Ellie is a 21-year-old woman who lives at home with her parents. Recently Ellie was assessed by the mental health crisis services after being referred by her GP. It was noted that since dropping out of university a year ago Ellie had become more withdrawn, preferring to spend most of her time in her room. When engaging with her parents Ellie would frequently become angry, accusing them of spying on her and on occasion she would threaten them with violence. On assessment Ellie admitted hearing voices; at times these voices were comforting and at other times quite threatening. Ellie also described feeling special, stating she could predict the future; she was also not sure that her parents were her real parents.
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(a) How would the mental health nurse collect the required assessment information?
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Correct answer: The nurse would ordinarily collect assessment information through formal assessments, which include checklists, questionnaires, rating scales, tools and structured interviews; and through informal assessment where information is collected through less formal and planned methods such as the nurse observing and interacting with Ellie. Both methods would provide the nurse with valuable information and both should have equal weight, though formal assessment tends to be viewed as being more objective and value free. The strength of using both methods is that information can be triangulated in a way that captures the whole clinical picture rather than just part of the picture. Assessment information that is effective should describe Ellie's situation, both generally and specifically; it should also identify the degree to which any identified problem has and is impacting upon Ellie's ability to function. To elicit assessment information the nurse would use a question approach that would use: open questions to scope the broad issues; probing questions to identify the specific issues; and closed questions to confirm that the nurse's understanding of the specific issues is correct.
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(b) When assessing risk what factors should the nurse consider and how would they positively manage any identified risks?
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Correct answer: When assessing risk the mental health nurse would need to consider:
- Types of risk – self-harm, neglect, to others and from others.
- How recent were the risk related incidents, how severe is the risk and what is the level of intent?
- How frequent have the risk-related incidents been?
- When do they happen, are there trigger factors, does the individual use drugs and alcohol at the same time?
- What is Ellie's understanding of the identified risks, what is Ellie's present mental state like and does Ellie have capacity?
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(c) Clinical risk management can at times lead to over-defensive practice. To ensure a positive approach is taken the nurse would:
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Correct answer:
- actively listen to Ellie's views;
- undertake action planning and make decisions collaboratively;
- thoughtfully consider potential benefits and harms when deciding on actions;
- implement decisions that involve an element of risk where the benefits outweigh the risk;
- ensure that the risk management plan is fully communicated.
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(d) Ellie is diagnosed with schizophrenia. How is schizophrenia diagnosed?
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Correct answer: A diagnosis of schizophrenia is usually assigned if at least two of the following symptoms are present for a significant portion of time within a period of one month:
- hallucinations
- delusions
- disorganised speech
- catatonic behaviour
- disorganised behaviour
- negative symptoms.
Currently Ellie can be described as displaying "positive" symptoms, which are distortions of normal functioning, such as:
- hallucinations
- delusions
- thought disorders.
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(e) When devising a care plan for Ellie, what types of psychological intervention should be considered?
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Correct answer: While managing risk the nurse should start to deliver psychological interventions that are shaped by a cognitive behavioural approach such as:
- establish a collaborative and therapeutic relationship;
- normalise psychotic experiences;
- reduce psychotic symptoms by modifying thought processes and enhancing coping strategies.
Other psychological interventions that have been found to be beneficial include interventions that:
- prevent social isolation;
- promote social functioning;
- focus on relapse prevention;
- alleviate symptoms.
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(f) Ellie is prescribed antipsychotic medication. On this basis what physical health issues might arise?
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Correct answer: A specific issue within the field of mental health is the issue of weight gain. Service users treated with antipsychotic medication are more likely to be clinically obese than the general population. This in turn can increase an individual's chances of developing diabetes and coronary heart disease. On this basis once Ellie commences antipsychotic treatment it is important that Ellie's weight is monitored regularly and action is taken where there are concerns about weight gain.
Consider Chapters 6, 11, 12 and 15.
Initially Ellie agreed to take her antipsychotic medication and has been well for over a year. Over the last 6 weeks it has been noted that Ellie has become increasingly unwell exhibiting symptoms that were first highlighted on admission to the mental health service. Ellie has also stopped taking her medication.
Subsequently Ellie attacked her mother and a decision was taken to admit Ellie to an acute mental health ward. Ellie was admitted informally to the ward but since refusing to take any medication and also refusing to stay on the ward Ellie is now on a section 3 of the Mental Health Act 1983 (amended 2007).
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(a) The ward organises care through a primary nursing approach. What other ways of organising nursing care could be used?
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Correct answer: Different models are used to organise mental health nursing care. Whatever model is used it should always aim to provide a good quality of care. At an operational level as nurses deliver the majority of this care they will organise care delivery through a number of different approaches such as:
- The task approach – the focus will be on delivering tasks such as administering medication or undertaking observations.
- The service-user allocation approach – a nurse will be assigned to care for a specific number of service users.
- The team nursing approach – a team of qualified and unqualified nurses will care for a specific group of service users.
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(b) A key issue in deciding that Ellie needed to be placed on a section relates to the judgement that Ellie did not have capacity. How does capacity relate to an individual making their own decisions?
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Correct answer: Generally individuals are presumed to have the capacity to make their own decisions when they are able to:
- understand information relevant to the decision;
- retain, use and weigh that information in the process of making that decision;
- communicate that decision.
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(c) During Ellie's admission there was an incident where Ellie was physically restrained and then placed on supportive observations – level 4. What are supportive observations?
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Correct answer: Supportive observations are part of managing risk within a ward environment. The level of supportive observations is implemented as indicated by the level of identified risk:
- Level 1, or general observation, is the minimum level of observations for all in-patients.
- Level 2, or intermittent observation, is where the service user's location on the ward is checked every 15 to 30 minutes.
- Level 3 observation is where the service user is kept within sight at all times.
- Level 4 observation is where the service user is kept within arm's length of the observing nurse.
Consider Chapters 31, 29 and 12.
