Alex is 75 years old and was diagnosed with dementia 5 years ago. He lived at home with his wife Ruth, who has recently died; currently he lives with his daughter and her family.
Alex has become increasingly aggressive and restless since moving in with his daughter's family and they are all struggling to cope with this behaviour.
Recently Alex was found wandering the streets looking for his wife and claiming that people whom he did not know had kidnapped him. His family had reported him missing but when he was found by the police he refused to go back home. He did agree to go into hospital and on this basis was admitted to a “dementia” ward for further assessment. The student nurse with support from their mentor has been asked to assess Alex.
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(a) Why is communication within mental health nursing practice so important?
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Correct answer: A mental health nurse when working with Alex and his family is professionally expected to be an effective communicator, which includes being compassionate. The therapeutic relationship in mental health care is both the medium for treatment as well as in most cases the main treatment. Being an effective communicator gives the mental health nurse a platform on which to deliver a range of psychological interventions tailored to meet the specific needs of Alex and his family.
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(b) What is the role of the therapeutic relationship when delivering mental health nursing care?
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Correct answer: The therapeutic relationship is of central importance in the delivery of safe and effective mental health nursing interventions. These interventions where possible should be evidence-based and they should also take into account Alex's narrative. The mental health nurse is required to build a therapeutic relationship that acknowledges Alex's diversity and at the same time delivers positive therapeutic outcomes. The therapeutic use of self is crucial within the process of developing a meaningful and positive therapeutic relationship with Alex.
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(c) Why is the assessment process so important?
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Correct answer: The assessment process is a fundamental part of mental health nursing practice. On this basis the student nurse aims to establish a working understanding of Alex's situation. This process is not a one-off; it is an ongoing process, built on partnership working, which starts with Alex's admission to services and continues until Alex is discharged from the ward.
As Alex's care journey will potentially cut across a number of care settings so it is crucial that assessment information seamlessly follows Alex throughout his journey.
Information gathered from the assessment process will be the first step in planning and delivering Alex's care, to ensure that this care is effective. Then the mental health nurse needs to collect the right information by having excellent assessment skills.
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(d) How is risk managed within the context of the therapeutic relationship?
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Correct answer: Clinical risk within mental health nursing practice tends to be viewed as the potential of the mental health service user to pose a risk to self and/or others. Risk management in this context needs to be partnership focused; it also needs to be systematic. This process will be dynamic in nature as levels of risk can change quite quickly and at times it can be controlling especially where risk is managed through the use of legally restricting an individual's freedoms.
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(e) Why is it important for the mental health nurse to understand the diagnostic process?
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Correct answer: Mental health disorders are specified through a diagnostic process that is supported by internationally agreed frameworks or classification systems. Diagnoses do not fit as easily into the practice of the mental health nurse as it does for the psychiatrist.
A fundamental problem with this approach for mental health nurses is that classifying or applying labels is not holistic enough to identify all the needs of mental health service users. However, mental health nurses have to be able to understand and work with this approach as diagnosis and classification is a fundamental form of communication used throughout mental health care.
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(f) How can understanding the diagnostic process complement the care delivery process?
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Correct answer: Mental health nurses will have the greatest amount of direct contact with Alex. This unique position should shape the care the mental health nurse delivers. The knowledge generated from being in this unique position must be used to complement the information gathered from the diagnostic process. Using a psychiatric diagnosis on its own provides only limited information as it does not tell the mental health nurse how to support Alex at a person-centred level.
On this basis the nurse needs to pay attention to Alex's narrative and deliver any subsequent interventions through a collaborative and therapeutic relationship. These interventions should be:
- underpinned by psychological methods and theory;
- clinically effective and where possible evidence-based;
- person-centred;
- focused on considering values and meanings.
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(g) What kind of mental health nursing interventions should the nurse deliver?
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Correct answer: When nursing Alex it is important to consider that the environment has a significant role to play in keeping Alex well. Changes to an environment can compensate in part for reduced sensory, cognitive and motor ability. It is also important to ensure that Alex's physical needs are not neglected. Depending on the skill of the nurse the types of interventions the nurse could deliver are:
- Establish a therapeutic relationship based on a person-centred approach.
- Provide tailored support that focuses on assisting Alex to meet his physical needs.
- Work on improving cognitive ability including memory.
- Reduce disorientation through memory prompts both verbal and environmental.
- Be empathetic to the emotional context and meanings of Alex experiencing memory loss and confusion.
- Provide behavioural strategies that positively modify challenging behaviour.
Consider Chapters 1, 2, 11, 12, 13 and 23.
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(a) What other symptoms of an acute confusional state may Alex be experiencing?
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Correct answer:
- memory problems;
- language disturbances;
- hallucinations;
- transient delusions;
- sleep disturbances;
- drowsiness;
- mood fluctuations;
- restlessness;
- apathy;
- sweating;
- tachycardia.
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(b) What investigations may have been carried out to determine Alex's urinary infection?
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Correct answer:
- a full and comprehensive history;
- mental state assessment;
- physical examination;
- blood tests;
- urine test.
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(c) How will Alex's acute confusional state be managed?
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Correct answer: As Alex's acute confusional state delirium has an underlying physical cause then this will be treated first; psychological interventions include:
- reduce disorientation;
- promote physical wellbeing – nutrition and physical activity;
- utilise verbal and non-verbal de-escalation techniques where required.
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(d) What nursing interventions should the nurse deliver to help manage Alex’s incontinence?
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Correct answer: The nurse may need to consider when managing Alex’s incontinence that it may be the case that if Alex could reach the toilet in time he may no longer be incontinent. While undertaking bowel and bladder care the nurse must remember to:
- wear disposable gloves and wash your hands even when wearing gloves;
- wash the person and keep the skin clean;
- use a barrier cream sparingly and preferably a cream that has a pH near to that of normal skin;
- do not use solutions with alcohol or disinfectant.
Consider Chapters 24 and 7.
