·       Using a case study as a framework, critically explore how you would care for someone with complex needs (physical, mental, social needs). This should include consideration of collaborative working with patients and carers, working with other professionals, legal and ethical decision making, pharmacology and evidence-based interventions. A critical exploration of the evidence base should be evident.

THIS VIDEO IS AN EXAMPLE OF SOMETHING SIMILAR WHAT CAN BE USED AS GUIDANCE , I WILL DO MY OWN POWER POINT https://www.youtube.com/watch?v=ZcKNmluZkP8

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·       This assessment will be marked in line with the Level 7

·       This assessment is testing all of the module learning outcomes

o   Demonstrate application of the nursing process in caring for people with complex mental health needs, their families and carers.

o   Critically discuss the knowledge and skill required in order to refer people safely to other professionals within a range of health and social care organisations to deliver the best person-centred mental health outcomes.

o   Justify care decisions which take into account the safeguarding of vulnerable people.

o   Integrate knowledge of biosciences and pharmacology when engaging in the collaborative evaluation of care and be confident to make changes to mental health nursing care using best available evidence.

Case study

Satya is a 27 year old woman of Asian origin. She has a diagnosis of bipolar disorder. Satya also has type 1 diabetes but doesn’t manage this well, her blood sugars are frequently high and has in the past had the occasional hypo, usually after getting drunk. She doesn’t seem to be overly worried about this. Lives with her daughter Crystal who is 12 years old and her partner Annabelle who has lived with them for the last year. Family have distanced themselves from Satya stating this is because of her ‘lifestyle choices’ and said that they want nothing to do with her.

Satya has been low in mood of late and recently attempted suicide by insulin overdose following a failed attempt to reinstate contact with her biological family. She was found by her daughter when she returned home from school, who called the ambulance. After being treated and assessed in A&E she was admitted to a psychiatric assessment unit. She had been on the ward, which is a notable distance from her home for three weeks. Last week, she had arranged to go and spend some time off the ward seeing her daughter but at the last minute she was told that the section 17 leave paperwork had not been signed. She became verbally hostile with a member of staff and she was physically restrained and as a result the leave did not go ahead and some staff are questioning if she should be allowed leave in future as she is ‘volatile’. Satya is still very angry about this incident.

Currently, Satya is taking Lithium which she has been taking since her last admission several years ago when she was first diagnosed. Whilst she is concordant with the Lithium and adjustments based on her blood tests her Lithium levels have been erratic. She has been tried on Fluoxetine in the past for her low mood and also was previously prescribed Olanzapine when she was in a manic phase.

Similar mock example from another university and a lot shorter : https://www.youtube.com/watch?v=ZcKNmluZkP8 presentation example

You can put the Los in the order that you want.

Guidance

LO1 800 words.          Demonstrate the application of the nursing process in caring for people with complex mental health needs, their families and carers.

Complex needs: what is it? Needs to be collaborative, person-centred, and holistic. Then… medical diagnosis doesn’t necessarily mean that people with being complex or not, also that people might have an ongoing diagnosis such as bipolar, but their level of complexity and needs will change over time. Include the NMC code of conduct 2018)

Explain the stages of the nursing process. Critically discuss the Nursing process. Engagement (service user engagement with services, plans for treatment, etc.) What are the barriers and how can they be overcome with Satya.

Therapeutic relationship (TR) why is vital in Satya’s case how can TR be beneficial what are the barriers (restraining her, not signing her section 17, denying home leave can all impact the TR therefore to engagement and how this can be overcome, shortage of staff can be a reason for the above problems that have resulted in her section not been signed). Use of self. The power dynamic in planning. Involving family: can we? Capacity? Right to refuse. Is it moral and ethical? data protection, can we share information with family withy Satya explicit

Please talk about the NP that we will use for Satya, first define the NP (UK).. NP is a systematic approach…. 4 stages: assessment, planning, implementation, and evaluation. Mention all parts of the nursing process but concentrate on 1 or 2 in order to get this deep level or critical writing level 7, why we do it, what are the benefits, what are the barriers and how they can be overcome with Satya.

If its assessment (mental state examination (critique: subjective data, why) Formulation 5Ps or biosocial model (benefits and barriers, is dynamic needs updating) Consider risk factors from an internal and external perspective in relation to the service user: Is the risk factor stable? (e.g. history of child abuse)

Is the risk factor dynamic? ( e.g drug and alcohol use, current mental state)

Staff factors Organisational factors physical checks observation (objective data). If its physical observations what are you going to do to Satya and why (evidenced-based interventions NICE guidance UK sources)

If it is planning to identify the risks … collaborative risk management … therapeutic relationships, what are the barriers?

If its implementation: barriers safeguarding… consents,

To make the NP effective is to engage the patient and their family in the whole NP. Person-centred care (NICE guidance ref) is an integral part of the NP having the patient in the centre of the process. However, with Satya we have the barrier of her family being distanced from her because of her drinking and etc.. so engaging the family seems to be inecessaryto Satya but can be difficult if the family refuses especially in the early stages of the NP. In order to overcome this barrier, we need to build a therapeutic …relationship (TR) one sentence to define TR and why iit s Important. What are the berries to the TR (she may not share all the information, fear to put herself in a worse situation, losing her daughter or e.tc)

Nurses seem to be in a position of power when it comes to the power dynamic in planning however is crucial to involve the patient and make sure she is at the centre of any decision-making process, providing her with information and involving her family when possible and with Satya explicit consent (she has the capacity and flow nicely into ethics are legislation we have to assume capacity until assessments and formulation prove otherwise)

https://www.magonlinelibrary.com/doi/pdf/10.12968/bjha.2017.11.8.388

LO2 800 words: I put some info

Critically discuss the knowledge and skill required in order to refer people safely to other professionals within a range of health and social care organisations to deliver the best person-centred mental health outcomes.

Referrals, safeguarding (is it needed and if yes, why), collaborative working with services, why we do I,t why is important (NICE guidance recommends this way of working,) engagement and barriers to the engagement.. how can we overcome barriers (TR, communication, trust, consent, involving the patient). What is the benefits from working together: Patients will be empowered. Engage will increased. Responsibility for actions responsibility using the NMC code of conduct 2018). Motivator for change. Greater commitment to progress – positive outcomes? Working together is a part of the NHS long term plan reference the long term plan. How is this going to help Satya?

Department of Health (2008) emphasises the need for a focus on delivering person-centred mental healthcare and also repeats that crisis, contingency and risk management are an integral part of assessment and planning processes. There are 4 key points of the CPA Assessing the health and social needs of service users, Formation of a care plan which identifies the health and social care needs to be required, The role of a care coordinator, Regular review of the care plan. The nurse in charge -The role of care co-ordinator should usually be taken by the person who is best placed to oversee care planning and resource allocation. They should have a good relationship with the service user, be able to provide person-centred care, coordinate with others involved in the care process and have specific skills in relation to the service user’s needs. How is this going to benefit Satya

Therapeutic TR relationship is enhanced and, therefore recovery? TR … who are we going involve in Satya’s case and why. We need to make sure we address all care needs in the right places, and we also need to follow up and make sure we track the process. Who are we going to involve and, why, c? Concentrate 2/3 referrals that you can justify the reason for? What skills the nurse needs to have.

Skills needed. Disempowerment of the individual may result in a failure to foster a sense of responsibility and positive agency, thereby potentially acting to enhance rather than mitigate risk—shift in the way that risk is viewed. (from paternalistic, clinician-directed care towards patient engagement, autonomy, and choice, where patients are supported to make informed decisions).

‘Done to’ (where the patient is a passive recipient of judgment and management strategies) Vs ‘Done in collaboration with’. The role of the clinicians within this model is to support the process of recovery by empowering the patient to broaden the scope of his autonomy and sharing the responsibility for decisions about care and treatment. Independent Review of the MHA recommends ‘shared decision-making between clinicians and patients and that these should be used to develop care and treatment plans and to make treatment decisions as far as is practicable. A mutually respectful and trusting relationship is an essential part of SDM; however, a psychiatric patient may only be able to reciprocate when their illness is under control. Once certain symptoms (especially suspiciousness and paranoia) develop, the patient’s ability to trust their clinician may be compromised. ‘Statutory advance choice documents should be created that enable people to make a range of choices and statements about their inpatient care and treatment’

Drinking (why is she drinking is it a coping strategy what can we do to help her.. provide information, signpost, support, and encourage, however wise or unwise Satya’s decisions may seem once she is proven with capacity the decisions lays with her? diabetic nurse specialist? social workers/safeguarding the child, contacting the school etc. therapist what dose NICE guidance recommends for ppl like Satya. Alcohol promotion health

Cultural needs and what are the barriers (Asian, cultural needs, family view)

Mention person-centred, and autonomy. What can make her not go to those referrals and how can it be overcome (TR, communication). Justify decisions for referrals.

So now we have all those services involved in the care of Satya now we need to make sure that excellent leadership are in place for the nurse ca coordinator to ensure that communication between services and back to Satya is taking place. As there are some barriers when too many services are involved in the care of a patient with complex MH needs, WHAT ARE THOSE Barriers and how we can overcome them (therapeutic relationship). Mention that they qualify for financial aid PIP that the nurse can support (non-maleficence comes in this).

LO3

Justify care decisions which take into account the safeguarding of vulnerable people. 700 words

Presenting factors and facts: capacity UK, the impact of care decisions UK (compare with the presenting situation and future. Autonomy.

Laws (MH act) principals and act applicable to her case and why… here consider ethics (was it in her best interest for her to be secluded, what does seclusion involve, what was the best thing to be done with her). Also, the least restrictive practice that we must follow, are beneficence, and non-maleficence (poor experience on the ward by patients is the case with Satya). What was the reason for Satya’s aggressive reaction, was it preventable (escalation phase). What are her rights? Is there anything in ger history to indicate risk? Mention Positive risk-taking? Four of the six safeguarding principles, The Four P’s-Partnership, Prevention, Proportionality (was it proportional, why) and Protection

https://www.england.nhs.uk/wp-content/uploads/2017/02/adult-pocket-guide.pdf

https://www.gov.uk/government/publications/safeguarding-policy-protecting-vulnerable-adults/sd8-opgs-safeguarding-policy

Lo4 750 word

Integrate knowledge of biosciences and pharmacology when engaging in the collaborative evaluation of care and have the confidence to make changes to mental health nursing care using best available evidence.

Showcase knowledge of medication.

Start with talking about bipolar and type 1 diabetes and bi polar and her current medications, don’t forget to mention the risk of her suicide attempt by overdose with insulin and her erratic Lithium levels. Information about the medication is provided bellow.

What she is currently on medication wise, and what is the evidence saying in the Uk about other treatment options that the nurse may Consider. Identify eds work Lithium, how is taking what is involve (blood tests sct.) – evidence-based, any alternatives we use in the UU for Bipolar, side effects. Was the previous treatment successful can we add the fluoxetine again, can they be mixed, what about drinking alcohol with those meds? MDT referral meeting and discussion about meds, inclusive decision, including Satya. Also, how is diabetes type 1 treated in the UK are there any other alternatives. polypharmacy, meaning, action.

Talk about alcohol Misuse & Dual Diagnosis in relation to her.

The medication we recommend must fit with the individual’s lifestyle, health history and personal situation. The newer forms of anti-depressants appear to have the increased focus in terms of research and efficacy, one would encourage a transparent conversation focused on the needs of the individual prior to making any such suggestions.

How do we asses and manage side effects of medications? Example Prescribed medication needs to be person-centred and a collaborative process. Education should be an ongoing

process – patients may not be in a good place to take on board everything that

is said to them at the start of treatment

Advice can change – keep up to date -to update your patient!

Make a list with your patient on previous medication and side effects they have had – including dates taken, dosages, benefits and side effects. Make a list of the symptoms they wish

their treatment to target. Obtain a base line of current physical, psychological, neurological and mental

complaints- it is important to ascertain if these symptoms were absent or

present prior to commencing treatment. However; Much of the literature you see written about the nursing process refers to ‘diagnosis’. This comes particularly from US sources and refers to ‘NURSING DIAGNOSIS’. A nursing diagnosis differs from a medical diagnosis as it focuses less on the individual’s symptoms and much more on their needs. These needs may indeed be viewed entirely from a holistic point of view. It is much more accurate for nurses within the mental health field to use the term ‘FORMULATION’. So that may include: What are the person’s holistic needs, how can we support them & who else can offer this help?

NICE guidance recoomends Mild Depression

Low intensity CBT / Computerised CBT / Group CBT, structured group physical activity programme, Sleep hygiene

Moderate Depression

CBT

Interpersonal psychotherapy

Behavioural activation

Couple’s therapy

Medication – SSRI recommended

Bipolar Lithium is a mood stabiliser prescribed Long term management

Psychological therapy, Lithium first choice, Valproate 2nd choice

Lithium citrate and Lithium carbonate – not the same and do not have the same dosages.

Regular blood tests are needed to ensure that blood lithium levels are high enough to have a therapeutic effect and low enough to avoid toxicity. 0.4 – 1 mmol/ l – therapeutic

1.5+ potentially fatal. Dosage guided by lithium levels

Due to risks of toxicity – kidney function, thyroid function, weight, and BMI testing/recording should be completed PRIOR to commencing lithium. NSAIDs (such as Ibuprofen) should be avoided.

Diabetes

This is due to the body not producing any/ enough insulin, or the body’s cells don’t react to insulin.

Type 1

Insulin injections

Insulin pump

There are many different types of insulin, each with their own

things we must consider. However, some types insulins are extracted from pigs or cows which make

them unsuitable for Satya depending on her religious beliefs. People with

type 1 diabetes have to think about this for everything they eat or drink so in her case Alcohol is affect her conditions.

Holland, L. (2018) The Nurse’s Guide to Mental

Health Medicines. London: SAGE

Mutsata, S. (2017) Medicines Management in

Mental Health Nursing. 2nd ed, London: SAGE

https://bnf.nice.org.uk/

https://www.clozaril.co.uk/

https://www.mind.org.uk/

https://www.nice.org.uk/

https://www.nhs.uk/medicines/

https://yellowcard.mhra.gov.uk/

Sources to be used

Professional perspectives on service user and carer involvement in mental health care planning: A qualitative study – https://doi.org/10.1016/j.ijnurstu.2015.07.008

WHO: Recovering from mental illness with dignity – https://www.youtube.com/watch?v=4e7uobXp9z0

“From the edge of the abyss to the foot of the rainbow–Narrating a journey of mental health recovery” the process of a wounded researcher – https://librarysearch.uclan.ac.uk/permalink/44UOCL_INST/1jklcnf/cdi_gale_infotracacademiconefile_A507012518

Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems – https://doi.org/10.1002/wps.20084