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Care planning, provision and management are essential parts of the mental health nurse’s role. Ongoing interaction and assessment of clients needs creates a basis for providing and organising care that is inclusive, effective and adaptive through evaluation and review. The creation of a framework of care established on the premise of recovery, as it is viewed in mental health terms, can not only provide for a client’s basic needs but can also allow them to continue to grow as an individual and lead a fulfilling life even in the presence of a mental health problem or illness (Hall, Wren & Kirby, 2008). This case study will explain and discuss the nursing care of an individual that has a mental health problem. A plan of care will be outlined including the reasoning and evidence base that prompted such direction. Parahoo (2006) reminds us that all nursing practice should be based on sound principles and processes that stem from reliable sources. Firstly we will look at the specifics of the scenario and set up some working premises which will then allow us to further speculate on the development and implementation of a structured care plan.
The case study is based around a 69 year old female named Simone. After recent lapses in memory, orientation and changes in mood were disclosed to her GP she was further assessed and consequently diagnosed with early onset dementia. Simone lives with her 40 year old daughter in a semi detached bungalow in a quiet suburban area. Simone’s daughter has paraplegia after an accident ten years ago. She is able to care for herself to a certain extent but does require occasional assistance from Simone. Simone’s daughter also recently experienced bouts of depression which lasted several months. Recently Simone had an incident when she became disorientated on a trip to the local shops and had to be escorted home by a neighbour.
The role of the nurse in this case study is that of a community psychiatric nurse working with older adults. After meeting Simone and carrying out an initial assessment there are several pertinent pieces of information to continue with: Simone appears to be physically well and her home is clean and well equipped for both her and her daughter; She seems to understand where she is but at times can become flustered when unable to answer certain questions; Her daughter reports that, on a few recent occasions, Simone has burned food while cooking; She has no other family living locally and has lost touch with many of her friends since looking after her daughter; Simone states that she does not require any assistance at this time as she feels that she will be able to cope, however, she seems to be very anxious about her diagnosis and the consequences for her and her daughter and whether they will be able to continue managing to live at home.
To be able to begin to make any kind of conjecture on what plans of care may be suitable for Simone we have to make several key assumptions about the skill of the nurse. For this we will use some of the attributes identified by Gerard Egan (2010) in his ‘skilled helper’ model. Firstly we must assume that through accomplished communication skills and core empathic values a working therapeutic relationship is possible to establish. Also that the care plan proposals which are being put forward are ones that have been discussed and accepted by all involved parties as suitable to Simone’s preferences after reviewing alternatives. Finally, we must presume that through encouragement, motivation and reasoning, Simone will consent to nursing, psychiatric and other agency involvement.
From the initial assessment it would seem that Simone has an apparent need for information pertaining to her condition as well as emotional support and counselling. She may require psychiatric input in terms of ongoing assessment, medication prescribing and monitoring. It also seems as though Simone may need some sort of support or assistance in certain daily activities, this could be direct support or the creation of systems and routines which enable her to perform tasks independently. A growing level of social isolation looks to be occurring and Simone may benefit by having assistance to address this. Simone may need access to support groups relating to her diagnosis of dementia, her role as a carer but also to her social and personal interest or activities. These could promote social inclusion as well as cognitive enhancement. Simone has also stated that she has concerns over the wellbeing of her daughter if she should be unable to perform the duties for her that she has up until this point. This may require a level of involvement within Simone’s care for her daughter, to learn about Simone’s condition and also to look at possible ways in which she can assist, perhaps by considering some form of support for herself or by means of being actively involved in the care plans.
Therefore, with these needs in mind, we can begin to create an all encompassing, holistic care plan which is not purely based on the historical medical model that you are ill and we can cure you, or even the more modern social model that purports that you have needs and we can meet them but is instead more firmly based on the progressive view of recovery which states that you may have a problem but with help you can grow beyond it (Hall, Wren & Kirby, 2008). This positivity in the face of such adversity may go against the grain of traditional treatment of dementia sufferers but the goal of restoring and maintaining mental health to its achievable optimum capacity, even when it may be in inexorable decline, should remain exactly the same as in all other areas of mental health treatment (Hughes, 2006). For care plans to be efficient they also have to be specific, measurable, achievable, realistic and timed (SMART), as this allows a flexibility to the planning process because effectiveness can be evaluated and appropriate changes can be made as required (Brooker & Waugh, 2007).
So for this particular case study, the initial care plan would comprise of tasks for the nurse to complete, either as a direct care provider or as a care manager. These tasks would hopefully address the current needs of Simone over an interim period, whilst improving relations, knowledge, involvement and empowerment which could help to provide her with a greater amount of control over her current situation. The tasks will firstly be detailed in a basic format and then what each task entails will be comprehensively discussed thereafter.
As care provider:
Weekly home visits
Liaise with psychiatrist, monthly psychiatric appointments
Creation of advanced statements
As care manager:
Link in with multidisciplinary team
Signpost, assist to access support/interest groups
Being able to have face to face communication with an individual on a regular basis is the cornerstone of effective nursing practice (Ewels & Simnett, 2003). As Simone had stated that she did not feel that she required any external involvement at this time, even when we are working on the assumption that she will accept it, it would be important not to initially overwhelm her. She may be feeling very frightened and vulnerable. A study of older independent living people in 1998 identified dementia as a primary fear, rating higher than cancer (Mackinlay, 2006). General awareness of dementia issues is relatively low even though it is a common enough condition to affect more than 1 in 100 people aged over 65 (Alzheimers Scotland, 2010). A bombardment of too much input or information may cause her to be defensive and withdraw her engagement with CPN services. Starting off with a planned weekly visit of around one hour in length which follows up on the preliminary visit and assessment would perhaps not seem overly intrusive. During this time the nurse can provide much needed emotional support and counselling, building up a more robust working relationship. Information about Simone’s diagnosis, such as how her dementia developed to this point, how it may progress in the future, what to expect, how to prepare, what options are available and any other pertinent questions can be answered as and when Simone feels ready to discuss such things. Overtime Simone can start to identify weaknesses to focus on and strengths which can be utilised and begin to compile her own plans and goals which she can work on in a more independent fashion. These can be more specific goals such as taking up a new hobby or interest or could even be to plan how to visit the local shops and return home safely or cook a meal without the worry of burning it. These goals can then be broken down into achievable tasks for Simone which she can carry out with minimal support. Increased independence can often involve an element of therapeutic risk and it is important not to confuse care with control (Watkins, 2009).
Weekly visits give the opportunity to provide tangible support and to continually assess the progress of Simone’s dementia, mental health, general health, the continuing suitability and condition of her residence, activity levels, relationships and inclusiveness in the wider community. Informal and also formal rating scales, such as the MMSE (Mini Mental State Examination), MADRS (Montgomery Asberg Depression Rating Scale) as well as clinical observations can be regularly recorded to monitor any developments, patterns or trends. Frequent visits allow more effective methods of communication techniques to be developed which suit Simone’s personality and current capabilities. Care becomes not only person centred but also relationship centred and this bond can foster trust and relieve anxiety, stress and agitation (Innes, 2009)
The community psychiatric nurse would work in tandem with a designated psychiatrist, reporting to them weekly. The psychiatrist that originally assessed Simone and made the diagnosis of dementia would be most preferable to aid continuity of care. For this commencement period of Simone’s involvement with psychiatric services to have a monthly appointment with a psychiatrist would be both realistic and achievable. This would be an opportunity to receive further support and review ongoing mental health and mental state assessments such as the MMSE or the more comprehensive ACE-R (Addenbrooke’s Cognitive Examination – Revised). A psychiatrist would be able to provide any ongoing prescription support if required or provide access to relevant psychosocial therapies. The NICE-SCIE Guidelines for Dementia Care (2006) states that this would depend on the results of cognitive tests and perceived cognitive functioning. Using the MMSE as an example, it is recommended that only people with a score between 10-20, denoting moderate Alzheimer’s type dementia should begin courses of acetylcholinesterase inhibitors such as donepezil, galantamine and rivastigmine. The effectiveness of these drugs for individuals scoring lower than 10 points drops dramatically. For people with mild to moderate Alzheimer’s type dementia, scores over 20, should be given the opportunity to participate in structured group cognitive stimulation programmes and alternative therapies. In the journal article, ‘Dementia: Symptoms, Diagnosis and Management’, Salama (2008) recognises the effectiveness of these programmes and therapies for the management of cognitive symptoms such as agitation, anxiety, depression and aggression. It would seem from the needs outlined from the scenario this type of intervention would be beneficial to Simone.
It is always important to remember that often people with dementia do not exist solely in isolation and inevitably family members and friends will become involved in their journey. Innes (2009) talks about the importance of a partnership between the nurse and individual diagnosed with dementia and states that these partnerships can extend to close family members or carers creating a triad of care. With Simone’s consent, sessions could include her daughter, helping to educate and inform her therefore better preparing her to cope with the possible demands of continued cohabitation with her mother. The NICE- SCIE Guidelines for Dementia Care (2006) state that people living in the community diagnosed with dementia should be supported to remain living in their own homes for as long as possible rather than being uprooted to an unfamiliar environment. Also if Simone’s dementia is seen to have a possible genetic link her daughter should be briefed on the risk of developing the condition herself. Simone’s daughter may be able to inform of ways in which she may be able to assist, however, the information provided in the case study suggests that due to Simone’s daughter’s disability her ability to support her mother in some aspects of care may be limited. Studies have consistently shown that stressors faced by family members of people with dementia are amongst the most difficult to cope with of all chronic illnesses and this can lead to an increased risk of depression, loneliness and self injury (Keady cited in Norman and Ryrie, 2009). As Simone’s daughter is already prone to depression a recommendation of how to assist her mother could be to receive more direct support herself subsequently alleviating some of the caring duties for Simone. The importance of relationships and friendships should not be underestimated. The emotional support from an extended social network can be invaluable and Simone should be encouraged to renew links with family and friends to strengthen existing relations and reduce isolation. Leff and Warner (2006) identify social inclusion as one of the key factors to maximising mental health in dementia.
One of the most important duties of the community mental health nurse is to ensure the health and wellbeing of the client, their family and wider community. In order to do this they have to assess the risks involved within the situation. For Simone, her recent dementia symptoms pose new risks, to herself and others, which consequently have to be identified and managed. The most appropriate way to assess risk is in conjunction with the individual you are working with, even though their view of the risks involved may vary from yours. This collaboration means that any decisions feel agreed rather than imposed and are therefore more likely to be conformed to whilst also enhancing the therapeutic relationship between the individual and nurse (Ramsay et al, 2001). From the case study we can see that there are possibilities for Simone to inadvertently bring harm to either herself, her daughter, her neighbours or even the wider community through a number of negative eventualities such as wandering, causing fire hazards or lapses while driving if she does indeed drive. However, although assessing risk can highlight the dangers a situation or condition can cause it can also help to recognise positive skills and strengths which may be utilised. As part of a recovery focused care plan therapeutic risk must be considered and encouraged in order for Simone to maintain the sense that she is still author to her own story. Barker (2009) promotes the idea that personal growth and development through new or continued experiences does not stop with a diagnosis of mental illness or dementia but should be encouraged to continue unabated.
Another consideration which could be brought to Simone’s attention is advanced statements. These are personal statements of preference in terms of the types of treatments a person with a mental illness may or may not wish to have in the future in the event of a decline in their mental health. These wishes and preference must then be upheld under Part 18 of the Mental Health (Care and Treatment) (Scotland) Act 2003. Simone may not feel ready to start compiling these statements straight away but if she is aware of them, over time, her preferences can be documented. Under Part 17 Chapter 2 of the same mental health act Simone also has the right to independent advocacy which she may wish to utilise to create any advance statements or to reinforce them if required. If Simone’s dementia does decline to the stage where she is no longer deemed to have adequate capacity for appropriate decision making she would come under the legal realm of the Adults with Incapacity (Scotland) Act 2000. In times of better mental health Simone may wish to select a named person to act on her behalf should this be required in the future. All decisions made on Simone’s behalf must be to her benefit and be the least restrictive option. With these factors in mind, part of the community psychiatric nurse’s role would be to promote the use of advance statements in order that Simone may continue to be cared for in a manner of her choosing, even after the possible loss of capacity, thus maintaining a sense of self and control over her own treatment. Both of these elements are identified by Pilgrim (2009) as being key points in aiding recovery in mental health treatment.
Multidisciplinary team and multiagency working is an essential part of modern health care provision (Brooker and Waugh, 2007). Community nurses can appear to be working autonomously but are often supported by and linked in with a number of other health professionals and social care workers such as physiotherapists, dieticians, occupational therapists, social workers, general practitioners, psychiatrists and care assistants to name but a few. Norman and Ryrie (2009) claim that the effectiveness of this way of working lies in the diversity of skills and experience which is able to be drawn upon to facilitate more effective care for specialist needs or requirements. In the case of Simone any identified needs that would be unable to be met by the community nurse or that would be more effectively met by other workers could be referred on. In this way Simone’s care becomes collaborative, with her at the centre and people with the specific knowledge and skills being utilised around her.
As well as engagement with health and social care professionals there are numerous charities, agencies, groups and organisations that offer external support. For Simone this could be in the form of local support groups for issues that affect her, such as dementia, stress or being a carer, or could perhaps be more focused on activities that suit her general interests. The community psychiatric nurse could possibly assist Simone to source, access or even in the short term, attend these kinds of pursuits. Interacting with others in groups or focusing on enjoyable tasks has the therapeutic benefit of enhancing both social and cognitive proficiency for a person diagnosed with dementia (Gilhooly et al 2003). Leff and Warner (2006) also stress the importance of social inclusion by naming it amongst their four key areas for improved quality of life alongside independence, health and choice.
So in summary, we have outlined the case study scenario of Simone, identified her needs and created a plan that is intended to meet these needs. In addition to meeting the identified needs, a deeper analysis of the plan depicts how it will benefit Simone in a more holistic sense. By keeping the notion of recovery firmly in mind, the overall aim is to build up Simone, the person, as a whole and not purely to assist with the symptoms of dementia. For Simone to ‘recover’ she must be supported to live a full life in the existence if her dementia, be able to remain independent for as long as possible, be included in the community, plan for the future and enjoy a quality of life that she finds gratifying. As this care plan created for Simone progresses, being updated and augmented as required, it should mean that her dementia should become to be viewed as illness which is being managed and not as a defining characteristic of her personality. Paraphrasing from a letter written to the notable neurologist Oliver Sacks: A person does not consist of memory alone. They have feeling, will, sensibilities and moral being, matters of which neurology cannot speak. It is here, beyond the realm of an impersonal psychology, that you may find ways to touch them, and to change them (Luria cited in Sacks 1985).
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