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This assignment is a client-focused study based on the four stage nursing process- assessment, planning, implementation and evaluation. After a brief introduction to the client and clinical setting I shall provide evidence of a comprehensive mental health assessment, discussing both the formal and informal techniques employed. Through this assessment and in collaboration with the client a specific need was identified and highlighted for intervention.
After justifying my choice of intervention, based on the current evidence available, I shall move on to the application of the intervention itself, paying particular emphasis to the skills needed by the nurse for an effective working. The principle area covered by this assignment is the use and efficacy of Cognitive Behavioural Therapy (CBT) when applied to the positive symptoms of psychosis. In particular I shall be concentrating on coping strategies aimed at reducing the negative impact that some of the clients auditory hallucinations created.
Finally I shall evaluate the intervention discussing whether it was efficacious or not. Throughout the assignment I have placed particular emphasis on collaborative working with the client, and have as far as possible attempted to respect and incorporate their views and opinions. Confidentiality has been maintained at all times in deference to the NMC Code of Professional Conduct (2002). The Client The client is a forty-two year old male with a diagnosis of schizophrenia.
Planning Nursing Process
Schizophrenia is a condition characterised by both positive and negative symptoms. Positive symptoms include delusions, hallucinations, disorganised speech/thought, and grossly disorganised behaviour. Negative symptoms include affective flattening, alogia and avolition (Fortinash & Holoday Worret 2003). The DSM IV Diagnostic criteria for Schizophrenia states that two (or more) of the above must be present for a ‘significant period of time’ during a one month period for a diagnosis to be made.
The client under study experiences auditory hallucinations, hearing both benevolent and malevolent voices at differing times, and possesses little insight into the nature of his condition, ‘I’m not ill it’s just chemicals in my brain’. As a consequence his compliance with taking his medication is poor. His current admission is due to an increase in symptomology caused principally by a reduction in the effectiveness of his prescribed medication. As a result he has been started on a regime of the anti-psychotic drug Clozapine.
The client has been known to local services for around six years when he was forced to leave his job due to the increasing severity of his illness. Apart from an initial assessment on admission the client had recently undergone a KGVM assessment by the Psychology department, and was awaiting the results. The Environment The ward on which the client is based is a twenty-one bedded all male acute psychiatric unit converted some years previously from its initial function as a ward for the elderly.
It consists of three dormitories- two six bedded and one seven, and two single bedded side-rooms, primarily used by clients who are deemed most unwell. The dormitories and side-rooms occupy three sides of a wide communal area which also doubles as the dining room. A television room and smoking lounge complete the picture along with a small ‘quiet’ room for therapeutic usage. Along with the physical environment it is also important to understand the milieu or social surroundings that impact on staff and clients alike.
The unit in question has a full complement of staff of varying degrees of experience from ‘D’ to ‘H’ grades. The clients themselves also have a mix of illnesses, bi-polar disorder, depression, personality disorder and schizophrenia. The atmosphere is generally pleasant and clients are allowed the freedom to express themselves openly within certain boundaries concerning safety, both their own and that of others. I shall discuss the environment and its possible impact on therapy more fully in the section on evaluation. Assessment
During this section of the assignment I shall be addressing the following: – What is assessment and what is its purpose? How do we assess and what tools do we use? I shall then provide evidence of a comprehensive mental health assessment of a client in practice before prioritising and highlighting a specific need and giving my rationale for this. Due to constrictions of space I have not gone too deeply into the evidence base behind the formal assessment tools used in practice. I am however fully aware of the importance of a tool being valid and reliable in order for it to be of any real use.
The client had already undergone a complete bio/psycho/social assessment on admission and his physical health in particular was being closely monitored due to the possible unpleasant side-effects of Clozapine i. e. a destruction of white blood cells resulting in possible death. As a matter of Trust policy all clients on the unit undergo a weekly ‘risk assessment review’ along with continuing informal daily assessment and as such I have concentrated almost exclusively in this section on the psychological and social aspects affecting the client’s condition.
What then, is assessment? Mosby’s Nurse’s Pocket Dictionary defines it as ‘1. An appraisal or judgement made about a particular situation or circumstances. A stage of the nursing process involving the collection of information and data relating to patients and their healthcare needs. 2. A test of measurement or competence’ (Mosby 2002,p. 31). Thompson and Mathias (2000) confirm this definition and add that assessment must not be seen as just the initial stage of a process but should be an ongoing and integral part of its entirety.
Fortinash and Holoday Worret (2003) see assessment as the means by which the nurse gathers the relevant information from a myriad of sources. The most important source of all being the client themselves (Wilson & Kneisl, 1996). Why though, do we assess? The purpose of assessment is manifold but is essentially undertaken to identify risk and highlight general problem areas in order to provide a platform for possible future intervention (Hinchliff et al, 1998). Assessment should be comprehensive and cover the biological, psychological and social spheres of an individual’s life.
Apart from identifying negative areas such as problem and risk, a good assessment should also highlight a clients strengths and motivation. This knowledge is of particular importance when applying cognitive and behavioural interventions (Thompson & Mathias, 2000). The therapist can utilise the client’s strengths to motivate them and increase their self-worth. Ultimately, assessment allows us to determine appropriate intervention strategies to meet the client’s needs and provide a baseline against which future assessment may be gauged (Wilson & Kneisl, 1996).
Perhaps a more cynical but nevertheless very real reason for assessing clients is that the nurse is obligated to. Mental Health Trusts unquestionably view assessment as a legal requirement, and at all costs wish to avoid any litigation. The government through the NHS have also emphasised the importance of assessment in Mental Health services. Consequently, assessment forms an integral part of Standards four and five of the National Service Framework: Mental Health (1999), that deals with people with severe mental illness. How then do we assess? There are a number of ways in which the nurse may assess the client.
Formal assessment tools are widely used and can range from a Trusts and wide in scope admission form to more specific and highly detailed tools which may only cover a particular symptom or aspect of a clients illness e. g. PSYRATS – Psychotic Rating Symptom Scale (Haddock et al 1999), which focuses on the delusions and hallucinations of people experiencing psychosis. Why use these standardised assessment tools? Apart from the more general reasons for assessment outlined above standardised tools provide additional aid to those connected with the process.
Thompson and Mathias (2000) state that assessment tools may be used for a variety of reasons and it is important for both the nurse and client to be aware of there usage in order to make the process effective. Apart from clinical audit and quality monitoring the tools can also be useful in the collection of research data and as a focal point for therapeutic interaction, providing the client and members of the MDT with a base reference useful to both (Thompson & Mathias 2000). Assessment tools provide a structure for both questioning/interviews for the nurse and the client.
This can often be helpful where difficult or awkward questions may be embarrassing for either the client or nurse e. g. questions around the issue of sexuality. Also the fact that the questions are written down gives the client some indication that this is standard procedure and not something personalised (Fortinash & Holoday Worret 2003). On an equally practicable level standardised tools also assist the nurse by acting as a reminder to ask all the relevant questions, some of which, if there are many, they might otherwise forget.
The omission of an important question at this stage of a clients care could have serious ramifications further down the line when an intervention package is being formulated (Wilson & Kneisl 1996). Formal interviews are another useful method of assessment. This type of interview usually takes place when the client is first admitted to the unit and is comprehensively broad in scope. Hinchliff et al (1998) claims that the inherent flexibility of this type of assessment is more meaningful and useful to both the client and nurse than is often the case with standardised tools.
Through the therapeutic use of self and interpersonal techniques the nurse may be able to encourage the client to discuss areas that a more formal tool might miss. An equally important area of assessment is the constant day-to-day, minute-by-minute assessment that takes place on an informal basis. This includes such things as simply observing the client, their posture, gait, speech etc, but always in an unobtrusive manner so as to respect the client’s privacy.