Developing Autonomous Practice in Mental Health Nursing - Essay Example

?Introduction Assessment is one of the most significant aspects of the Nursing Process, especially in mental health nursing (Basavanthappa, 2004). Indeed, Kozier et al. (2008) discussed that no proper intervention can really be given unless the nurse performs an effective assessment. Through assessment, the nurse gains a window into the problems and complaints of the patient, as well as the underlying factors that have contributed to the disease condition. More importantly, in the field of mental health nursing, assessment serves as a significant tool in determining the deepest causes mental illness (Boyd, 2008). Assessment in mental health nursing is something that is most understood through its application in the case of a patient. In relation, this essay will then examine case of a patient with Paranoid Schizophrenia, who was the patient during my community placement. Performed in a form of a case study, this essay will pay attention to the patient`s psychiatric and personal history. The current sociological, psychological and physiological needs of the patient will be also examined from the point of view of therapeutic approaches. Moreover, this essay aims to demonstrate how the nursing therapeutic approaches work in practice and develop a deeper understanding of applying some therapeutic methods in the care of individuals suffering from paranoid schizophrenia. More specifically, this paper will utilize Maslow’s Hierarchy of Needs as the main guiding theory or theoretical perspective in the assessment and intervention processes. In addition, the goal of the paper is to examine the role of the nurse, especially as a health educator, in caring for the mentally ill patient. Finally, this paper will discuss therapeutic nursing interventions, assessment of needs, and patient`s progress, analyze the therapeutic efficacy of environment where the patient is being cared for. Case Study Patient’s Background and History As mentioned, the case to be studied involves schizophrenia. This condition is usually diagnosed in adolescents or young patients. In some cases, it can even manifest in the person’s earlier years of life. The peak incidence for the onset of the disease lies between 15 and 25 years for men and 25 to 35 years for women (America Psychiatric Association, 2004). More specifically, this case study will involve the case of Patrick Jones (pseudonym; the name of the patient is changed for confidentiality), a 25 years old who was diagnosed with paranoid schizophrenia last year. Paranoid schizophrenia is considered to be the most common type of schizophrenia all over the world. The clinical picture of this condition is characterized by delusions, paranoia. As with most paranoid schizophrenic patients, Patrick Jones usually has perceptual disturbances and hallucinations, generally of the auditory type. Two months before Patrick was diagnosed with paranoid schizophrenia, his girlfriend was killed by a gang committing acts of violence in the neighbourhood. Patrick`s relatives and friends were concerned about his constant complaints of abdominal pain and headache. He experienced severe appetite loss and as a result he lost a lot of weight in two and a half months - about 12 kg. Patrick stopped taking his showers and did not pay attention to personal hygiene. As a result, his body acquired an unbearable odour. Patrick also developed an ungrounded fear that he was about to be run over by a car, so he constantly stayed at home and refused to leave it even to go to the store to buy himself some food. His behaviour became utterly anti-social. He stayed locked in his bedroom for days. He also had episodes of outbursts of anger with elements of violence, which greatly terrified his family. Because of these different occurrences and observations, as well as the assumed cause of the patient’s condition (death of girlfriend), Patrick’s family opted to call for medical assistance. Thus, Patrick was brought in for assessment and evaluation. After a series of assessments and interactions with the patient, Patrick was diagnosed with paranoid schizophrenia. Paranoid Schizophrenia Overview and History Paranoid Schizophrenia is a psychiatric condition that causes bizarre and distorted thoughts, emotions, perceptions, and behaviour (Elder, Evans, & Nizette, 2009). Schizophrenia is not a single illness; rather, schizophrenia is a syndrome including many different symptoms and varieties (Videbeck, 2010; Dexter & Wash, 2000). During a long period of time, schizophrenia was misunderstood by the general public (Antai-Otong, 2008). Certainly, before the underlying causes of schizophrenia were fully understood by the scientific world, people were afraid of schizophrenic patients (Keltner, Schwecke, & Bostrom, 2007). However, recent studies and literatures revealed that schizophrenia is not a punishment of the gods but rather a biological condition, and that it can be controlled with the help of therapy and medications (Wilson & Kneisl, 2001). Improvements in evidence-based nursing as well as research developments have led to the increased effectiveness of new antipsychotic medications and therapies (Brooking, Ritter, & Thomas, 2002). Theoretical Approach: Maslow’s Hierarchy of Needs The main theory that will serve as the basis for assessment as well as the different interventions will be Maslow’s Hierarchy of needs. The main needs of any human being are represented by Maslow's hierarchy, which is usually depicted as a pyramid consisting of five sections. The lowest section of the pyramid is associated with physiological needs of an individual, while the top section of the pyramid corresponds to psychological needs. According to the said model, deficit needs should be met first, before higher levels needs in the pyramid can be met. When the said needs are met, a person starts to take care of one`s growth (Barker, 2001). The lower four sections of the Maslow's pyramid are called "deficiency needs". These are: physiological, security and safety, belonging and love, and self-esteem. In case these four "deficiency needs" are not met, individuals feel tense and anxious (Barker, 2001). After safety and physiological needs are met, the highest layer of human needs is involved. This section of Maslow's hierarchy involves relationships based on emotions like friendship, intimacy and family (Milliken & Honeycutt, 2004). In these levels, it can be observed that every human being needs to feel a sense of acceptance and belonging, whether in a big social group (professional organizations, clubs, sports teams, religious groups), or in small social connections (intimate partners, family members, close colleagues, mentors, confidants, etc.). Every person needs to love and be loved by someone. When this element is absent people start to feel lonely and socially anxious (Rosdahl & Kowalski, 2008). This hierarchy of needs will then serve as the basis for the analysis of the patient’s needs, presented in the succeeding section of this paper. Detailed Analysis of Patient’s Needs (Psychological, Physical, Social) Before an analysis using Maslow’s hierarchy of needs will be conducted, it is important to first look into the underlying reason for Patrick’s condition. In order to better understand the patient’s state, the nurse has to look into the causes of his condition, or the situations that may have caused or triggered his mental problem. For Patrick, his condition can be greatly attributed to the trauma and stress he experienced after the violent death of his girlfriend. This case Patrick can be easily explained by the statement of a famous experimental psychologist Steven Arthur Pinker (1997), who said that when an individual finds himself/herself in a highly stressful situation, he/she may acquire acute paranoia. Certainly, patients suffering from paranoid schizophrenia with thought disorder can be in acute states, characterized by sudden anger, irritability, anxiety and suspicion. There are also "negative" symptoms, like impaired volition or blunting of affect which can be presented but are not dominant in the clinical picture. Schizophrenia may declare itself episodically, having complete or partial remissions. However, in chronic cases, majority of symptoms persist during a long period of time (O'Leary, 2004). Moving now into the analysis of the patients needs using Maslow’s Hierarchy of Needs, it can be seen that the patient has needs in all the different levels of the pyramid. The main task of care team is to help him fulfil his needs from the lower sections of the pyramid so that he could work hard on fulfilment of his self-actualization needs. In terms of physical or physiological needs, Patrick needed a great amount of food and sustenance, in order to balance out the great amount of weight that he had lost during his schizophrenic episodes. Patrick also needs a bath and proper hygienic measures, for the sake of preventing infection and other organic diseases. In terms of security needs, Patrick requires a shelter that will safeguard him from the elements, and at the same time protect him from his paranoid fears, especially involving being run down by a car. Furthermore, in terms of love and belonging needs, Patrick is greatly in need of the love from his family and friends, especially since his girlfriend, probably his main source of the sense of love and belonging, has been uprooted from him by her untimely death. Therefore, the patient’s support system must endeavour to keep the patient happy and help him recover from the loss of his girlfriend. In addition, the patient’s self-esteem needs occur in the form of the need for a bath and grooming, since appearances can most often serve as a source of self-esteem and confidence. The patient is also in need of support from his family, in order to stop feeling inadequate. More importantly, the client needs occupational therapy and similar activities to help him keep forget his girlfriend. The end products of the activities and occupational therapies can also serve as powerful sources of the feeling of accomplishment as well as worth. Finally, self-actualization needs involve the patient’s need to come to terms with his mental condition, all its implications, and the different aspects of his life that he still has control over. With these needs, different interventions have been recommended and implemented. Efficacy of Current Clinical Environment/Service Quality of life and duration of illness are the variables used to measure efficacy of nurse interventions (Hamera et.al, 1992). A research conducted to investigate whether the cognitive-behavioural therapy (CBT) is able to produce significant results in relation to symptom burden or recovery in patients suffering from paranoid schizophrenia has shown that brief CBT helped such patients to avoid depression and has proven the necessity for training nurses in CBT (Turkington, 2006). Another study has also stressed the importance and efficacy of CBT as a component of treatment paranoid schizophrenia having positive effects and reducing the possibility of relapse (Chi-Chan et.al, 2002). Therefore, in the different interventions administered to the patient, their efficacy will be assessed based on the patient’s quality of life. For four months, Patrick became a patient of a psychiatric hospital where he was treated by a team of mental health care professionals. Later, he was sent back home, and during this time I became a member of care team. He was prescribed pain killers – Codeine and Paracetamol – to help fight his headache and abdominal pain. It was agreed that members of the care team should try to redirect him in case he starts to complain about head or abdominal pain. Patrick liked tea, so the healthcare team agreed that when he complained of pain he would be offered some calming tea. Patrick was also prescribed Multivitamins to be taken in the morning and evening. Now, Patrick prefers to ask for a cup of calming tea every time he has headache, though he understands that in case pain persists, he will be allowed to take Codeine and Paracetamol. He likes to receive positive feedback every time he prefers tea to painkillers. He even asked me to serve a cup of calming tea every hour as he realized that this would help him to control pain. However, Patrick did not ask the other colleagues from the other shift for tea. Instead, he gets the same headache during the said colleague’s shift. Here, one wonders whether this may be compared to statement of Sorensen, Paul, and Mariotto (1988) that paranoia diminishes and increases due to psychological factors rather than due to the drug's influence. The nutritionist, who was a member of care team, offered to involve Patrick into the planning of a daily menu. Patrick`s opinion was taken into account and he was encouraged to pick the meals he liked. That plan of action had a lot of success as Patrick felt very proud to serve others the meals that he has prepared. He took interest in reading the labels attached to food packages and tell everyone about the nutritional value of different meals. In addition, as a sign of the efficacy of this intervention, Patrick`s appetite has improved. Apart from that, Patrick took interest in shopping. The success of this intervention was observed when Patrick agreed that he had to take shower and wear clean clothes to go shopping. This plan also improved his perception of personal hygiene. These events may indicate positive improvements in the patient’s self-esteem. The healthcare team also organized going to the grocery store in a form of an excursions. I also observed that Patrick`s need to drink a cup of calming tea has disappeared every time he prepared to go shopping. The head of the care team signed Patrick up for the local organization, a Mental Health charity, where he had the possibility to attend meetings and talk to other people suffering from the same illness. Clients who come to the organization are trained in different spheres so that they get an opportunity to attain some skills of reasoning and concentration. A few months later, Patrick was invited to work some shifts at local charity shop. Now he works three hours for four days each week. He cleans the floor, desks, dry cleaning and puts the goods to the shop windows. Patrick seemed to like his job. His boss reports Patrick to be an asset at work, all the other workers at the shop are pleased and speak highly of their co-employee. In addition, the Mental Health charity enabled Patrick to visit courses aimed at helping people like Patrick in handling their finances. Now, he is able to work with his bank balance himself. He can draw a budget from what he earned and had his allowances for the week. These interventions show how the healthcare team was able to address the patient’s need for occupational therapy and also address the patient’s self-esteem and self-actualization needs. Also, a qualified physiotherapist helped Patrick to find the best way to relax. He taught Patrick how to exercise, meditate and breathe when one feels anxious. Care team also organized social events at the weekends. At first Patrick was reluctant to visit these events; however, he soon felt much more comfortable to have fun at such parties. He has already found several friends in his age group, with whom he visits these events. Still, some more self-actualization needs may require further addressing since the patient is still sometimes confused with his condition. Indeed, Pennington et al. (2003) claims that some patients suffering from schizophrenia who begin to show any positive symptoms may have distorted abilities to perceive their own conditions. Patrick understands that he missed a lot of interesting things like parties, so he might be trying to overcompensate and surpass his fellow patients. This may be the reason why during socializations, Patrick becomes difficult to control especially when he is excited. During my placement, I observed that not every family member of Patrick took part in discussions, events or attended special meetings organized to help him, resulting to an information gap. One day during holidays, Patrick went out with his younger brother and came home in the early hours of the next day. They had visited a bar, where Patrick argued with some drunken people. The rest of the weekend was spoiled as Patrick spent it in low spirits: he used foul language and banged the doors. In a few days Patrick told me that he was disappointed with his own behaviour. However, Patrick would not have had this problem, if his brother attended therapy meetings, and knew about Patrick`s needs to be considered (Patel & Jakopac, 2010). All in all, a great majority of the interventions provided for Patrick were successful. Indeed, in spite of the fact that paranoid Schizophrenia has drawn attention of scientists for many decades, there still exist more questions than answers. Not every study examining schizophrenic condition is consistent, valid and reliable. This is confirmed by the fact that Patrick was the one to show remorse, not his brother after their night adventure (Bentall, 2003). Nowadays, a mental health nurse`s responsibilities include communication with patient, monitoring his or her physiological status after medication treatment and decision making concerning some aspects of rehabilitation (Brown, 2000). Psychosocial and medicamental interventions for paranoid schizophrenia contribute to a lower prevalence and incidence of schizophrenia (Falloon et.al, 1999; Chan, 2002). Numerous studies in psychiatry have proven the nurse-patient relationships to be the central concept in psychiatric nursing (Dearing, 2004). After a long-term history of care for a patient suffering from paranoid schizophrenia I would stress the importance of building trust relationships with the patient, and not ever threatening him or making promises one cannot keep (Wilson & Kneisl, 2001). One should also avoid crowding around the patient psychologically and physically (Whitfield & Gibson, 1990). A nurse should give a neutral response to the patient`s condescending remarks and should not try to defend oneself or take patient`s remarks personally (Hamera et.al, 1992). The main task for a mental health nurse is to minimize stimuli and maintain safe environment, find an individual consistent approach to the patient. It might be useful to engage the ill person in some activities involving human contact, such as outpatient day care, training groups, and so on (Neeraja, 2008). If the patient is hallucinating, the nurse should explore the nature and content of these hallucinations (Saxton, 1980). In case patient begins to feel nervous, one should change the subject (Coler & Vincent, 2000). One should not joke or tease the patient suffering from paranoid schizophrenia and try to choose unambiguous words and phrases so that the patient could clearly understand them (Barker, 2001). Conclusion Nursing care of patients suffering from paranoid schizophrenia is connected with many challenges. There exist numerous nursing models and theories, created to help nurses in management of nursing process. These nursing models and theories differ linguistically, but they all stress the importance of the patient-nurse relationships and the necessity of having good communication skills. Although today, there are no methods to prevent paranoid schizophrenia and to cure it, there exists treatment that is able to minimize the impact of illness on patient’s life. The results of treatment greatly depend on early diagnosis and, individual approach in choosing psychological and pharmacological treatments. The said diagnosis is especially important in determining the interventions needed by the patient. This paper conducted an assessment of the needs of a patient, with the aid of Maslow’s hierarchy of needs. Several needs of the patient have been observed, and addressed . Still, the most important aspects of these interventions is the nurse-patient relationship. Numerous studies in psychiatry have proven the nurse - patient relationships to be the central concept in psychiatric nursing (Dearing, 2004). After a long-term history of care for a patient suffering from paranoid schizophrenia, I would stress the importance of building trust relationships with the patient, without making promises one cannot keep. The main task for a mental health nurse is to minimize stimuli and maintain safe environment, find an individual consistent approach to the patient. It is also necessary to reward positive behaviour of the schizophrenic patient to improve his level of self-esteem. Word Count: 3,260 References American Psychiatric Association (2004) Diagnostic and Statistical Manual of Mental Disorders. Amminger, G.P., Leicester, S., Yung, A.R., Phillips, L.J., Berger, G. E., Francey, S.M. (2006). Early-onset of symptoms predicts conversion to non-affective psychosis in ultra-high risk individuals. Schizophrenia Research, 84 (1): 67-76. Antai-Otong, D. (2008). Psychiatric nursing : biological & behavioural concepts. Clifton Park, NY: Thomson Delmar Learning. Barker, P. J. (2001). 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