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Assessment In Mental Health Practice
The aim of this paper is to identify and focus upon the many different types of assessment utilised in patient care including risk assessments, physical and mental health assessments and specific mental health assessment tools; the paper will also focus upon the need to acknowledge the importance of patient history in making assessments and the need for a person centred approach to care delivery.
The author will cite relevant references to support his statements and conclusions and appendices are provided giving examples of different types of assessment documentation used within his sponsoring trust.
To maintain confidentiality and protect anonymity, certain parts of this original essay have been omitted such as the patient history, this is done in accordance with the Nursing & Midwifery Councilís Code Of Professional Conduct (2002) guidelines.
The author will however highlight the following issues that the patient had which are relevant to this essay:-
*Observed difficulties in mobilising including reported observations of a Ďshuffling gaití when walking.
*Deterioration in short term memory - a referral being made for assessment by the Consultant Psychiatrist in Older Personís Mental Health regarding this.
*C.T. head scan required to ascertain if any organic issues needed addressing.
*Regular Blood Pressure Monitoring for Hypertension.
Throughout this essay ĎThe Patientí will be the given title for the person focussed upon in the text; although this makes the piece look rather disjointed this again follows guidelines in order to ensure confidentiality.
The Assessment Process
The author feels it is important to identify what assessment actually is and what is its purpose - Barker (1997) defines assessment as trying to gain an Ďoverall pictureí that defines positive characteristic as well as problems, describing skills and assets as well as handicaps, disabilities and other dysfunctions.
The author feels that although assessment can focus upon positive aspects, the process generally acknowledges and addresses the negative more - if not, why would the patient be in hospital in the first place? Stott (1996) highlights the need for assessment in that the client and the assessor can together recognise the clients functional deficits and also his/her areas of ability and Wilkinson (2002) argues that without accurate and comprehensive assessment, other elements of the nursing process such as planning, implementation and evaluation will be informed by flawed information.
Another important aspect of the assessment process regards goal setting: Fox and Conroy (2000) define goals as being something that the client would like to achieve in relation to the identified problem and Stevens (1996) states that goals should be clear, realistic and regularly monitored, with written standard establishing how this monitoring may take place.
Each of the patientís goals were recorded on Acute Nursing Intervention Plans which were updated on a regular basis - each plan discussed with the patient, requiring both the patientís consent and signature.
One specific goal plan regarded the issue of incontinence and how it might be reduced by prompting - the author however found this to be unrealistic however as the patient showed no insight into this issue.
Another important aspect of the assessment process involves the management and monitoring of risks: Pugh (1996) defines risk as the likelihood that an unpleasant outcome will occur because of the presence of a hazard.
One such risk regarded the patientís impaired mobility and recent falls - this necessitated the completion of a Risk Management Plan which was regularly updated on a Risk Assessment Review Sheet.
The patient had had falls in the past and issues surrounding the patientís mobility and ability to function at home could be seen from the patientís history: Ryrie (2000) remarks that the patientís history should be taken into account regarding risk assessments as circumstances surrounding past behaviour can provide useful insights to reduce the likelihood of recurrence.
The author feels that although identified, unfortunately, the risk of falls could not have been prevented from occurring - once a fall did occur however, the patientís observations were maintained more closely.
When placed Ďon obsí, a patient is monitored at a regular recognised time period (as it Trust Policy) and the observations are recorded on an Observation/Nursing Intervention Assessment And Record Sheet. The patient was placed on ĎMedium Observationsí after a fall that is, at fifteen minute intervals and information was mainly recorded by Nursing Assistants.
It could clearly be identified in the patientís history that many physical issues needed to be considered for the patientís effective treatment and care planning: various healthcare professionals were consulted/referrals made regarding these issues, including the Occupational Therapist, Incontinence Nurse and Neurologist, and assessments were made and regularly updated by the wardís multidisciplinary team including a Waterlow Pressure Sore Prevention treatment Policy, and regular daily Blood Pressure/Pulse Monitoring.
The author wishes to highlight the importance of these assessments is not only effective in monitoring physical healthcare, but also that certain physical factors can have an effect on/address the presenting mental state; for example Stewart (1999) explains that raised blood pressure is a risk factor for future cognitive impairment and dementia in later life.
With regards to incontinence, Coni et al. (1992) define it as being the involuntary loss of urine to a socially or hygienically unacceptable degree, Jackle (1989) further explains that it may accompany underlying diseases such as a urinary tract infections that can clear up after successful treatment; Bennet and Jones (2001) point out that urine infections are a frequent cause of acute memory difficulties and confusion in elderly people - the author feels that this is worthy of note as the patient had no insight into this issue when it was discussed with the patient by members of the multidisciplinary team.
Although difficulties regarding the patientís mobility appeared to be sporadic throughout the patientís treatment, the patientís walking movements were often described by the multidisciplinary team as a Ďshuffling gaití or similar when documented in the Joint Assessment And Daily Records sheets; this description is often given in Parkinsonís disease.
Bauvette-Risey (1989) describes Parkinsonís disease as being a movement disorder resulting from abnormalities in the extrapyramidal motor system causing difficulties in balancing and walking; Tunmore (2000) further states that forty per cent of those suffering from the disease progress to dementia - Muir et al. (1997) concur with this, explaining that in the latter stages of the disease intellectual and cognitive functioning can become impaired.
In the Clinical Review, the Consultant Psychiatrist addressed this issue with the patient, and it was explained that the patientís father had Parkinsonís disease and that the patientís mother had been diagnosed with Alzheimerís disease.
Could genetic factors therefore be influential regarding the patient?
With regards to Alzheimerís disease, Bennet and Jones (2001) state that first degree relatives of a person with Alzheimerís disease (father, brother, mother or sister) are three times more likely to develop the condition than non-affected families in the population, yet further go on to state that these cases are sporadic.
In addressing this issue, it was decided that a CT Scan would be required.
The Radiological Society of North America (2004) explains that Computed Tomography (CT) scanning uses specialist x-ray equipment that provides more detailed information than plain x-ray films and can identify such as head injuries, stroke, brain tumours and other brain diseases.
Bennet and Jones (2001) state that in assessing and investigating memory loss most people will require some form of brain scan such as a CT Scan, however they further state that generally in Alzheimerís disease nothing remarkable is shown on a scan, although radiologists may be able to observe shrinkage of the hippocampus - a condition indicating Alzheimerís disease as opposed to normal ageing changes.
Mental Health Assessment - The Use Of Specific Assessment Tools
In using the Mini Mental State Examination in addressing short-term memory issues, one must be aware of certain factors that could affect the scored results - one such factor is the patientís educational and cognitive abilities taken from his/her history.
Ritter and Watkins (1997) point out that an assessment of cognitive ability must include independent information about his/her educational achievement so that individual measures are interpreted within their true social context: The author addressed this by discussing many issues of the patientís past in informal Ďone-to-oneí chats prior to completing his first assessment with the patient - he feels that there was nothing indicative of affecting the score as the patient was quite proud academic achievements in the past, including going on to study further after leaving school.
Initially the author found the MMSE testing to be somewhat invasive and that itís format might appear quite interrogative; however, as he had developed a good rapport with the patient who willingly consented to complete the MMSE each time, and because he was utilising it on a regular basis he felt more confident in its use.
The author found that it was quite easy and quick to complete (that is, easy for him): Moran (1999) states that the MMSE takes about ten minutes to complete and is reliable giving similar results time after time amongst different examiners.
Each resulting score that the author recorded was twenty-four or less which appeared to indicate impairment (once educational factors had been ruled out): Bennet and Jones (2001) state that when completing an MMSE lower scores should not be interpreted as dementia unless they are consistently given and produce the same results over time, and Pitt (1996) suggests that an MMSE score of less than 24/30 indicates significant cognitive impairment though allowances should be made for the patientís likely intelligence, education and cooperation.
As the patient seemed to be fully cooperative, the author does not feel that this was an issue - however he highlighted certain recurring factors in each of the completed examinations in that the patient frequently scored the lowest in the Ďorientationí scores.
Bennet and Jones (2001) explain that disorientation involves not knowing where one is or the correct time, date or month and regarding dementia Pitt (1996) states that orientation is usually lost for time, then for place and finally, less commonly for person: in the patientís case, she frequently could not correctly answer the day, month, date and year - yet scored full marks for orientation to place.
After completing each MMSE, the author asked if the patient would like to know the results, and each time the patient wished to do so: Stott (1996) states that the client should be given some indication of how he/she fared during testing and what implications the test results have for him/her.
The author will discuss this in more detail in the next section of this paper.
A Person-Centred Approach To Care
Prior to undertaking each MMSE, the author ensured that he would spend some considerable time in conversation with the patient - this he felt was important in that it showed value for the therapeutic relationship and that he was not solely interested in completing the examination and rushing off to document the results.
Both the author and the patient agreed as to an appropriate time and date for the MMSE to take place (usually after lunch, once fortnightly), and on each occasion the author again ensured that the patient was happy to do the assessment: this he felt was of paramount importance in maintaining autonomy.
Pearson and Vaughan (1986) define patient autonomy as being the freedom to make decisions within the limits of individualís competence rather than having to comply to the dictates from people in a superior position - therefore, the author made sure that the patient was not simply performing the MMSE because the patient felt forced into doing it.
The author ensured that on each occasion he told the patient the reasons for the MMSE needing to be completed, and afterwards gave the scores attained, allowing the patient the opportunity to ventilate feelings and ask questions regarding the results.
In discussing the results of the MMSE the author ensured that he was supportive towards the patient and offered reassurance: for example, he stated that they were used in assessment rather than diagnosis and that there were many other factors to be taken in consideration regarding memory issues.
On one occasion, the patient had obtained a score higher than that recorded previously - the author informed the patient of this, and the patient was pleased with this stating that the patient felt memory had improved because the patient had been going out for afternoons with s support worker. The author was also pleased for the patient who seemed to benefit in mood from being told this.
One thing that the author particular noted was the lack of evidence for short term memory loss when engaging in conversation with the patient - the patient could engage in conversation about recent events and news items with much detail and clarity; indeed, this had been observed regularly by other members of the multidisciplinary team.
The author therefore feels that there is some validity in completing the MMSE, in that only when specific questions are asked does it then become apparent there are short term memory issues, that is, in general conversation, one would hardly be likely to ask a patient if he/she knew what day it was on a frequent basis as this would be more formal and therefore less person centred.
The author feels that this paper has highlighted many important issues regarding assessment yet was surprised to see the many similarities and common themes that occurred within the different types of assessment: for example, issues regarding memory problems and confusion being highlighted in Parkinsonís disease and Urinary Tract Infections and Hypertension.
Although not addressed elsewhere in this paper, the author wishes to add that he could also have focussed upon medication issues: for example, the patient was administered the antidepressant Mirtazapine - the British National Formulary (2004) lists possible side-effects to this drug such as memory disturbances and falls; however, the author decided not to concentrate on this issue too much as other members of the multidisciplinary team informed him that the patient had been receiving the drug for quite some time and that no observations regarding these issues had been previously observed or recorded.
The author feels that he has been effective in the patientís care planning and implementation and that he would be confident in utilising assessment tools in the future because of this experience, in that he had gained a good therapeutic relationship with her which helped him develop his skills in this.
The author feels that the MMSE is an important tool in identifying issues that might not otherwise be observed in a less formal evaluation (such as disorientation to day, date and year) yet is aware of the importance of spending as much time as possible with a patient - not only to gain a Ďfull pictureí of how the patient is, but to also show value for that person which will effect a better standard of care delivery.
last updated 18/06/05
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