COMMUNITY PLACEMENT (Describe the chosen individuals background and history to date) - Essay Example

?COMMUNITY PLACEMENT Community Placement This essay will evaluate the nursing practice and the improvements implemented to the patient’s situation while establishing a therapeutic consideration to a client being cared for by the Assertive Outreach Team where I’m undertaking my semester 5 placement. In this critique, my client will be confidentially referred to as Ms. B. Her identity will be protected in accordance with the code of professional conduct as specified by the Nursing and Midwifery Council (NMC, 2008) which basically requires health professionals to respect the confidentiality of patients and prevent patient information from being improperly disclosed to other people. I would be establishing Ms. B’s background, as well as her medical history to date. Using therapeutic approaches, I will also describe her psychological, physical, and social needs; and I would also be describing how these approaches have helped in the assessment of needs, in the identification of goals, and in the identification of applicable nursing interventions. Describe the chosen individual’s background and history to date. Ms. B has been diagnosed with major depressive disorder and has already attempted suicide twice in the last six months. As described and defined by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) major depressive disorder is characterized by the following symptoms for a continuous period of atleast two weeks: having depressed mood most of the day, every day as observed by others; markedly reduced interest in daily activities nearly every day; significant loss of weight or significant weight gain; insomnia or hypersomnia almost every day; psychomotor agitation or retardation almost every day; fatigue or loss of energy; feelings of worthlessness or excessive guilt almost every day; reduced ability to concentrate almost every day; and recurrent suicidal ideation (Sammons, n.d, p. 1). Rottenberg, et.al., (2002, p. 135) also discuss that one of the characteristic symptoms of depression is anhedonia which basically refers to a person’s inability to feel pleasure. In effect, those with major depressive disorder are often unresponsive to repeated attempts to stimulate pleasure. Individuals suffering from major depression seem to have a diminished experience in terms of positive feelings in relation to non-depressed individuals, more often than not these individuals experience a lesser feeling of joy or pleasure from some of their activities (Allen, et.al., 1999). This reduced response to pleasure has been attributed to feelings of depression from their anxious states and their related forms of psychopathology. Those with major depressive disorder also seem to display a general affective flattening where they would have a standard emotional response to all emotional stimuli (Rottenberg, et.al., 2002, p. 136). In effect, these individuals show less electromyographic response during affective memory stimulation; less facial reactivity to facial stimulus; and a lack of autonomic response to various stimuli (Dawson, et.al., 1977). In most emotional stimuli, they seem to manifest a monotone and an unenthusiastic response. Ms. B is a White Caucasian female, 34 years old, who recently miscarried her child and then was left by her husband for another woman. She came from a broken family with her parents divorcing when she was barely 5 years old. Her mother was an alcoholic and abandoned her when she was 11 years old. She was then sent to live with her father, who was physically abusive. She was severely beaten by her father when she was 14 years old and was removed from his custody. She was then raised in an orphanage until the age of 17 when she run away and started living in the streets as a prostitute. She hustled the streets for 10 years until she was arrested for sexual solicitation. By that time, she was already addicted to cocaine and heroin. She was sent to rehabilitation and successfully recovered from her drug addiction. At the age of 30, she was able to turn her life around, by being drug-free and working as a waitress at a catering company. She even started a relationship with a fellow service worker. They married a year later. She got pregnant a year prior to her admission in the mental health institution. Four months into her pregnancy, she slipped on the bathroom floor and lost her baby. Initial feelings of guilt started manifesting then. She was emotionally devastated by her miscarriage. This drove a wedge between her and her husband who started an affair with a work colleague. Her husband left her 6 months prior to her admission because apparently he could not stand living with her depressed condition anymore; she later found out that there was another woman involved. This drove her further into her depression and weeks after her husband left her, she attempted suicide by slashing her wrists. She was found by one of her friends. She refused mental health interventions for her depression. On her second suicide attempt, she was admitted into the mental health institution. Current history Ms. B was put in the care of my team (AOT) because of the fact that she is very much unstable and she is sometimes failing and refusing to take her anti-depressant medications. She seems to still be in denial about her depressed state and she does not like some of the side-effects which her antidepressant drugs are causing. She is supposed to have follow-up checks about 4 times a week but she sometimes refuses to allow the office such visits. Home visits are conducted about three times a week to check her progress and ensure medication compliance. Orientation: Her behaviour is more of less the monotonous; she can be glum and unresponsive to our efforts. She sometimes refuses us entry into her home. She also refuses to socialize with other people and the community and our presence sometimes is the only social stimulation she gets. Feelings: She is easily hurt by our comments about her condition. She is still very much insistent on the fact that she is not suffering from any mental illness. But she refuses to try to return to her normal activities. Without her antidepressant medications, she is at risk of retreating into her depressive thoughts which would likely lead her to attempt to kill herself. Communication: She is often unresponsive to our attempts at communication. She is fond of monosyllabic responses and she refuses to talk about her feelings. In her frustration at us and her desire to be left alone, she sometimes lashes out in anger or unexpectedly bursts out crying. Interpersonal relationship: She does not have a good relationship with the staff, and she basically treats us as nuisances in her life. She has a handful of good friends with whom she communicates. But as far as her immediate community is concerned, she basically has a casual relationship with them. Her neighbours act accordingly and refuse to talk and communicate with her as well. Emotion and mood: For the most part, she is often unemotional about things. When anxiety sets in and she has not taken her anti-depressant medications, she cries easily and gets angry easily. She is never physically aggressive towards other people, more towards herself. And then, her physical aggression often affects other people who often prompt her further to get help or to take her medications. 2. Detailed analysis of Mr A’s current psychological, physical and social needs There are various biological elements which may have contributed to her depressed state, with her mother being an alcoholic. Alcoholism and depression often have a direct relationship with each other, with one causing the other, and/or vice versa. She may have inherited such tendencies for her depressive state from her mother. Her life history is however the more likely contributor to her depressed condition. In assessing her psychological issues, I will consider the bio-psychosocial model as a definitive treatment for this patient. This approach will consider the use of medications, in this case, anti-depressants and other psychological remedies. Medications are an important tool in the treatment of depressed patients. Various studies also set forth that psychosocial interventions are also useful tools which can be paired and combined with anti-depressant drugs to manage major depressive disorder and its manifestations. The biological approach will involve the use of Prozac which is an antidepressant under the drug group Selective Serotonin Reuptake Inhibitor or SSRI (PsychAtlanta, n.d, p. 1). This drug works in the nerve cells of the brain, and prevents the reuptake of serotonin. Serotonin comes from the nerve cells of the brain and often causes the lightening of one’s mood (Netdoctor, 2011). Prozac acts to prolong serotonin in the blood, helping lighten the patient’s mood and relieving depression. The psychosocial approach includes the process of understanding and evaluating the patient’s psychological, social, and environmental conditions and history (Nemade, et.al., 2007). Psychosocial interventions make use of a care coordinator found in an AOT; these interventions help ensure that the symptoms of depression are addressed as soon as possible without any possible sign of relapse. These interventions include the process of communicating and engaging with the patient therapeutically and evaluating them as a whole person without including standard set interviews. Social needs. Ms. B has experienced many bad and emotionally disturbing events in her life. She was physically abused, was raised in an orphanage, worked as prostitute, lost her baby, and was left by her husband for another woman. She is therefore in need of some social contact with other people to help reintroduce her into the real world and not to confine her to her own depressed and sad world. At this point, she only has a small number of friends, who are mostly her workmates. She does not communicate much with her neighbours and at times is unresponsive to the mental health staff. Psychological needs. She is in need of psychological help, to help arm her with the tools to emotionally cope with her depression. Due to her negative experience from her childhood and adolescent period, she has never been armed with adequate coping skills. Her family background, especially her mother’s abandonment and her father’s abuse led her to think that she was inadequate and weak. The fact that she was left again by her husband and that she lost her baby reinforced these feelings of inadequacy. Physical needs. She is in need of physiological remedies, including anti-depressant medications. 3. Demonstrate how the therapeutic/theoretical approaches chosen in part two can provide a structure or guide the nursing care. In assessing the patient needs while applying the biopsychosocial approach, the assessment would include evaluating the patient’s biological, psychological, and social needs. The patient’s biological needs are based on his physiology, in this case, possible deficiencies or issues with his neurological processes which are affecting his mental health. According to Andrew (2011), depression may be caused by changes in receptor-neurotransmitter processes in the limbic system, the prefrontal cortex, hippocampus and the amygdala. The author also discusses how gene-environment relationship, including the endocrine and metabolic mediators can impact on the development of depression (Andrew, 2011). It is therefore important, in assessing the patient, to review the patient’s family history, because some studies claim genetic links between families in relation to mental health disorders including bipolar disorder and its depression component. Possible defects have been seen in chromosome II or X; more genetic research is however needed to establish the accuracy of these reports. In terms of the psychological component of this approach, it is important to assess the patient’s mental processes, her thoughts, her feelings, her emotional state, and her coping mechanisms. In this case, an assessment of her psychological state would reveal that she is still very much depressed, sad, anxious, and helpless about her general condition. Her psychological and emotional state is very much a product of what is happening to her physiologically, and vice versa. In effect, “wellness or illness is not simply a matter of someone’s physical state, but is also influenced by that person’s psychological and social status as well” (Andrew, 2011). In assessing the patient’s social needs as part of the biopsychosocial approach, it is important to note how the patient is very much isolated from society. She seems to have withdrawn from her family, her friends, and her community in general. This further contributes to her needs as a social being, reducing her into a lonely existence – one which is very much in danger of an inexistent support system. In effect, her social needs include a support system and social interactions with friends and with the community. With these multiple needs, there is a need for the multidisciplinary care team to step in. This team includes a psychiatrist, a mental health nurse, and social worker. The AOT would work well with these health professionals as they are necessary members of the mental health team. Such a team would work with each other and coordinate their efforts to first assess the patient’s biological, psychological, and social needs, subsequently establish a plan of care, and then subsequently, implement such for the patient’s benefit (Carpenter, et.al., 2003, p. 1083). The nurses in this case help coordinate and link the services of the various mental health professionals. They are usually the health professionals which spend the most time with the patients, and as such are more likely to have a more accurate picture of the patient’s mental and physical health (Brooker and Nicol, 2003, p. 285). They continually update the other members of the mental health team regarding changes in the patient’s condition, as well as reactions to treatment. They also observe the patient’s symptoms, evaluating the interaction between the patient’s biological, psychological, and social aspects and establishing how the interaction of these aspects affect the patient’s needs and mental health symptoms. Recommendations of her observations would then be made to the other members of the MDT. After coordinating with the team, the goals of treatment include the following: to improve emotional coping by 50% after 6 weeks of biopsychosocial therapy sessions and antidepressant medications; to reduce suicidal ideation by 50% after 2 weeks of biopsychosocial therapy sessions and antidepressant medications; and to interact with friends and with the community by attending atleast one social activity per week after 2 weeks of biospsychosocial therapy. In applying the biopsychosocial model to this depressed client, the biological aspects which are likely causing the patient’s condition would be considered and treated accordingly. In order to address the psychological aspects of the patient’s illness the cognitive behavioral therapeutic approach can be applied to the patient. This approach can help adjust the patient’s thought processes (cognitive), to change his patterns of understanding and cognition, and shifting them towards other possibilities and choices, helping ensure that the usual responses to stimuli or the usual patterns of behavior would not be followed (Leichsenring, 2001, p. 401). Based on the patient’s mental health progress, the biopsychosocial approach was successful first in assessing the patient’s needs and condition. The biopsychosocial therapeutic approach ensured that possible neurological defects were addressed by the antidepressant. The application of the cognitive behavioral therapy as part of the psychological approach to therapy was able to assist the patient in detecting faulty patterns of behavior and to avoid following or applying such faulty patterns into their daily activities. CBT was able to realign the patient’s cognition. It was able to teach her to not to think of herself as inadequate and not to think of the negative things happening to her life as a reflection of her capabilities or value as a person. In the process, the student was able to establish less negative and depressing thoughts about herself. She was now able to think of herself in a less self-destructive, self-pitying, or depressing manner. The MDT was able to work well within this biopsychosocial approach as the team was able to assist each other from the assessment of the patient’s needs to the implementation of the interventions. 4. Efficacy of the current environment or service where care is being provided In reviewing the biopsychosocial approach, this approach is able to offer a well-rounded approach to the management of the patient’s depression. It was able to consider the physiological and the psychological aspects of a patient’s depression and subsequently pattern the treatment based on such aspects affected. Other therapeutic approaches are available in the current context. For this patient, group therapy and dialectical behavioral therapy can also be applied. Group therapy “captures the interpersonal or social component not seen in other forms of therapy and thus allows older adults to share with and learn from each other while acquiring behavioral and cognitive coping skills” (Spielberger, 2004, p. 598). Group therapy may be applicable to this patient, as it can help the patient cope with her disease with the help of other individuals who may be in the same depressed state as she is. It would also encourage her to socialize with other people – to help remind her that she is not as alone as she thinks she is. The dialectical behavioral therapy is one of the recent forms of therapy in the mental health setting. This therapy helps restructure treatment. The functions and modes DBT sets forth that for a psychotherapeutic approach to be comprehensive, it must include critical functions on enhancing and maintaining the client’s motivation to change; enhancing the client’s capabilities; ensuring that the client’s new capabilities are applied to relevant environments; enhancing the therapist’s motivation to treat clients; and structuring the environment so that treatment can take place (Behavioral Tech, 2008). The DBT has so far proven to be effective against depression because according to studies, it has managed to reduce suicidal ideation, hopelessness, and depression; it has also reduced episodes of self harm, and self-mutilation. In considering which among these treatments would be applicable to the client, I believe that applying the biopsychosocial model is still the best treatment for this patient. Moreover, it already includes the cognitive-behavioral approach which can also include group therapy as a method of CBT. The psychosocial approach will be holistic in its approach and would help improve the patient’s social life, as well as his coping mechanisms. Works Cited Allen, N. B., Trinder, J., & Brennen, C. (1999), Affective startle modulation in clinical depression: Preliminary findings, Biological Psychiatry, volume 46, pp. 542–550. Andrew, L. (2011), Depression and Suicide, Medscape, viewed 13 August 2011 from http://emedicine.medscape.com/article/805459-overview#aw2aab6b3 Behavioral tech (2008), DBT at a glance, viewed 13 August 2011 from http://behavioraltech.org/downloads/DBT_FAQ.pdf Brooker, C. & Nicol, M. (2003), Nursing adults: the practice of caring, London: Elsevier Health Sciences. Carpenter, J., Schneider, J., Brandon, T., & Wooff, D. 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