Preparing and presenting your care studies-telling the person’s story

Nursing Care

Preparing and presenting your care studies-telling the person’s story

Based on a service user that you cared for on one of your placements who was experiencing one or more of the following mental health problems:
Depression
Anxiety
Hypomania
Psychosis
Suicidal ideation/intent

Fiona is a 52-year-old widow living at home with her with two teenage sons (Wayne 16 and Fiach 13). Fiona grew up in a happy family with one sister and brother.  Her brother lives in the US and her sister lives 200 miles away from her, but they keep regular contact and Fiona considers her sister to be her best friend.  She attended primary and secondary school and has a BA in English and Music.  Fiona married Tom when she was 25 and they had a good, happy marriage. She worked as a school secretary (a job she loved) from aged 20 until five years ago when Tom died a following a sudden heart attack.She gave up work then to look after the boys. While she coped well at the time, she concentrated on supporting the boys, she still finds it hard to mention his name. Fiona has two close friends who she knows since she was at college, but time and family commitments mean that they rarely get to meet up. When Tom was alive she used to be quite active in her local Catholic Parish, singing in the choir and working on the baptism team, but she gave that up as she had to be at home with the boys.

For the past sixmonths, she has been getting no enjoyment out of life, or from activities that she previously enjoyed.  She cannot get off to sleep at night if she does not have a couple glasses of wine (previously she only had an occasional glass of wine at the weekend). This means that she falls asleep quickly but wakes up around 4am and can’t get back to sleep. Her usual sleep pattern is 7 hours sleep per night between 11-12pm and 6-7am.Fiona constantly worries about money and the boys.  She feels lonely and can see no way out of the situation she is in. Fiona has no interest in eating and spends her day going from her bed to the couch until the boys come home from school. She has lost 2 stone in weight over the past 6 months and has no interest in her appearance (Height 5ft 2inches, Weight 7 st). She finds dealing with her sons difficult; Wayne has been in trouble in school for truancy and picking fights with other boys and generally being impertinent to teachers; Fiach is very attached to Fiona and tends to be anxious when she is not with him. She has found recently that she is very short-tempered with them and is worried about the effect her current state has on them. They are a close family unit and when Tom died they supported each other well. Fiona has no previous history of depression or mental health difficulties and no family history of same.  She has no physical health problems.

Recently she has been thinking that the boys would be better off without her and has thought of ways of killing herself.  She talked to her GP and was tearful and hopeless at the appointment, which resulted in a referral to the community mental health team. You are her Community Mental Health Nurse.

Prepare a case history of the person including the following information:

Biographical details
Social circumstances and history
Family history
Developmental history
Mental health history (current and past mental health problems, history of present distress, including periods of good mental health)
Physical health history (current and past physical health issues)
Alcohol and substance misuse history
Current (when you were working with them) presentation and presenting problems
Circumstances of admission/referral to the care setting
Person’s understanding of their needs,
Usual coping skills
Include any other information relevant to their care for example relevant assessment regarding signs, symptoms, functioning and factors contributing to their current difficulties
A clinical formulation providing an explanatory framework that will support the care plan.

The person’s story should be written in a way which demonstrates an holistic account and understanding of the service user as a person, focusing in strengths as well as difficulties.

A summary of the person’s current mental health issues is provided with some explanation as to how and why they have developed. This  provides details of contributing factors (pre-disposing, precipitating, perpetuating and protective) and reference to some theoretical framework that explains development of mental distress.

“an interpretation of what is happening for the client based on the client’s and the nurse’s explanatory frameworks – what she or he understands to be the precipitant and nature of mental distress and how best it can be alleviated”