Assessment and Care Planning for a Patient with Severe Depression

The essay aims to presents a discussion and analysis of the assessment and the care planning process by focusing on a 39-year-old woman called ? suffering from severe depression. The patientName of patient? was admitted to an adult acute female ward because of her mental health problems. According to the World Health Organization (WHO) fact sheets (2016), depression is a mood change condition characterised by depressed moods and feelings of unhappiness, fatigue, self-denial, and suicidal thoughts. As a result, I have chosen to focus on the Care Programme Approach (CPA), and approach where I will demonstrate an understanding of the process by examining how it is used to provide patient-centered care as introduced by the Department of Health. The Department of Health introduced the system to coordinate the care of patients with mental health disorders  Additionally, I will also utilise the a nursing model of - the Tidal model (REF), introduced by Baker as a model for acute mental health nursing care. Similarly, I will discuss the need for good communication skills to communicate with a patient to establish a connection between patient and nurse in order to create a therapeutic relationship. Understanding the care planning process will be demonstrated by recognizing the needs of the patient and the treatments that have been agreed upon with the patient. Finally, I will summarise the care provided and reflect on my role in practice and my learning. "Emily" has been used as a pseudonym for the service user on whom the discussion focuses. 

My first contact with Emily was when she was admitted initially onto the adult acute female ward as an in-patient where I was doing my placement at the time. The unit is a 24 female bedded ward catering for people within their acute phase of mental illness. Emily's care was chosen for this task because her story caught my particular interest . I also chose her for the study because I wanted to understand better how depression could harm people's lives and mental health. The patient is a 39-year-old woman who is a single mother with three daughters aged 12, 9 and 6 who lived with her. Emily explained that she grew up in a family of six, with two sisters and one brother in a home where education was an essential factor. According to Emily, her family did not value education, especially for women. Even though she did not receive support from her family, she still managed to complete her A (Advanced) level qualifications. However, she did not manage to go to university after completing her 'A Levels'. Instead, Emily worked as a legal secretary in a law firm for 15 years. 

Assessment

Even though she claimed  to love her job, she was forced to stop working as a legal secretary after her continued absenteeism and lateness. She claimed that the absenteeism and tardiness were because she had reached a point that she did not feel interested in the job anymore. Emily also explained that she lost both parents two years ago following a car accident that left her broken and lonely and said she was damaged by losing both parents the same day. Emily expressed a sense of guilt, blaming herself for the death of her parents because she had planned a getaway that led to their death. She also stated that her only brother died of pancreatic cancer one year after her parent's death. Emily was also struggling with her relationship, which led to a separation. According to her explanation, she felt guilty for losing everyone she loved and cared for almost in the same period. As a result, Emily said she no longer wants to be around anymore; stating that her family member raise concern about her safety following her comment of wanting to die, the family member contacted the police that brought her into the hospital under section 135 to enable the police to take Emily to a place of safety so that she can be assessed by an approved mental health professional or a doctor (REF)  all the mishaps in her life is her fault and cannot even give her children the love they deserve.?   Emily also spoke about how she had enjoyed making new friends, traveling and an active participant with her local charity raising money for cancer research. After losing her parents, brother, and lover almost simultaneously, she felt depressed, which led to her mental condition. Similarly, Emily has not been able to find anything that she can enjoy doing, considering that her friends had deserted her since her problem began. The police brought her in.  

Assessment is the first stage of treatment conducted by a registered nurse when a patient visits a mental health service facility . The assessment is performed through interviews and examterminations  as the baseline for the patient mental health.  According to Barker (2004), assessment is the decision-making process that is based on the gathering of relevant information and the application of a formal set of ethical criteria to make a meaningful contribution to an overall estimation of a person and his or her conditions. The nurse collects, organises, evaluates, and documents information about the patient's well-being. Similarly, Varcarolis (2014) stated that mental health assessment is an interview that explores the patient's mental health. As a result, the assessment procedure entails gathering the information and utilising the data to determine the patient's current mental health state and develop a care plan.  Besides, a mental health assessment is critical because a patient might reveal some vital information that can be utilised when formulating a care plan with patient participation, collaboration, and a shared decision making (Jørgensen and Rendtorff, 2018). 
However, for a mental health assessment to take a therapeutic relationship must exist between or the nurse and the patient to create an enabling environment for the patient and establish trust Mohr (2013). The therapeutic relationship according to Mohr (2013), is the foundation of all nursing care. It is the nurse’s close relationship with the client that is essential in assisting the client in growing, learning to cope, solving problems, and achieving developmental goals and to boost the patient’s self-esteem and reduce mental distress. Thus, communication plays a central role in establishing and maintaining the therapeutic relationship between the nurse and the patient. Forchuk, et al., (2000) suggested that a positive nurse-patient relationship is the most critical nursing situation where interpersonal interaction is employed in promoting the recovery of mental health patients. As a result, there is a need for every mental health nurse to establish a quality and positive therapeutic relationship with patients through communication. 

The Importance of the Therapeutic Relationship

I have chosen to utilise the Tidal Model (Barker and Buchanan-Barker, 2010) for the assessment because its standards make it possible for the assessor to pick up a more superior comprehension of the patient's needs.  Additionally, the perspective of the Tidal Model offers a patient-centered and realistic approach for helping the patient toward recovery (Barker and Buchanan-Barker, 2010).  As a result, the modelsystem  will support the practitioners view during the assessment process to know the nature, extent and severity of their mental illness and how it affects them. HoweverSimilarly , it will allow the practitioners to identify the patient's support needs involving service provision with regards to therapeutic intervention that will best support the patient towards recovery (Wrycraft, 2015). The assessment process is characterised as having two phases  where the registered nurse collects information to be utilised correctly to identify the patient's requirements. As a result, the critical criterion of the Tidal model (Barker and Buchanan, 2005REF ) was employed because it provides an all-encompassing approach amid the assessment time. 

The police who brought Emily in also provided all details of her the patient's  suicide attempt, which was helpful during the assessment. According to Varcarolis (2014), it is essential to collect all information from the police or bring a patient to the mental health services facility to aid in the assessment process.  Moreover, Emily medical record shows that she has a long history of suicide ideation influenced by her major depression. For instance, she was once saved while trying to jump off a cliff near the main road. Similarly, everyone around the community, including the in-patient units and community mental health team, is aware of her history of suicide attempts. Her medical records also show that her initial medical interventions to help Emily overcome her depression had failed. During the Assessment with Emily, myself and my supervisor spent time with her to establish a good rapport. Videbeck (2010), stated that trust, expression of empathy, reciprocated respect, and power-sharing between the registered nurse and the patient should be the basis of establishing a therapeutic relationship.  As a result, the first phase of the assessment also entailed enhancing the interaction with Emily by improving the level of social engagement with the assessor.  It was necessary to enhance the interaction  because Emily did not show confidence when communicating with the assessor . To understand the patient's situation, it was important for the assessor to control the emotions, thoughts and behaviour through self-awareness when assessing Emily (Liao & Murphy, 2019).  However, it was also essential to ensure that the assessor  does not abuse the language  because it can affect the willingness or openness of nurses to explore sensitive issues . As a result, the assessor only employed clinical judgment and denying personal feelings about treatment to the patient (Buchanan Barker and Barker.

The Tidal Model in Assessment

According to NMC (2018), Nurses need to treat service users with dignity and respect and ensures complete confidentiality  to the service user. The power of nurses begins with a professional position and an understanding of the personal details of service users.  Therefore, priority should be given to Emily's vulnerabilities and needs as the service user during the assessment.  Similarly, Geddes et al., (2012) stated that the importance of providing the patient with a calm and quiet environment in an evaluation interview is essential for pain and difficulty.  Finlay, (2004) suggested that encouraging people to speak freely without rest, the safety and fear of service users, increased levels of disturbance or anxiety can promote faster recovery.  NMC Code (2018) indicated that it is essential to provide safe, ethical and quality care while protecting sensitive information because maintaining professional vigilance  remains the responsibility of nurses. Before starting the assessment, the supervisor also explained to Emily that the interview is designed to encourage and support her by developing therapies  that fit her needs. The information collected only concerns Emily for safety  because the information is shared with the relevant professional agencies unless it is deemed harmful or dangerous to others (Blightman, Griffiths and Danbury 2014) . Liao and Murphy, (2019) provided support for the claim  by stating that it is essential to maintain professional boundaries of accountability, reliability, efficiency and protect the gap between professional strength and integrity . (Liao & Murphy, 2019). The interviews  were initiated by introducing the team  to Emily before letting her know the purpose of the interview assessment. The supervisor also informed the patient that the information provided during the interview will be confidential and will not be shared with any third party to encourage Emily to give correct information.  

According to NMC (2018), a clear objective must be established when establishing a treatment plan for the patient after the assessment. Following the transparent promise of the Tidal model, baker, (2010) we describe the purpose of Emily’s assessment. The nature of the information collected will be used for collaboration between service users and experts (Rakovshik and McManus 2010). Mion, (2009) suggested that it is crucial to building trust and relationships at the beginning of the assessment, which can create an environment for effective communication and engagement. Besides, some of the members involved during the evaluation included a social worker who had accompanied the patient, the care coordinator and the supervisor.  After correcting the patient' medical history records, we prepared the assessment before the interview to encourage the future progress of a working relationship. The preparation started by gaining consent from the patient. According to Kornhaber, Walsh, Duff, and Walker (2016), gaining support from the client is an essential element in all phases of care and treatment. Similarly, it was also necessary to explain to Emily how the interview will be conducted and why it was required. The team also informed Emily that it was her choice to participate in the discussion to make her feel comfortable during the assessment by letting her know that she was not obligated to answer the questions. 

Care Planning and the Care Programme Approach

The setting for the assessment was a separate room within the facility that was quiet and away from the disruptions (Geddes et al., 2012). The seats for the room were kept so that the interviewer can maintain eye contact with the patient. The environment was set so that the participants can enjoy an open posture to make the patient feel relaxed during the interview process (Mion, 2009). The process began by complimenting Emily on how well dressed she looks and asking her how she felt. Emily was also offered a glass of water to establish a therapeutic relationship and make her feel comfortable during the assessment.

The questions for the interview were asked randomly, starting with the simple question to the complicated ones. The interviewer began by asking her how she was feeling about the setting and her health. Without making eye contacts, Emily replied that she felt okay and that the environment was also okay. However, she also mentioned that she wished that death would take her since everyone around her had died which she blames herself. The interviewer then asked her questions to assess her social life. She revealed that she had lost everyone she cared about, including her partner, parents, and friends. 

According to Rakovshik and McManus, (2010) communication skills are the key to presenting and obtaining information from a client. Therefore, it was critical to show proper communication by acknowledging what to say, and how to say it during the interview with Emily. Similarly, it was also critical to make the patient feel encouraged to participate in the discussion by keeping the questions short and simple. Keeping the questions simple and clear also enabled Emily to give the correct information during the assessment (Hiskey, 2012). Wrycraft (2015) also stated that the registered nurse must ensure that the client's history does not affect the ongoing review and care planning. The study also states that the assessor may be preoccupied with prejudice even before meeting the client because of utilizing the information presented by the records to make the judgment (Mann, McCleskey, Marques & Adamski, 2016). Therefore, it was necessary to ensure that the assessment was not affected by the existing knowledge from the records when dealing with Emily. 

It was also essential to observe the patient non-verbal cues to determine the question to ask to avoid making her feel upset. Besides, Varcarolis (2014) also explained that it is critical to observe and consider the client's non-verbal cues during the interview because it helps to know which questions. As a result, knowing the question helped avoid upsetting the patient during the assessment. Emily remained engaged and comfortable during the entire review, which took approximately thirty-five minutes. Although Emily appeared stressed, she managed to respond to all question asked during the interview assessment. Before thanking Emily for her participation and cooperation during the interview, she was asked if she had any question or clarification that she wished to present.

Reflection on Care Provided and Learning

In the United Kingdom, healthcare philosophies and nursing patterns had a low profile in clinical and mental health nursing (Baker 2001). The Tidal Model builds on and expands on some of the common ideas about the importance of interpersonal relationships in nursing. The paradigm also has distinct mechanisms for re-empowering people who have been disempowered by mental illness, medical treatment, or both. The Tidal Model emphasises a utilitarian approach to identifying living issues while also being mindful of the patients. The paradigm seeks to create a narrative-based practice that treats each patient as a distinct individual. This contrasts with most other recent nursing models that use evidence-driven methods, in which characteristics are based on the premise that each patient is an equal topic to the study community. The key goal is to use a series of dimensions, including the World dimension, the Self dimension, and the others dimension, to discuss the patient's life experiences and diverse needs. The nurse investigates the patient's pain, accident, or sickness that contributed to the present situation she or he is in under the Tindal’s World dimension. This may involve things like the patient's perception of how her or his illness has changed their bond with their loved ones and what they believe needs to be done to aid in their rehabilitation. The Tidal Model's Self factor examines topics relating to the patient's mental and physical well-being, including emotional wellbeing and the risk of him or her injuring themselves physically. The nurse often looks for ways to help the patients preserve their sense of confidence by validating for them what helped them more safe in the past and what the nurse might do to assist them with their new condition (Miller and Johnson, 2020). The ‘Nursing' metaparadigm examines what nurses do to help patients who are sick. These include the medication, support, and compassion given to patients. These can be shown by nursing techniques to aid patients in their recovery; but, in the psychiatric environment, an efficient and efficacious therapeutic nurse-patient partnership is required first and foremost (Vella et al., 2017). Most clinical nurses believe that the nurse-patient interaction must be collaborative before the patient can willingly participate in any therapy intervention provided by the nurse. Each patient is a person with a diverse set of life experiences and issues that must be addressed. In order to assist the patient, the nurse must have a greater understanding of the patient, rather than only looking for obvious signs and symptoms, the nurse can cultivate a sincere interest in what the patient has to say. Healthcare providers have a habit of thinking that they are the ones who know the most about their patients, and this mindset prevents them from getting to know them better.

Conclusion

Care pPlanning can be explained as the process of utilising activities established by the care provider to help a patient based on their circumstances (REF). Chong et al. (2013), suggested that an evidence-based practice can be described in treatment decisions and treatment plans should be evidence-based, which and alsoare based founded on professional partnerships with service users to support effective interventions (REF). Consequently, a mental health nurse is tasked with demonstrating responsibility and transparency, to explain the rationality of treatment decisions, and make the best decisions in the right way and ethically to be completely honest (REF). Also, planning care aims to concentrate sensibly on those  individuals and what is  important to the patient (REF). According to Barker (2001), trust and the development of transparency are shared, and that information, interventions and future care plans can be shared with the patient. A mental health nurse can start future care plan participation by generating genuine interest, empathy, respect for choice, and alliances by encouraging the patient (REF).? 

From the assessment, we have determined that Emily requires a care plan that will help her overcome significant depression, characterised by behaviour and moods changes, feelings of sadness, tearfulness, emptiness or hopelessness. The assessment has also determined instances where Emily showed angry outbursts even over minor issues, which might trigger her suicide attempts. As a result, a care plan was obtained that included a one-to-one level of observations of a patient's whereabouts, behavior and mood changes and feelings of hopelessness (Mann, McCleskey, Marques & Adamski, 2016).  According to Barker and Buchanan-Barker, (2005), care planning can be accomplished in collaboration with service users who continually evaluate their effectiveness and regularly evaluate management plans. It wasis, therefore, essential to include achievable goals and solutions to satisfy service users, and service users should sign their copies after agreeing to the plan (REF). 

Additionally, cCare planning can be developed by working closely with the patient to ensure that all aspects of the person are considered using a holistic framework and a patient-centered care plan. Thus, the method incorporated the approach of Collaborative Therapy, a social constructionist approach that works to stabilise, normalise, and create acceptance in the patient (Eales, 2009).  According to the Tidal model, Barker, and Buchanan-Barker, (2005) throughout the time spent planning care, the patient must lead the charge and that a psychological well-being specialist would facilitate this event since the patient is the primary master of their tale (Hiskey, 2012). The approach entailed making sure that the patient is involved when developing the care plan. Including a patient in planning their care has been shown to benefit an individual from several points of view, promoting consistency, empowering individuality, and improving the quality of care.  

The approach  allowed the supervisor to use the patient words when recording the plan in the hospital data. It also raised the patient's level of commitment to the care plan (Mion, 2009).  With the support and encouragement of the patient, emotional well-being practitioners may often feel surplus to requirements.  Working along with the client and team of experts is important when mind planning,  engulfing diverse distinctive skills  that can assist the delivery of care and ensure a clear strategy from several administrations , overcoming any barriers that inhibit care (Hall et al., 2013).? 
Efforts to stay strength-focused involve discrediting unhealthy or unproductive client worldviews (Barker Buchanan and Barker, 2008). Treatment plans are necessary because they act as a map for the therapeutic process and provide a way of measuring whether therapy is working (Mion, 2009). As part of a collaborative model of treatment planning, nurses help clients develop a clear picture of what they want to be different or improved as a result of participating in treatment (Hall et al., 2013). As a result, the approach logically involves discussing goals and the positive consequences of those goals.  ? 
Similarly, the care plan also employed electroconvulsive therapy, which is also known to affect patients suffering from significant depression-like Emily, positively (Thomas, White & Dursun, 2018). A course of anti-depression medication to be started to lift the patient's mood and monitor for her concordance, effects, and side effects of the drug and encourage the patient to contact her children, family, and friends (Eales, 2009). However, using the approach of electroconvulsive therapy has its advantages and disadvantages .

I chose to utilise the tool to address Emily’s condition  because it offer the best for addressing patient with major depression in mental health care (Kornhaber, Walsh, Duff, and Walker, 2016). Likewise, I also found the tool subjective, and there are inconsistencies as health care professionals produce different results within 24 hours of admission (Buchanan Barker and Barker, 2008). As a result, the advantage was that the instrument was easy for the team to complete in few minutes (Mann, McCleskey, Marques & Adamski, 2016). 

Conclusion

The assessment and care planning has concentrated on Emily's case, who is suffering from significant depression. I have employed the assistant model of the Tidal Model for the assessment because its standards made it possible for the assessor to pick up a more superior comprehension of the patient's needs from their point of view. Additionally, the perspective of the Tidal Model offers a patient-centered and realistic approach for helping the patient toward recovery. As a result, the system has provided support to the practitioner's view during the assessment process to know the nature, extent, and severity of their mental illness and its effect. Additionally, the model has made it possible to identify the patient's support needs regarding service provision regarding therapeutic intervention that will best support the patient towards recovery). The assessment process is characterised as having two phases where the registered nurse collects information to be utilised correctly to identify the patient's requirements. As a result, the key criterion of the Tidal model was employed because it provided an all-encompassing approach during the assessment time. 

I have used the assessment and care planning approach to express Emily's concern throughout the assignment. The assignment has taught me the need to incorporate communication skills when dealing with the patient. Working with Emily has taught me the importance of good interpersonal skills, strengthening the compatibility with the patient. I have also learned the need to establish a therapeutic relationship by providing the service user with a quiet environment during the assessments to make her feel comfortable during the interview. Besides, the evaluation has shown the benefit of pursuing a compassionate nursing style when operating within the framework of the Care Program Approach and providing exemplary care. The assessments have provided me with an opportunity to assist Emily during a troubled stage while documenting non-judgmental mentalities. The task has taught me about withholding my beliefs that might influence the care delivered. I have therefore learnt about the need to let the patient convey her thoughts and feelings straightforwardly when developing a therapeutic relationship.?