In this paper, we analyse a service user who is admitted informally to an acute inpatient unit where the doors are locked. The service user is presenting with depression and having ideas of self-harm. The assessment of patients from biological, psychological along with social history will be conducted.
In addition, risk assessment will be carried out to understand risk through selection of rights tools as well as prioritisation of social needs to develop a recovery plan with nursing intervention. The effective communication and documentation will highlighted to develop an optimum care plan.
At last, not legal and ethical framework will be examined in order to understand how make an effective decision in the best interest of vulnerable adult.
Schultz et al (2015) explained that mental health is an important and integral component of individual’s Capacity to live good and fulfilling life. Good mental health is a state in which it is important to maintain balance and create harmony between individual and surrounding world. The value of mental health is to make number of life decisions such as leisure, study or work along with the ability to maintain the healthy relationship.
The indicators of good mental include adequate contact with social realities, self-control on imagination, efficiency in play and work as well as balanced emotional life. Nevertheless, an individual with disturbance to mental health does not have capacity to fulfil these choices (Loshak, 2013)
Elder, Evans and Nizette (2012) added that poor mental leads to diminishing function for individual welfare but challenges are also present at the broader level of society and household. The range of mental problems is depression, anxiety, phobia & eating disorder, self-harm, panic attack as well as suicidal feelings. There has increasing incident of self-harm of in-patient and, i.e. careful risk assessment of these patient required in order to prevent suicide or self-harm (Jenkins and Elliott, 2014).
Loshak (2013) elaborated that personality is composed of distant behaviour, emotions and thoughts to characterise the individual situation in life. The different phase of personality development includes babyhood (Birth – 2 years) in which attitude and behaviour, as well as expressions, is established.
The personality traits developed in this phase is very important as the infant is self-trust in what sees and hear. The next stage of personality development is early childhood (2-6 years). The personality at this stage is slow compared to childhood. However, factors like fears, emotional outburst as well as curiosity are developed at this stage of life (Deci and Ryan, 2016).
At this stage, personality traits of individual are able to develop rules and behaviour as well differentiate between good and bad. One of the most personality traits at this stage involves guilt, antisocial or anxiety. The next stage marked as late childhood (6-11 years) which shows uniform growth and psychological development include social skills, self-esteem, and interaction with peers. The next stage involves adolescence (12-19 years) which results in body and sex development in the individual. The personality traits involve sense of maturity and self-consciousness (Sanavio, 2016).
Moreover, Weiner and Freedheim (2013) elaborated that at stage the problem develops are delinquencies as well as identity crisis. The early adulthood stage (20-40 years) involves psychological development in an individual along with reproduction capacity. The psychological traits at this stage involve coping with roles and responsibilities as well as participation in social processes and fulfilling as well as maintain social status.
The next stage marked as middle adulthood (41-60) which involved impaired body functions, diseases, as well as hypertension. The psychological difficulties include martial or social conflict physical changes as well as social failure.
Keyes (2005) analysed that the fundamental factors behinds the mental health problems could involve numbers of factors, such as violence, neglect, trauma, the death of someone, social disadvantage, unemployment, discrimination or serious accident. There have been several models to explain the mental disorder.
The first is a medical model which describes people have mental health problem when they have disturbance in thought and psychomotor activities. Moreover, the statistical model involves testing behaviour variables and results derive statistically to determine the degree of abnormality.
Jones, Fitzpatrick and Rogers (2015) stated that the third important model is known as the sociocultural model in which individual acceptability social norms and believe is tested to distinguish between normal and abnormal behaviour.
At last, not least, behaviour model classify maladaptive practices as abnormal which are developed through learning. The table below shows the range of factors which result in mental health problems in an individual. The range of risk mental health over the life course is attached in appendix 1.
|Factors of Mental Health problem|
|Predisposition||Precipitating (induced)||Perpetuating (Prolonging)|
|· Genetic disorders|
· Damage to nervous system
· Adversarial psychosocial impact
|· Psychosocial distress|
· Physical stress
|· Biological Problem|
· Physiological changes or impact
· Social influences and factors
|Long-terms (prolonging) Factors|
|Biological Factors||Psychological changes||Social influences|
|· Directly inherit through genes (heredity)|
· Neurotransmitters malfunction (Biochemical factor)
· Nervous system damage (Brain injury /illness)
|· Social status, isolation, frustration, stress, childhood problems, sexual dis function, failure of task, loss of job, financial or educational incompatibility, childlessness||· Migration, social insecurity, Alcoholism, divorce, religion, social crisis’s, injustice Gambling|
The purpose of ‘Mental Health Act’ (MHA) 2007 is to ensure the safety of those who are experiencing mental health problems, as well as other people of the community. The Act makes the provision of mental health care either compulsory or involuntary provision, when an individual is experiencing poor mental health and appropriate care, is deemed necessary for the health of safety of individual or other members of the community.
Individuals are admitted to hospital for mental health care under the section 1 of MHA. When an individual is admitted under the section 1 of MHA Act and there is the threat of physical harm to itself or immediate, then coercive intervention for control and restraint can be used (BHUI et al., 2014).
The MHA 2007, implementation has resulted in three ethical issues which are; 1) individual right to received medical care; 2) right to liberty as well as dignity; 3) protection of public and community. The individual has the right to treatment but in case of coercive intervention there is an issue of right and dignity of the individual. Service user might perceive the involuntary treatment as unnecessary and results in physical resistance.
According to the universal declaration for human right individuals, are born free with equal rights along with dignity. Moreover, nursing code of ethics states that nursing should respect human rights including the right of choice and cultural rights along with treatment with respect (Barcham, 2015).
In case of aggression by service user who is admitted under the section 1 of MHA, conceive force can be used such as tranquillisation. There is the constitutional duty of care quality planning commission to examine how the service provider has acted. Nevertheless, there are clear guidelines provided by National institute for Health and clinical excellence (NICE) for the management of physical aggression. Nevertheless, according to NICE recommendation, coercive intervention should be used as last resort (NICE, 2011).
Mental health is diagnosed through examination as well as analysis of data. This examination is an important component of nursing practice and diagnosis. The first step involves is to gather data to develop a database in order to provide best care. The nursing assessment is systematic as well as a deliberate process to collect data in order to evaluate current and past history in terms of health and functional status of inpatient (Fourie et al., 2015).
The range of techniques used to gather data involves patient observations, interview with a patient, physical examination, mental status examination, diagnostic report as well as communications data to colleague to develop collaboration.
Risk assessment is growing importance area for mental health nurse. In order to effective plan and deliver the service based on patient care, it is important that mental health nurse should be proficient in this area. The risk assessment should be integral part during the evaluation of patient health rather conducting as an independent activity (Barker, 2014).
Therefore, four fundamental area mental health nurse should address include the risk of self-neglect, self-harm, the risk to others or serious exploitation of the general public. In general, there are three classification of risk which low, medium and high based on the probability and impact of the incident. The risk is usually measured through quantification by assigning rating to the probability and impact of the risk (Barcham, 2014).
Cooper et al (2015) discussed that in case of imminent risk of self-harm, the action plan should be developed based on protocols agreed by the hospital management. Nevertheless, there are clear guidelines are available from NICE in to tackle the situation in the event of self-harm. Moreover if there is a risk of medium nature then trigger should multi-team assessment and it is the duty of to communicate the urgency of action. It is fundamental important for the nurse to take care while carrying out a risk assessment as this could provoke adverse event.
In normal cases, risk assessment can be managed through carrying nursing diagnosed and data collection on biological, psychological and social circumstances of the patient. However, in case of ‘Acute care’ need tension may exist as patient suffer from acute distress and may not able to control their behaviour and require detention, restraint or compulsive disorder or even coercive force. The form to conduct self-harm assessment is attached in appendix 2 (Jones, Fitzpatrick and Rogers, 2015).
In the UK, to tackle with people who pose a high risk to themselves to their surrounding; a new approach has emerged. The concept of supervision of people emerges who pose high risk. To effectively supervise these people, it is important to understand the management as well as identification of risk.
Skegg (2015) added that it is fundamental to understand the significance of risk through ‘Prodromal signs’ as well as identification of relapse indicators in order to develop a plan for patient’s require high care. The crucial in delivery of patient-based care need to understand of climate in which services are delivered through identification along with relapse indicator in order to develop effectively action plan. Moreover, suicide risk matrix to assess the risk of self-harm is on in-patient is attached in appendix 4.
Rassool (2015) explained that the first stage involve in data collection is gathering biological dimensions of the patient. This includes present and past mental medical history, personal information (Parental, childhood, educational and marital), conducting physical examination (body system and neurological), physical function (activity, sleep, appetite and nutrition, self –care) along with current pharmacological condition.
Once the biological data is collected, the next stage involves is a psychological evaluation of the patient. This involve conducting appearance and behaviour test, emotions, Mood, thoughts, cognitive function, memory and abstract reasoning, behaviour response, self-esteem and personal identity, behavioural response, as well as detail risk assessment, is carried out. The next stage involves conducting a social factors evaluation on the patients. The fundamental factors involve are economic and legal status, spiritual and functional status as well as carrying out cultural and family assessment (Loshak, 2013).
Once the data is collected on the patient, the next stage is nursing diagnosis. This involves clinical judgement based on the biological, psychological and social factors. The judgement about individual helps to highlights actual health problem. The nursing diagnosis stage is useful in order to determine the condition of the patient and recommended nursing interventions in order to develop parameters for desire outcome (Weber and Kelley, 2009).
Smith (2012) highlighted that the nursing diagnose is useful to identify high-risk area for the patients and should be based on statement having three sections which are; 1) Patients health problem; 2) Factors contributing to patient problem; 3) Characteristic which include symptoms and sign of the problem. For example, in the case of mentioned patient; the high risk would be self-directed violence because of depressed mood. The patients have feeling of worthlessness and in response anger has directed towards self-harm.
Moreover, the patient has a lifestyle of helplessness and has control over the situation of his life. In addition, patients have to rely on other to fulfil his financial and social needs. The range of available tool to perform the psychological test on the patient is attached in appendix 5 (Whittington and Logan, 2013).
Jenkins and Elliott (2014) explained that the planning stage is most in order to devise a plan to deliver the quality of care in timely and safe manner. The nursing care provided should be based on the risk identified and characteristics of the symptoms.
The four fundamental factors at the planning stage; 1) identification of priorities of care required; 2) decision to use psychotherapeutic practices; 3) collaboration with other members of team for treatment; and 4) delegation of responsibility and maintain co-ordination among the collaborative team. It is important for the planning to prioritise the risk in the relevance of importance.
The Maslow hierarchy of needs is usually used to prioritise the problems and highest priority is given to risk which is considered as life threating or self-destructing (Schultz and Videbeck, 2016).
Townsend (2014) claimed that risk having low priorities usually treat as development and patient are treated through provides a session of therapies. The next stage involves is the identification of outcome based on the treatment received by the patient. The outcome is not only mark care provision effectiveness but also help to improve decision making on the part of the nursing assessment. The outcome report should be patient centred, measurable timeline, singular and measurable.
Whittington and Logan (2015) elaborated that in order to manage the patient of high risk, it is important to develop detail management to manage the patient of high risk. If the patient is classified as a high-risk patient, then the self-harm assessment should be carried out twice a day. Moreover, in case of patient classified as low risk, the evaluation should be carried out on a daily basis.
If the patient is classified as low risk, then the weekly assessment should be carried out. The recovery stage involves a nursing intervention to prescribe the action developed in the planning phase. Nursing intervention is most important action to achieve the result and to provide quality patient centred care in order to reduce the problem (Barcham, 2015).
Elder, Evans and Nizette (2015) added that the Range of nursing interventions could be interdependent, dependent or independent. The range of nursing interventions available for biological factors is self-care activities, nutritional and hydration interventions, relaxation and pain management as well as medication and exercise programme. Moreover, in provide quality care for psychological factor range of intervention nurse could prescribe counselling, behaviour and cognitive therapy, psycho-education as well as conflict resolution programme.
At last, not least, in order to tackle the social dimensions the wide range of nursing intervention could be group intervention, support from family through family intervention as well as milieu therapy to resolve the development issues in the patient (Schultz et al., 2015).
Davies and Janosik (2015) mentioned that the documentation relevant to risk assessment, observation and management plan should be carefully recorded in patient medical file. The patient current state should be carefully communicated with other members of staff along with suicidal thoughts and management action plan.
The family of patient should be made aware of the risk of suicide and they should be consultant in order to devise effective care plan. Moreover, another important factor involve is nursing observation risk for self-harm patient. The appendix 6 shows detail management action plan is based on level of risk.
|Level of risk||Clinical indicators||Observation level|
|High||· High level of restriction required to manage patient|
· High risk for other patients
· Patient required continuous review
|· Patient should be in locked facility|
· Patient should be in direct site of nurse
· Check for sign of life throughout night
· Chart should be managed as part of observation plan
|Medium||· Patient require restriction in order to carefully managed|
· There is risk of absconding
· Risk to patient personal financial status or reputation
· Patient should be review on daily basis
|· Keep patient in locked facility|
· Throughout night patient should be checked for sign of life
· Should be escorted member of staff
· Chart should be managed as part of observation plan
|Low||· Patient required minimum level of observation and no threat of self-harm|
· The is no threat to other people in surrounding
· No current self-harm or suicidal though.
|· Patient should be check after 2-4 hours|
· If patient is out of ward, the reason should be document in file
· Medical recording should be done in group form
The multiple disciplinary team include a psychiatrist, a psychiatric nurse, psychiatric social worker, occupational and clinical psychiatric and a counsellor. In order to provide effective and quality care treatment, mental health care relies on team efforts. The intervention offered by the nurse, therapist session, psychological intervention, as well as role of social workers, helps to deliver quality treatment (Almedom, 2013).
Weber and Kelley (2014) added that the benefits resulting from interdisciplinary involve working of multiple professional in their area of expertise. The information is mutual in the group to manage the communication through goal setting. The team based on range of professional can deliver patient based care in timely manner.
The mental health patients are difficult to tackle and in case of acute care need, patient need immediate assessment in order to get proper treatment. In order to tackle the high risk patient, the fundamental area to address is risk assessment of these patients along with complete mental assessment.
The level of nursing care provided is based on the risk level. The patients who are classified as high risk required continuous attention. These patients are considered as danger to themselves and other people and monitor through detail management action plan.
Furthermore, role of nurse if highlighted in this detailed processes as individual to carry risk assessment, communication and development of action. Moreover, as part of multi-disciplinary team range of professionals can manages highly vulnerable patients through providing a safe environment.
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