Psychiatric Assessment - Case Study Example

Running head: THE CASE OF BRONWYN Managing the Bronwyn case Name Course Instructor Date Psychiatric assessment As part of the wider nursing process, assessment and diagnosis are not isolated activities. They are systematic and ongoing processes occurring throughout the nursing process alongside other activities of the process such as outcome development, intervention and evaluation. According to Boyd (2007), assessment refers to the process by which biopsychosocial information is collected and interpreted for the purposes of determining the functional, health and human response to mental health (p. 155). There are several types of assessments one may conduct depending on client’s history, current needs and individual preferences (Basavanthappa, 2007).One may conduct either a comprehensive, focused, screening or holistic assessment. Dulcan (2010) highlights that it is imperative to address the questions of whether there is a disorder, what it could be (from the signs and symptoms) and possible social, psychological and biological causes of the problem. In beginning the process of data collection, the initial contact is important as it sets the tone for whole process. The contact and subsequent activities are based on the establishment of a rapport with the patient or the designated source of the information (Boyd, 2007). The patient must be assured and enable to develop a sense of trust in the nurse. The contact person informs the parent or the patient the process of the assessment and it requirement in the clearest way possible (Dulcan, 2010). Directness and thoroughness are vital to ensure maximum preparedness. The nurse must also be aware of the legal and ethical considerations especially with reference to voluntary consent. The media of contact notwithstanding, the nurse making initial contact must be aware of the emotions of the parents or guardian, and the patient. Literature underlines the importance of conducting multifaceted data collection when assessing an adolescent patient (Barker, 2008). This may be collected through direct interviews. The nurse may also consider collateral contacts for information such as community service providers, school records and relevant agencies such as health institutions, child welfare, foster care and legal institutions (Dulcan, 2010). The nurse should maintain a non-judgemental attitude and respond to the disclosure honestly and with acceptance. The nurse should record and organize objective data, subjective data and historical data (Basavanthappa, 2007). Objective data includes observations, signs and findings from testing and physical examination. Subjective data includes data on client’s perspective of oneself and situations as captured in the clients words. Historical data focuses on the past data of the client. According to Basavanthappa (2007), any assessment guideline should focus on elements such as biographical data, health history, the subjective and objective data, and behaviours. The collected data are organized into discrete areas for the purpose of analysis. In diagnosis, it is vital to weight the diagnostic evidence in order to have clarity of thoughts about a case (Harrison et al, 2010). A diagnosis may overwhelmingly remain, but it is important to look for differential analysis requiring further investigation. As such it is advisable to make a list of diagnostic possibilities and identified features in favour or against each possibility (Harrison et al, 2010). Dulcan refers to this as formulations which may be done using a biopsychosial model or temporal axis. The former involves categorizing the diagnostic evidence into biological, psychological and social factors. This enables the nurse to establish predisposing factors, precipitating factors, perpetuating factors and prognostic factors (Shen et al, 2010). The assessing nurse is expected to adhere to legal and ethical standards. In addition, there are underlying theoretical principles upon which successful use of different assessment methods depend (Barker, 2004). Firslty, the nurse is expected to collect data systematically while involving all relevant sources through effective interviewing. One should prioritize data collection with reference to anticipated needs, gets appropriate consent, and synthesises data critically to identify vita patterns and documents the data in a way it is easy to retrieve. Theoretical, legal and ethical frameworks There is a dynamic relationship between the concepts of mental illness, its treatment and the law (Kumar, 2011). Mental illnesses and disorders and care of the patients present unique problems in biomedical ethics (Eastman & Starling, 2006). The legal and ethical framework and context is vital in providing holistic psychiatric care especially with respect to the rights of clients. As such, every care giver should have an understanding of the underlying legal and ethical considerations in the care and treatment of the mentally ill. According to Paul (2004), all clinicians are expected to work within the law, code of professionalism, ethics and guidelines of general health care. In practice, enabling clients with mental health recover and benefit from the nursing process requires a sound theoretical framework. USPRA outlines a series of premises upon which mental health care should be based. These premises assert the need to view mental health care as interactive and as developmental whose core focus is the future of the client. Secondly, the mental health professional engages in a relationship of mutual influence with the client (Corey et al, 2011). In this relationship, the professional’s concern is more on human responses to the mental distress than the disorder. Finally, the premise entrenches the need to use assessment evidence of events known only to the client. This is a relationship-based care which entrenches the tenets of mutual relationships (Barker, 2008). It is also vital to approach the health care with an all-systems framework. This is a holistic approach that addresses the interrelationship between the predisposing, precipitating and perpetuating factors (Barker, 2008; Ebert et al, 2000). A systemic approach which incorporates mutual interactions may enhance person-centred care which is now regarded as being the mainstay of acceptable mental and physical health care (Mueser & Jeste, 2008). The legal framework in addressing Bronwyn’s case as an adolescent revolves aspects such as informed consent, autonomy, parental rights and responsibilities, client participation and confidentiality. There is often an overlap between legal and ethical issues in mental health care for children and adolescents (Prout & Brown, 2007). Confidentiality is both a legal and ethical consideration of importance. It is a complex obligation closely related to privacy and privileged communication. These legal and ethical aspects are consistent with their developmental needs into maturity and autonomy and many adolescents would forgo care due to lack of confidentiality protection (Society for Adolescent Medicine, 2004). As such, the health care professional should not only protect the client’s confidentiality, but also educate the client and parents on the scope, importance and limits of confidentiality. The professional is prohibited from disclosing any information without the consent of the client. Privilege communication is based upon the provisions in the special mutual relationship between the professional and client. The professional must also respect and protect the privacy of the client throughout the interactive process. A critical concept that requires critical ethical analysis is decision making. According to Corey et al (2011), ethical decision making for any clinician, individually and in a multidisciplinary team requires thorough grounding in principle and virtue ethics. Principle ethics entail the principles which focus on acts and choices enabling the determination of what are acceptable socially and historically. They may be enhanced by application of moral ethics of autonomy, beneficence and non-maleficence (Barker, 2008). Post-psychiatry care reintegration The nursing process is established on the premise of enabling a developmental path for the client for the future (Barker, 2008). As such, it is vital to focus the treatment interventions on helping the individual recover and be integrated back into the community. Integration back into the community involves empowering an individual to take up increased positively productive participation and presence in the community (O’Brien et al, 2008). Recovery and integration back to community and normal life for clients seeking mental health intervention are products of complex interaction of three main interrelated factors: the individual characteristics, environmental characteristics and the characteristics of the nursing process (Onken et al, 2003). Individual characteristics include the self, sense of hope and holism; environmental characteristics include social relationships, peer support, material resources available to the individual and community and the effectiveness of formal support services; the characteristics of the nursing process or the process of exchange include empowerment, referent power, independence, interdependence and decision making. In view of enhancing the clients opportunities and abilities with respect to integration, various literatures underline the importance of empowerment (O’Brien et al, 2008; Davidson & White, 2007). Davidson & White (2007) underlines that recovery is the ultimate objective of the nursing process and that psychiatric interventions should enable a client re-establish normal roles and community life. All the core principles of the psychiatric rehabilitation entrench an empowerment theme (USPRA, 2007). According to Nelson et al (2001), the concepts of the empowerment and mental health are largely interrelated. Empowerment aims at involving the self in community, developing a positive personal dimension of perceived and actual power, and enabling the individual access valued resources. O’Brien et al (2008) conceptualizes empowerment as helping the individual take control of their mental health and decision making. This may be done by providing the client with proper psychiatric rehabilitation with skills such social skills, group work, interpersonal training, vocational training and management of medical issues (O’Brien et al, 2008). In order to achieve this, there are various suggestions in literature. Firstly, it is vital to develop support mechanisms in the community. A key aspect of environmental support is the client’s immediate family. The family may be involved in the nursing process from the point of assessment, formulation and administration of intervention as well as evaluation. In this approach, the role of mental health professional is to work with the client and the family enabling them to be in control of decisions and their mental health. Thus, in preparing the individual for effective reintegration, the approach in therapy and administration of the intervention is the family approach. Secondly, it is vital to conduct community education (Arvaniti et al, 2009). This creates awareness and empowers the community in understanding, appreciating, accepting and reducing the stigmatization of those who have had mental illness. Individuals with mental illness are prone to stigmatization and discrimination due to stereotypes and prejudices in many societies (Arvaniti, 2009). Community awareness creates social support in the family, peers groups, support groups thereby enhancing the individual’s self esteem, sense of identity, belongingness and other coping behaviors (O’Brien et al, 2008). It is also vital to arrange for outreach support services aimed at providing support networks for the discharged individuals. This involves a community or family-based care in which the individual negotiates the system with the help of the nurse and social relations. Rights to be enjoyed by Bronwyn during treatment According to the world Health Organization (2003), all people living with mental illness have the right to quality treatment and care which is provided through health care services. Such people should be protected against all forms of mistreatment and discrimination. A medical practitioner is required to make a diagnosis of mental illness in accordance with acceptable psychological, mental scientific and even ethical standards without compromising the patient’s right as a human being. Bronwyn, at the age of 15 years, in her health condition would enjoy the following rights while undergoing treatment. The rights of people who are diagnosed with, treated or identified as mentally ill shall be the same as to all other citizens (Johnstone M, 2008). It is in this respect that Bronwyn, should be treated with professionalism that does not violet her right as a person especially that she is young. She has the right to protection from both physical and psychological abuse during treatment. Johnstone M (2008), further acknowledges that right to treatment is critical for mentally ill patient and it includes hospitalization and psychosocial treatment as may be deemed appropriate by the health practitioner. This should of course be done in regard to acceptable medical practices, ethics and legal opinion. Young mental ill patients should be impartially represented and reviewed in order not to go against their fundamental rights. It is important to note that all mentally impared persons have the right to treatment that is carried out on the basis of equal professional and existing ethical standards without any form of discrimination. As Isohanni et al, (2007) explain, mentally ill patients are normally incapacitated to managing themselves. Treatment of such persons require considering psychosocial rehabilitation which is aimed at reinstating their skills for living. For the case Bronwyn, this should take into account the needs for her housing and continued care after she is discharged from hospital. Bronwyn should also be given special preventive together with therapeutic attention and care that would enable her protects her health and fundamental human rights as a young person (Whitaker R, 2010). Under the European Convention, no person shall be exposed to torture or treated in a degrading way and this is relevant to mental health (Johnstone M, 2008). Bronwyn has the right to good health conditions while in the hospital. She should be provided with enough sanitary facilities and sleep in a well ventilated room that is not crowded and on good beddings. The whole idea is that she should not be exposed to degrading treatment. She shouldn’t be treated in a way that causes mental and physical harm. Whitaker R, (2010), emphasizes that mentally ill persons have the right against physical or any other form of restraint which amounts to inhuman treatment. Bronwyn should be allowed to move around freely under the watch of a medical practitioner, and using medicines to sedate her because of given reasons is not acceptable under the Human Rights Act for people with mental health problems. In regard to the above, it is prudent that moral standing and social justice for people suffering from mental illness should be improved especially when they are undergoing treatment. Unless the stigma people with mental illness go through is not overturned, they will continue being marginalized and their rights violated or even ignored. Strategies to help deal with Bronwyn’s feeling of disempowerment The disempowerment Bronwyn felt during her depression is common among teenagers. It is one of the wide ranges of negative outcomes which includes but are not limited to severe social impairment, long-lasting effects on cognitive development, suicidal behavior, and a high risk of recurrence. Depressed teenagers are at increased risk for a number of problems including increased medical and psychiatric hospitalizations, suicide attempts, and life challenges at home, at work, and in social groups even when they grow up. To help her avoid these eventualities, it would be important for the treatment to be targeted, putting into consideration the specific circumstances that are unique to her. These would typically include her family, social and educational circumstances. It is from this basis that the case manager would be able to determine which course of action would work for her. Her social and educational circumstances would definitely influence how much she knows about her condition. The said circumstances would also affect her understanding of motivation which would be rekindled in the quest to make her feel empowered. In order to make Bronwyn feel empowered it will be important for the case manager to understand how much she knows about the condition affecting her. It is from this basis that misinformation particularly regarding her inability to fight and win the war against the condition would be corrected. Gaps existing in what Bronwyn knew about her condition would also be filled. This issue would best be dealt with using Interpersonal Therapy as a specific factor in treatment while at the same time employing non specific factors to improve mood. However, by and large the psychotherapy to be used in the case would not confine itself to being approach THE BRONWYN CASE specific. This is because such factors affect the outcome more than approach specific factors (Lambert, Shapiro and Bergin, 1986). It is for this reason the creation of a good relationship between Bronwyn and me as the case manager would be of critical importance in dealing with the problem of the feeling of disempowerment whose root cause is normally the patient’s inability to tackle the symptoms that they exhibit as a result of their suffering from depression. This is the relationship described by Kelly & Deane (2009) as the therapeutic relationship through which a patient needs to feel understood, be respected be able to generate the interest of another person in themselves, be forgiven and accepted and also be encouraged to face and overcome difficulties. As the case manager, I would also seek to ensure that in case of my absence, the patient would hold sessions with an individual who has the ability to build strong relationship while also ensuring that the treatment regimen is basically the same as the one the patient is used to. Possible ways of giving care to mental health patients The case confronting Bronwyn was a typical case of Major Depressive Disorder whose management would require the psychotherapy. This is because the patient being under the age of eighteen years, the standard accepted practice would be to avoid the use of medication (Nice, 2005). Psychotherapy in this case would primarily involve the employment of Cognitive Behavioral Therapy to help the patient manage dysfunctional emotions caused by her condition. The first step in the use of CBT would be to use Background, Affect, Trouble, Handle and Empathy (BATHE) procedure. This procedure will ensure that all the psychosocial problems affecting the patient are thoroughly understood by the caregiver. Once they have been understood, the caregiver would be able to concentrate resources according to the severity of the problem to ensure all of the problems are effectively dealt with. The other CBT procedure that could be used on a teenage patient like Bronwyn is Change it, Accept it, Reframe it or Leave it (CARL) this procedure would allow Bronwyn take credit for decisions she made previously concerning her life in order for her to feel back in charge. Her involvement in different marathons and her previously active life could be used to help her feel that she has the power to make decisions that could positively affect her life CARL is important for Bronwyn as it would help her understand that it is okay if she cannot have everything go her way and that does not mean that she is not in control (American Psychiatric Association, 2000). It would also be an important part of CBT to teach the patient how to solve social problems such training helps them to accurately gauge the magnitude of the social problem they could be facing while working out solutions that could be multifaceted and anticipating obstacles and thinking of solutions to the obstacles beforehand (Clabby, 2003). This is because stress in poor problem solvers is one of the causes of depression owing to the helplessness concomitant to the inability to effectively deal with a problem (Clabby, 2006). Apart from CBT, depression could also be treated using antidepressants such as selective serotonin reuptake inhibitors which include drugs like escitalopram , sertraline, fluoxetine among others the side effects seen in patients on these drugs are rather mild making them the more preferred ones in the treatment regimen. A combination of medication and psychotherapy is often preferred in patients over the age of eighteen years. Should medication and psychotherapy fail, treatment could be offered using electroconvulsive therapy. In cases of severe major depression especially in cases where the patient is in a catatonic state, and is incapable of taking medicine orally, this may be the only way to treat them. Electroconvulsive therapy involves inducing of seizures electronically while the patient is anesthetized. References Arvaniti, A., Samakouri, M., Kalamara, E., Bochtsou, V., Bikos, C., & Livaditis, M. (2009). Health service staff's attitudes towards patients with mental illness. Society of Psychiarty and Psychiatric Epidemiology, 44 , 658-665. Barker, P. (2004). Assessment in pyschiatric and mental health nursing: in search of the whole person (2nd ed). Cheltenham: Nelson Thornes. Barker, P. (2008). Psychiatric and Mental Health Nursing: The craft of caring, 2nd Ed. Florida: CRC Press. Basavanthappa, B. (2007). Psychiatric mental health nursing. New Delhi: Jaypee Brothers. Boyd, M. (2007). Psychiatric nursing (4th Ed). London: Lippincott Williams & Wilkins . Davidson, L., & White, W. (2007). The concept of recovery as an organizing principle for integrating mental health and addiction. Journal of Behavioral Health Services & Research, 34 (2) , 111-120. Dulcan, M. (. (2010). Dulcan's textbook of child and adolescent psychiatry. Washington, DC: American Psychiatric Publishing. Eastman, N., & Starling, B. (2006). Mental disorders ethics: theory and empirical investigation. Journal of medical ethics, 32(2) , 94-99. Harrison, P., Geddes, J., & Sharpe, M. (2010). Lecture notes: psychiatry (10th Ed). Hoboken: John Wiley & Sons. Isohanni, M., Nieminen, P., Moring, J., Pylkkänen, K., & Spalding, M. (2007). The dilemma of civil rights versus the right to treatment: questionable involuntary admissions to a mental hospital. Acta psychiatrica scandinavica, 83(4), 256-261. Johnstone, M. J. (2008). Stigma, social justice and the rights of the mentally ill: Challenging the status quo. Australian and New Zealand Journal of Mental Health Nursing, 10(4), 200-209. Kumar, R., Mehta, S., & Kaira, R. (2011). Knowledge of staff nurses regarding legal and ethical responsibilities in the field of psychiatric nursing. Nursing and midwifery research journal, 7 (1) , 1-11. Mueser, K., & Jeste, D. (2008). Clinical handbook of schizophrenia. New York: Guilford Press. O'Brien, P., Kennedy, W., & Ballard, K. (2008). Psychiatric mental health nursing : an introduction to theory and practice. Sadbury: Jones and Bartlett Publishers. Onken, S., Dumont, J., Ridgway, P., Dornan, D., & Ralph, R. (2003). Mental health recovery: What helps and what hinders: A national research for the development of recovery facilitating system performance indicators. Paul, M. (2004). Decision-making about children's mental health care: ethical challenges. Advances in Psychiatric Treatment, (10) , 301-311. Prout, H., & Brown, D. (2007). Counselling and psychotherapy with children and adolescents: theory and practice for school and clinical settings (4th Ed). Hoboken: John Wiley & Sons. Shen, H., Hales, R., Shahrokh, N., & Dulcan, M. (2010). Child and adolescent psychiatry: a companion to Dulcan textbook of Child and Adolescent Psychiatry. Arlington: American Psychiatric Publishing, Inc. Society for Adolescent Medicine. (2004). Confidential Health care for adolescents: position paper of the Society for Adolescent Medicine. Society for Adolescent Medicine, 35 , 160-167. US Psychiatric Association. (2007). Psychiatric rehabilitation principles. Available at https://uspra.ipower.com/Certification/USPRA_CORE_PRINCIPLES2009.pdf Whitaker, R. (2010). Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill. Basic Books. World Health Organization (2001) Atlas: Mental health resources in the world, 2001. Geneva: World Health Organization, Department of Mental Health and Substance Dependence. 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There is often an overlap between legal and ethical issues in mental health care for children and adolescents (Prout & Brown, 2007). Confidentiality is both a legal and ethical consideration of importance. It is a complex obligation closely related to privacy and privileged communication. These legal and ethical aspects are consistent with their developmental needs into maturity and autonomy and many adolescents would forgo care due to lack of confidentiality protection (Society for Adolescent Medicine, 2004).

As such, the health care professional should not only protect the client’s confidentiality, but also educate the client and parents on the scope, importance and limits of confidentiality. The professional is prohibited from disclosing any information without the consent of the client. Privilege communication is based upon the provisions in the special mutual relationship between the professional and client. The professional must also respect and protect the privacy of the client throughout the interactive process.

A critical concept that requires critical ethical analysis is decision making. According to Corey et al (2011), ethical decision making for any clinician, individually and in a multidisciplinary team requires thorough grounding in principle and virtue ethics. Principle ethics entail the principles which focus on acts and choices enabling the determination of what are acceptable socially and historically. They may be enhanced by application of moral ethics of autonomy, beneficence and non-maleficence (Barker, 2008).

Post-psychiatry care reintegration The nursing process is established on the premise of enabling a developmental path for the client for the future (Barker, 2008). As such, it is vital to focus the treatment interventions on helping the individual recover and be integrated back into the community. Integration back into the community involves empowering an individual to take up increased positively productive participation and presence in the community (O’Brien et al, 2008). Recovery and integration back to community and normal life for clients seeking mental health intervention are products of complex interaction of three main interrelated factors: the individual characteristics, environmental characteristics and the characteristics of the nursing process (Onken et al, 2003).

Individual characteristics include the self, sense of hope and holism; environmental characteristics include social relationships, peer support, material resources available to the individual and community and the effectiveness of formal support services; the characteristics of the nursing process or the process of exchange include empowerment, referent power, independence, interdependence and decision making. In view of enhancing the clients opportunities and abilities with respect to integration, various literatures underline the importance of empowerment (O’Brien et al, 2008; Davidson & White, 2007).

Davidson & White (2007) underlines that recovery is the ultimate objective of the nursing process and that psychiatric interventions should enable a client re-establish normal roles and community life. All the core principles of the psychiatric rehabilitation entrench an empowerment theme (USPRA, 2007). According to Nelson et al (2001), the concepts of the empowerment and mental health are largely interrelated. Empowerment aims at involving the self in community, developing a positive personal dimension of perceived and actual power, and enabling the individual access valued resources.

O’Brien et al (2008) conceptualizes empowerment as helping the individual take control of their mental health and decision making. This may be done by providing the client with proper psychiatric rehabilitation with skills such social skills, group work, interpersonal training, vocational training and management of medical issues (O’Brien et al, 2008). In order to achieve this, there are various suggestions in literature. Firstly, it is vital to develop support mechanisms in the community.

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