Apply comprehensive and systematic nursing assessment for individuals with mental health problems, their carers and families and colleagues

Introduction

The introduction begins with a general statement to introduce the main subject area and to set the context for the discussion.  such as

• A statement/ definition of the importance of the topic and the context ,background of assessment / and care delivery
• Introduce  how the assignment will focus on the learning outcomes
• Introduce the case scenario/study you have chosen
• Include statements dealing with confidentiality were necessary

Suggested word count

100

Background 

Background information refers to the service users history of real life situations and circumstances which is essential to understanding in that individual’s personal journey and presenting difficulties:- Such as

• Social history
• Physical history
• Work history
• Relationships
• Interests and coping skills
• Substance use
• Past psychiatric care

Within the discussion the student can make links to informed evidence based literature, to how life events can influence a person’s health presentation; for example the receptacle relationship between physical health and mental health.

Not all of the themes mentioned need to be addressed. Your choice of case scenario will determine the content to cover

200

Case presentation/discussion

The case presentation is the main body of the assignment where the student will discuss, analysis and evaluate the assessment material presented, using evidence based literature. Such as the following suggested themes: - The first 10 themes cited refer to  your learning outcomes and should be addressed within your report

1. The clients presenting problems/ Understanding of the current presentation
2. Mental State Assessment
3. Risk assessment
4. Assessment tools used and pros and cons of the tools
5. Health promotion linked to physical health
6. Clinical decision making
7. Care clusters
8. NICE clinical guidelines and care pathways
9. Holistic nursing assessment including carers and families/cultural and spiritual
10. Demonstrate and understanding of the care required through therapeutic communication
11. Models/ framework of assessments (e.g. Bio-psychosocial)
12. Medical diagnosis if any
13. Signs and symptoms of the condition/ Psychological distress
14. Engagement and communication skills used
15. Medication management
16. Policy frameworks
17. Hurdles to assessment

The case presentation section offers the student with an opportunity to explore and address the learning outcomes in greater depth.

1000

Case formulation

(case level)

The written report requires the student to develop a case level formulation which is a product of the assessment based on factual evidence. A formulation can be summed up as; Why does the person have these problems at this time and what factors are maintaining the problem.

Case level formulation structure:-

student can start to outline an initial plan of care under the following headings:-

• problem list
• activating events/triggers
• origins of the condition
• treatment goals
• predicted obstacles to treatment
• protective factors/strengths

100

Person centred care  content

Formulating a systematic plan of care is as essential part of mental health nursing. The care delivered should be tailored to the persons individualised holistic needs. Within this section the student needs to demonstrate the ability to develop and evaluate a plan of care as a result of your assessment (learning outcome 4). To demonstrate the process of care planning the following suggested themes and structure may be helpful as a guide.

• A brief  introduction about care planning related to policy in practice and the importance of the recovery approach
• Demonstrate decision making  within your discussion through the development of goal setting
•  Choose a conceptual framework of care planning such as the following: -
  Lloyd (2010).AIPE framework (assess, plan, intervention and evaluate)
  Peplau model(1952)
  Tidal model(2005)
  Recovery star outcome approach
  Care programme approach(CPA DH2008)
• Link your care delivery to NICE guidelines and care pathways

500

Complete a person centred care plan

Formulate a care plan from the identified needs from your written report/ assessment and attach as an appendix.

Conclusion

The student is summarising what has been discussed and can reiterate some of the key points. No new information is required

100

Harvard

Referencing

https://www.coventry.ac.uk/study-at-coventry/student-support/academic-support/centre-for-academic-writing/support-for-students/academic-writing-resources/cu-harvard-reference-style-guide/