The aim of this assignment will be to select a client cared for on a placement and look at the assessment tools used to provide holistic care for this client. It will examine the various assessments used on this client and discuss the holistic needs of the client. My placement area was with a Community Mental Health Team and so the assessment tool used was the Community Mental Health Team Assessment and Progress Record. Carpenito-Moyet (2005, p. 31) defined an assessment as “the deliberate and systematic collection of data to determine a client’s current and past health status and to evaluate the client’s present and past coping patterns”. Harrison et al (2005) explain that the aims of assessment is to obtain information needed to establish a diagnosis in order to make clinical decisions, to recognise the causes, signs and symptoms of the disorder and to build a trusting therapeutic relationship with the client. The nurse’s ability to assess the client appropriately and accurately is key to building a clear picture of the client’s needs, preferences and abilities.
The nurse will carry out this assessment in conjunction with the client, therefore empowering the client to be involved in their own care (Dougherty and Lister, 2008). As well as involving the client the nurse may also involve the client’s family in the assessment. The nurse will first gain consent from the client. This extra source of information will give the nurse a more comprehensive picture. This is known as collateral information and can be very beneficial when dealing with a client that is very unwell or withdrawn. A family member can be a very important source of information (Rothschild, 2009).
For nurses to be successful in building their assessment of the patient they must develop a trusting relationship with their patient, allowing them to work together and set goals and responsibilities to meet client’s needs. The nurse-client therapeutic relationship is a very important element of any assessments. The building of a trusting relationship between the nurse and client will ensure that the client is at ease and comfortable discussing any problems they may have. Varcarolis (2010) states that establishing a rapport with the client is vital while carrying out any assessments.
After collecting the relevant information, nurses must then identify the holistic needs of the client (Hood and Leddy, 2006). In holistic care all aspects of the client’s needs must be assessed to identify and promote the correct care for them. Psychiatric nurses must not only concentrate on the mental health needs of the client, the nurse must also assess aspects such as physical and spiritual needs of the client. Barker and Buchanan-Barker (2004) tidal model suggests that through holistic assessment nurses can gain an insight and understanding into who the person is, their needs, and wants.
After the assessment is complete a care plan is drawn up in conjunction with client. This empowers the client to take control and responsibility of their own healing and well being. The assessment used when a new client is referred to a Community Mental Health Team is the Community Mental Health Team Assessment and Progress Record. This assessment is usually carried out by a Community Mental Health Nurse (CMHN) in the client’s home. The first section of the assessment is gathering personal information on the client. Information such as date of birth, marital status, employment information, G.
P. , contact number and next of kin. The importance of confidentiality as set out by An Bord Altranais (2000) ensures that this information is only passed onto relevant individuals. For the purpose of this assignment the client will be given the pseudo name John. John is a forty nine year old single male who has a dual diagnosis of Bipolar Affective Disorder and Alcohol Dependency Syndrome. At the time of the assessment John’s mood was slightly low. In the next section of the assessment these diagnosis are listed and any associated problems are identified.
In Johns case there is a problem with medication compliance and so the was a plan put in place for John to be started on the depot injection Depixol. In this section the CMHN will also find out any previous psychiatric history that John may have and also they will list the medication John is on at present. This history allows the nurse to know who the patient is, where the patient has come from and where he likely to go in the future (sadock and sadock, 2008). It also lets the nurse know how much insight the client has into his illness. Next the assessment looks at the physical health of the client.
John suffers from poor hearing and this leads to anxiety when in social situations. A hearing test was organised for John so a solution could be organised for this problem. Then the assessment goes onto John’s personal and family history and present social circumstances. Areas in Johns life such as relationships, sexuality, finances, education, life events, upbringing and social interactions. John left school early before any exams, he is working on a FAS scheme, he is single, and he struggles socially due to the previously mentioned hearing problem.
The next section looks at alcohol and drugs misuse. There was no history of drugs misuse but John does suffer from Alcohol Dependency Syndrome. John was educated on the effects of alcohol and how it can lead to low mood. There is also a plan for John to attend Alcohol Anonymous meetings on a regular basis to help him with his alcohol problem. There was also a separate assessment, called an AUDIT, carried out by the addictions councillor assessing John’s alcohol problem. John scored very high on this assessment. There was also a mental health assessment carried out.
This looks at issues such as mood, emotion, thoughts, speech, appetite, sleep, cognition and motivation. A standardised risk assessment was also carried out also. This involved asking questions to obtain information as to whether the client is a danger to himself, through actions of self harm or self neglect. It also assesses whether John is a risk to others. John is no risk to himself or to others while he abstained from alcohol. But while drinking John’s diet is very poor and can lead to health problems. With all this information gathered there was a care plan put in place to ensure John functions while suffering from Bipolar.
In conclusion it is evident that assessments and information gathering are imperative in the nursing profession in order to plan the essential care for a client needs. These assessments ensure that the client gets the best holistic care possible. Sharma (2010) describes a new computer programme that assesses clients through questions asked by a primary healthcare worker and then diagnoses the client. I believe that this would weaken the rapport that is built up during an assessment and would not be beneficial to the client. The therapeutic relationship is very important in getting a patient well and in maintaining their health.