the depression. The author has experience with this type of intervention therapy and it has proven to be effective. The nurse/patient relationship can be an effective way to assist the patient in changing behavior as they struggle with alcohol and drug addiction.
The National Institute for Care Excellence recommends the first-line of pharmacological treatment for moderate to severe depression is selective serotonin reuptake inhibitors (NICE.org.UK 2004). A further important constituent of pharmacological treatment is side-effect management. The nurse needs to explain to Hilary the side effects of antidepressants to reduce any potential adverse effects. Since Hilary has been prescribed antidepressants, there is a possibility she will have an increase in suicidal thoughts. It is important for staff members and the patient to be aware of potential side effects of antidepressant medication. These include constipation, nausea, irritability, fatigue and drowsiness, loss of sexual desire and other sexual problems, such as erectile dysfunction and decreased orgasm, anxiety, increased appetite and weight gain, insomnia, increased appetite and weight gain, blurred vision, agitation, increased appetite and weight gain, dizziness, dry mouth, and blurred vision. Some side effects will disappear within a few weeks, but if they don’t the physician may opt for another medication.
Studies have revealed that cognitive behavioral therapy (CBT) combined with anti-depressant medication can help individual to cope well with depression. Antidepressants increase the serotonin level in the brain which transmits electrical impulses from one nerve to another (Blows 2003). The author has noted the drugs can take up to three weeks before taking effect. This should be included in the education to the patient for her drug therapy. The nurse could use CBT to help Hilary improve coping strategies to deal with her depression in conjunction with the drug therapy. She could also help her learn more realistic and adaptive interpretations of events, reducing the stress triggered by her delusional beliefs.
Counseling therapy has also been shown to be effective in reducing depression. Counseling can help individuals sort out conflicts and practical problems, and help them recognize the causes for their depression. Ingram (2009) claims that some of the roles and responsibilities of the nurse in counseling the patient include encouraging and reassuring the patient to express their feelings. They should demonstrate warmth, authenticity and understanding to the patients, building a therapeutic relationship with the depressed patient. Helping these patients recognize their strengths and supporting them appropriately are important tasks for the nurse.
Hilary is overweight, which can be measured in several ways. One useful measure is the body mass index (BMI). Based on height and weight, it approximates the amount of body fat present. Hilary’s elevated BMI can cause several health conditions such as hypertension, difficulty breathing, increased risk of heart attack, and diabetes (Nash 2010). Increasing physical activity is vital in maintaining weight loss (Gov.UK 2014) and it also benefits mood or behavior and general mental health. Studies have shown patients diagnosed with severe mental illness are at an increased risk for obesity. Factors such as poor diet and lack of exercise contribute to weight gain, but it may also be a side effect of some psychotropic drugs. These include Zoloft, Paxil, Lexapro, and Paxil. The author noted weight gain in patients taking antidepressants while in clinical practice. The nurse can help Hilary better manage her weight by promoting activities such as physical exercise and eating a healthy diet. Nurses ought to inform Hilary about resources available such as a gym or they can ask the gym instructor to come and speak to Hilary about their services.
4. Nursing Care Plan
A. Nursing Diagnosis: Risk for self-directed violence. Behavior demonstrates patient can
harm herself sexually, emotionally, or physically. Risk factors are severe depression with
an emotional state of suicidal ideation.
B. Ineffective coping devices. Patient demonstrates an inability to form appropriate concept
of stressors and choices of responses. She has a history of failure to use available
resources. She demonstrates lack of goal-directed behavior and problem resolving. She
has a history of misuse of drugs and inability to sleep. She doesn’t use social support and
experiences problems concentrating.
C. Nutrition less than required by the body. Patient is eating an excess amount of
nutrients to meet her metabolic needs. Although she demonstrates a lack of interest in
eating and states she has an inability to eat secondary to psychological factors, when she
does eat the food is not healthy and high in calories. Dietary counseling can assist in her
appropriate choice of food.
D. Possible alcoholism. Risk factors include family history, genetics, and depression.
alcohol intake, and body chemistry. A score of 8 or higher on the AUDIT scale indicates a
high possibility of alcoholism. Treatment includes intervention, detoxification,
rehabilitation, and medications.
E. Possible COPD. The diagnosis is made on inability to clear the airway related to increased
secretion production. Airflow limitation is not completely reversible. The disease is
generally progressive and associated with lung inflammation caused by irritants. Teach
patient postural relief options to allow gravity to assist with respirations. Keep
environment dust- and smoke-free to prevent trigger of an acute episode. Encourage
pursed lip breathing exercises to control dyspnea and teach improved coughing techniques
Provide supplemental humidification to reduce secretion viscosity and allow for
In the case of a potentially suicidal patient like Hilary, the steps for treatment the nurse takes are based on the findings and orders of the doctor. Nurses are required to have a thorough knowledge of the mental and physical aspects of patients to plan and carry out treatment effectively. Hilary requires a suicide plan, assistance in stopping smoking, education in the possible side effects of her antidepressant medication, and help connecting with community sources for support programs. In addition, the CPN needs to develop a follow-up plan to assure Hilary is compliant. Calls to confirm appointments and keeping a current list of contact information is important. This list should also include several friends or family if it becomes difficult to contact Hilary personally. In the event she begins drinking heavily, misusing medications, or has a crisis for self-harm or suicide, she may not contact assistance. It is crucial for the CPN to work with multiple teams to address Hilary’s health issues and provide her with a better future.
There was a time in history when patients exhibiting mental disorders and abuse of drugs and alcohol were left to fend for themselves. Their health would decline to the point where they would die or be placed in institutions to protect the public. Treatments for depression were frequently forms of torture and medications to treat the symptoms were not yet discovered. Today, counseling with therapeutic activities and antidepressant medication help patients like Hilary live full and productive lives.
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