Nursing - The Recovery Focused Nursing Care Plan Section - Assessment Answer

 The Recovery Focused Nursing Care Plan Section Assessment Answer

Assessment Task:

A crisis can be seen as an opportunity therefore when Joseph a young 25 year old man was admitted to an Inpatient Psychiatric unit (IPU) with Drug induced psychosis (DIP), the opportunity gave rise in providing a recovery orientated service that assisted Joseph when he became clinically stable to refocus his priorities and
move forward in his unique recovery journey. Firstly regular mental status examinations were undertaken in determining Joseph’s clinical progression. (Refer to the appendix regarding Joseph’s psychiatric history, need for admission and initial presentation). Secondly a care plan reflecting Joseph’s identified priority goals was
collaboratively negotiated between Joseph and the author, a mental health nurse. An example of both assessment and intervention is explored further within this paper where the expertise of experience and expertise in training was mutually utilised and respected (Rudnick, 2012). The role of the author, was in
providing a hope inspired therapeutic relationship that relinquished the power role and determined to deliver value based ethical care that respected Josephs autonomy, capacity, expertise and choice (Bryan, 2015; Chang, Scott, & Decker, 2013; Hall, Wren, & Kirby, 2013). Joseph’s identified perceived difficulties were
also explored and assisted in formulating his care plan that focused on his strengths, resilience, support network and ultimately achieving his goals (Clossey, Mehnert, & Silva, 2011; Norman & Ryrie, 2013).

Mental Status Examination

LEVEL OF CONSCIOUSNESS:

Clinical Assessment: Joseph was able to tell the author that he had been in the IPU “for six days, came in Thursday night, came out of that area (pointing to the ICA), on Monday” and requesting “to have day leave tomorrow with my family”, (Wednesday). It’s my birthday, I’ll be 23 ” Joseph was presenting as orientated and observably alert during our informal discussion, therefore there was no need to undertake a cognitive screening test

 Question: How long have you been in this Hospital now? The author was able to observe that Joseph was alert and orientated to time, place, person and contextual situation.

GENERAL APPEARANCE:

Clinical Assessment: Joseph is a young middle Eastern man that looks younger than his age. He is well- built and of average height. He was observably clean shaven and well groomed, wearing hospital clothing and socks. He appeared slightly thinner in the face since his last admission. He had a visible scar on his left eyebrow as well as dark tattoos with the letters LOVE written on each right finger excluding his thumb.

Question: Was the water hot enough this morning? The author observed that Joseph was attending to his hygiene regularly unprompted, therefore indicating an improvement in his mental state.

BEHAVIOUR:

Clinical Assessment: Joseph was approachable, maintaining a low profile within the ward however mainly in communal areas, socialising selectively with a couple of co-clients. He was co-operative, softly spoken and polite during nursing interventions however initially minimally engaging. No irritability, suspiciousness or hypervigilance was observed. Joseph made intermittent eye contact, with some visible psychomotor agitation present, moving his posture several times whilst engaging with the author
indicating some pre occupation, anxiety, and frustration. No overt responding to perceptual disturbances was observed and overall appearing generally settled.

Question: How are you feeling Joseph? It seems like something is bothering you, is there?

MOOD and  AFFECT

Clinical Assessment: Joseph appeared restricted and slightly flat in affect stating his mood as “good” however incongruent with his affect. Joseph became slightly more reactive upon engagement when discussing his skill in undertaking crossword puzzles, otherwise there was observable paucity, when discussing his mood. However when given the opportunity, Joseph became more animated and reactive as he elaborated on the psychosocial effects of ICE use, identifying and verbalising the desire to give it up and reclaim his life, Joseph’s mood appeared more euthymic as the engagement progressed.

Question: As Joseph verbalised his concerns, the author’s use of attentive skills, empathy and non judgmental approach assisted Joseph to further engage and clarify his concerns regarding his substance use, thereby promoting the prospect of change, eliciting the development of a clarified goal, and optimism, reflective in his observable progressive euthymic state. The author with the use of affirming cues and demeanour portrayed that recovery was definitely possible in key domains within Joseph’s life.

SPEECH:

Clinical Assessment: Joseph was quietly spoken initially and his speech rate was somewhat slower, there was some spontaneity in speech, however Joseph was observably hesitant with intermittent paucity when discussing his mood, otherwise he was clear, articulate and logical in his speech. Once given the
opportunity to further engage, Joseph mainly voiced concerns regarding the psychosocial effects of his illicit substance use and a desire to regain control of his addiction and life.

Question: The author was able to observe that Joseph was no longer tangential in conversation, neither was there any observable thought blocking present. The author gave Joseph the space and time to further engage regarding his mood using prompting cues such as hmm, appropriate pausing and nodding indicating attentive listening skills to elicit further dialogue and explore what was observably causing Joseph’s paucity and hesitancy in speech.

THOUGHT CONTENT / STREAM:

Clinical Assessment: No formal thought disorder was evident, though Joseph was hesitant when discussing his mood initially, his thought process was observably coherent, logical and goal orientated. With prompting Joseph became more engaging, denying Auditory hallucinations or paranoia, “No, they’re gone, I only hear them when I use ICE, it’s a love hate thing with ICE, you know, I feel invincible, but then I’m tormented with the voices, and the paranoia, I want to stop, it’s gotten in the way
of my studies, effected my relationships negatively and I’m here again! just feeling a little low I guess, but don’t worry I’m not suicidal, reality has kicked in, but I’m Ok

Question: So you recognise the effects that ICE has had on your mental health and how is that affecting you?! The author reflected on the arising opportunity in assisting Joseph to re-evaluate his ICE use therefore used motivational interviewing in promoting further engagement in determining Joseph’s motivational readiness to change his addictive behaviour and enhance his expertise and self- efficacy in facilitating change talk. As well as assess for potential depression, suicide and whether Joseph
may have pessimistic thoughts about his future, however no significant risk to self was verbalised.

INTELLECTUAL PERFORMANCE:

Clinical Assessment: Joseph was intelligent, articulate, logical and goal orientated in conversation and observed to be completing crossword puzzles, as well daily Sudoku.

Question: So you’re keen to back to Uni? The author observed that Joseph was undertaking crossword puzzles, and Sudoku in the ward, which requires memory recall, numerical articulations, and the use of metaphors, therefore no further evaluation was required,

PERCEPTION:

Clinical Assessment: Joseph denied experiencing perceptual disturbances ‘No, I haven’t heard the voices for about three days now, No, I feel safe, that’s not an issue any more”.

Question: Are you still experiencing unusual things, like hearing voices or feeling like you’re being followed, watched or threatened in some way?
There was no observable overt behaviour or features that indicated that Joseph was still experiencing auditory hallucinations, as he was no longer observed to be responding to perceptual disturbances, nor was he isolative or suspicious, he was less guarded in presentation overall, and socialising appropriately with clients.

JUDGEMENT:

Clinical Assessment: Joseph’s judgement is intact as he is able to recognise the negative effects his Methamphetamine use has had on his Mental health status as well as the psychosocial effects and therefore keen to get a referral to AOD, take his antipsychotics and “get on with reclaiming my life”

Question: So you understand the effects that ICE is having on your mental health? Would you like to see someone so you can get assistance with it?.
INSIGHT:
Clinical Assessment: Joseph appears to have good insight as he stated “This was the best place for me when I was psychotic, you guys seem to know what you’re doing! I was so irrational and my family were so worried! I just want to get on with my life and go back to Uni, and really if possible not come back
here, so I know I need to take the antipsychotic for preventative measures, I know I suffer from a mental illness now and basically I need to stay off the ICE”.

Question: Have you found it helpful being here?
The author promoted Josephs own expertise and self-efficacy regarding his substance use and consequential effects as Joseph was able to identify and articulate these issues, including the deterioration in his mental health status, and this is key in initiating the committed steps regarding change that potentially results in effective substance use treatment retention and assist in maintaining stable mental health. The author was inspired by Joseph’s acceptance of his illness, overall active coping and
reclaiming of his life.

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