I found this particular portfolio more challenging than previous ones. The main reason for this was the fact that I was the required to actively take part in the assessment, planning, implementation and evaluation of a patients care within the service. Doing this came with responsibility that I had not had in previous placements. My preceptor had explained to me the process involved in care planning for a patient on the unit, the doctor will do the majority of the assessment, the nurse carries out the risk assessment and completes Roper Logan and Tierney nursing assessment which is the nursing model used by the Louth/Meath services.
The nurse also carries out an admission checklist. When the patient has been admitted and the nurse has gathered all the relevant information they will then incorporate the care plan. I familiarised myself with the documents, I will admit I felt a little apprehensive; I was worried I might say the wrong thing or ask the wrong question. As John had a previous history, I had been informed that he suffers severe paranoid delusions. This immediately alarmed me in the sense of communication difficulties. When John arrived on the unit by Gardai escort he was extremely paranoid and agitated.
Initially he was seen by the duty doctor who conducted the assessment (appendix “A”). The assessment took place on the unit, my preceptor and myself were present. Throughout John remained guarded and uncooperative, it was difficult for the doctor to gather information from him. This is evident in the recovery care plan section as John would not engage or answer any more questions. Assessment is the decision making process, based upon the gathering of relevant information, using a formal set of ethical principles, that contributes to an overall estimation of a person and his circumstances (Arnold & Boggs, 2007).
Throughout the assessment I was thinking how am I going to gather information from John when the doctor who has years of experience is finding it difficult. After the doctor had finished their assessment, i carried out a risk assessment which was a priority. Assessing and managing risk is a core part of the practice of all mental health nurses, regardless of whether they practice in a high security unit or in a primary care setting (Townsend, 2008).
Mental Health Nurses need to be well trained in risk assessment and management. They should work closely with clients and others to develop realistic individual care plans (Schultz, 2009). I found the risk assessment (see appendix “C”) difficult to carry out as the questions were very personal and evasive. The risk assessment is a crucial element of the assessment process (Ashby, 2006); it was in John’s best interest and the best interest of the other patients on the unit.
Before beginning I explained to John that I was going to ask him some questions, I did tell him that the questions were quiet personal but that it was in his best interest to answer them honestly as his safety is paramount to us whilst he is in our care. I began the assessment and went through each section (see appendix “C”), John did to my surprise co-operate with me on some areas of the risk assessment. He refused to answer some questions and became un-cooperative towards the end of the assessment. When asked if he had any desire to leave the unit, he said no, this was untrue.
John was in denial he told us that the Gardai did not bring him unto the unit. The decision to place him on level 3 observations was made, even though he expressed no desire to leave the unit, this judgement was made considering Johns behaviour, the nursing staff were sure that once an opportunity arose John would abscond. The risk assessment process is an integral part of a nurses role (ABA, 2000), it enables optimum care levels, values risk taking and attempts to reduce risks, though it is rarely possible to eliminate them (Forster, 2001). The next stage was to complete Roper, Logan and Tierney’s nursing assessment (see appendix “B”).
For assessing individual patient’s needs various nursing models are used, Roper, Logan and Tierney are the most widely used model in nursing (Varcarolin, 2010). Roper, Logan and Tierney’s model has been criticised in the past; it has been seen as a checklist and a very simple nursing model (Townsend, 2008). I found that a lot of the information had already been gathered throughout the assessment stage. My preceptor told me that the nurse usually fills in as much of the Roper, Logan and Tierney assessment as possible not wanting to agitate the patient any further by asking the same questions over again.
John was far too paranoid to start questioning him again, the Roper, Logan and Tierney assessment was completed by information gathered during assessment. John was orientated to the unit and shown to his sleeping area, I then carried out a property checklist. I felt very uncomfortable doing this as I was going through his personal belongings. I explained to him that this was routine with every new patient. John did sign his consent to admission which surprised me.
To be honest I felt that so far the nurse had little intervention with the patient, to me it seemed like the doctor was doing the communication. I voiced this to my preceptor; she explained that this is the case within this service. The nurse’s input is predominantly around complying a care plan for the patient. This leads into the planning stage where the care plan is developed to meet the patient’s needs. Government policy ‘A Vision for Change’ (Department of Health & Children, 2006) advocates The need for consultation with patients and nurses, in order to construct a comprehensive care plan.
It further adds that care plans should be written and agreed between all parties, and includes a time frame, goals and aims of the user, the strategies and resources to achieve these outcomes and clear criteria for assessing outcome and user satisfaction (Schultz, 2009). A good care plan requires the care planning process to be an evolving process facilitating adaptation and change. The objective for John was to reduce his delusional beliefs and to discharge home. To be honest I did think the objective was a little vague. The care plan see (appendix “D”) consisted 8 interventions which were priority for the patient’s recovery.
The care plan has to be discussed with the patient. The quality framework for mental health services in Ireland standards relevant to care planning state Service users are facilitated to be actively involved in their own care and treatment through the provision of information. This was not possible with John as he was far too preoccupied by his delusions. My preceptor explained to me that in circumstances like this, the nurse will do the care plan and go through it with the patient. I felt that the care plan was an effective one and met all of John’s needs.
A huge part of the care plan was to develop a therapeutic relationship with the patient, this involved making time each day to meet with the patient and allow them to express any concerns. In John’s case I felt it good as each day he appeared less guarded (Stuart, 1995). Medication was administered as prescribed and John was informed of any possible side effects, even though he was still extremely paranoid he did comply with his medication with some encouragement. I think that the fact that he was told exactly what medication he was being put on, what the medication is for and what to look out for in terms of side effects.
Even I was under the prejudgement illusion of how medications was handled years ago, as in patients were put on high doses of traditional anti-psychotics which left them with serious side effects. Psychiatry has moved forward it so many ways; the patient is so involved in every aspect of their care. The care plan (appendix “D”) includes leasing with the multidisciplinary team which consists of the psychiatrist, psychologist, psychiatric nurse, social worker and occupational therapist. The nurse is an essential team member in evaluating the effectiveness of medical treatment, particularly medication.
Nurses bring unique nursing knowledge and skills to the multi-disciplinary team. Being part of the multi-disciplinary was a beneficial way of communicating John’s care, for me I felt the team as a support. As I had little experience they helped me and guided me in developing a suitable and realistic care plan. In patient care I feel the involvement of a multidisciplinary team is vital, especially as a newly graduate nurse, I felt knowing what to include in a care plan was all down to knowledge and experience. John was placed on level 3 observations which means he in checked in on the unit every 15minutes.
I felt that this wouldn’t of helped his paranoia but I do understand why it was necessary to do so. The care plan is reviewed weekly, this seemed an appropriate time frame, it gave the treatment plan enough time to take effect and for us to monitor John’s progress. When care plan (appendix “D”) was completed I and my preceptor, spoke with John. We explained the care plan and asked John if he would sign it, which he did. Implementing the care plan, started immediately. Over the next 7 days, alongside my preceptor we monitored John’s progress.
As I had said earlier John was guarded and unco-operative when he was admitted but there was a massive change in his behaviour as the week progressed. Initially when I was trying to speak with John it was like trying to get blood out of a stone, I thought how am I ever going to make any sort of progress if he won’t communicate with me. I decided to try a different approach, the days are long on the unit with not much activity going on. In the dayroom there is a supply of board games, I asked John if he wanted to play one. I thought it was worth a try, and to my surprise it worked, we sat for the best part of an hour playing trivial pursuit.
John spoke throughout and it was in such a relaxed informal environment (Zastrow, 2009). So over the week that’s how I got my opportunity to speak with him one to one. The rest of the care plan was implemented and you will see that a repeat risk screen was carried out and John was taken off level 3 observations and placed on normal hourly observations. In relation to the recovery care plan (Appendix “E”), this was not completed. I asked my preceptor why this was not completed and was told it was due to John’s paranoia. Even though John’s presentation had changed later in the week, the recovery care plan was still not completed.
The recovery care plan would have included long term goals and timeframe as identified by service user. (Mental Health Commission, 2012). It involves the patient and focuses on the positive areas of their life and their own views on what they feel would improve their quality of life (Varcarolin, 2010). The evaluation was carried out 7 days after admission. It contained changes made to John’s care plan and details of progress made. The evaluation stage is important as it doesn’t just focus on past needs and how they were met, it gives an opportunity to identify and new needs that need to be included in the care plan.
Overall I do feel that the care plan was effective for John, all his needs were met. As I said before my only concern would be that the recovery care plan was not completed. I feel that I did engage well as part of the team even though feeling nervous in the beginning this was due to inexperience which I feel is understandable. I worked well with John which in the beginning of would have never believed would have happened, I utilised my communicate skills effectively and used initiative where needed. Over all I was happy with my performance.
Reference List An Bord Altranais (2000) The Code of Professional Conduct for Each Nurse and Midwife, Second Edition, Dublin, An Board Altranais (Nursing Board) An Bord Altranais (2000). Scope of Nursing and Midwifery Practice Framework. An Bord Altranais, Dublin. Arnold, E. , and Boggs, K. (2007). Interpersonal Relationships: Professional Communication Skills for Nurses. Saunders, Michigan. Ashby, C. (Dec 2006) Models for Reflective Practice: Available Nursing Practice. [online], 15(10), pp. 800-807, available: ProQuest Nursing and Allied Health Source.
A Vision for Change: Report of the Expert Group on Mental Health Policy (2006) Forster, S. (2001) The Role of the Mental Health Nurse. Nelson Thornes. p. 214-217. Guidance Document on Individual Care Planning Mental Health Services. Mental Health Commission (April 2012). Schultz, J. and Videbeck, L. (2009) Lippincotts Manual of Psychiatric Nursing Care Plans. 8th Ed. Wolters Kluwer, Lippincott Williams and Wilkins. p. 127-132. Stuart, G. W. (1995). Therapeutic Nurse-Patient Relationship in: Stuart and Sundeen (1995). Principles and Practice of Psychiatric Nursing. 5th Ed. Mosby. St. Louis, p. 187-192. Townsend M.
C (2008) Essentials of Psychiatric Mental Health Nursing; Concepts of Care in Evidence-Based Practice. Philadelphia, F. A. Davis. p. 15-30. Varcarolin, M. E. (2010) Manual of Psychiatric Nursing Care Plan: Assessment Guides, Diagnoses, Psychopharmacology. 4th Ed. Saunders, Elsevier. p. 312. Zastrow, C. and Kirst-Ashman, K. (2009) Understanding Human Behavior and the Social Environment. 8th Ed. Canada, Nelson Education Ltd. p. 443. Appendix A – Mental Health Assessment Form Appendix B – Roper Logan & Tierney Assessment Appendix C – Repeat Risk Assessment Appendix D – Nursing Care Plan & Evaluation Appendix E – Recovery Care Plan