Faculty of Health, Social Care & Education. BSc (Hons) RN. Insight into Adult Nursing for Mental Health Nursing students v1.0

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1 Faculty of Health, Social Care & Education BSc (Hons) RN Insight into Adult Nursing for Mental Health Nursing students v1.0

2 INTRODUCTION: Welcome to your adult insight placements. Adulthood is a period generally characterised by self-reliance which centres on occupational and family interests. There is, of course, great diversity in the lifestyle and behaviour exhibited by individuals in this stage of life (Alabaster, 2006). The Specialist Area of Adult Nursing This insight package is designed to introduce you to the specialist area of adult nursing and to help students studying other fields of nursing to develop the knowledge and clinical skills that will help them to meet and understand the physical care needs of their patients whilst taking a holistic approach to care. It is aimed at increasing your knowledge and awareness of what services are provided in the adult sector both within acute and community settings. Use this workbook alongside your clinical skills learning log. In many areas of adult nursing you may find that the emphasis of care is placed on the physical needs of the person being nursed. However, a more holistic approach that promotes individualised, seamless care for patient and family is widely used. As with all fields of nursing, caring for the ill adult takes place in many settings. Nearly all of us have, at some time, been consumers of health care. This workbook follows a patient s journey through the health care system and includes activities designed to help you gain insight into the adult field of nursing. Whilst on placement work with your mentor to select 1 and ideally 2 patients to follow their journey from admission to discharge (these are referred to as patient 1 and patient 2 in the activity boxes). This will enable you to enhance your knowledge and undertake many of the skills in your clinical skills learning log on a number of occasions. Try to undertake at least 2 different skills in your skills learning log, each week. Make notes to reflect upon what you have learnt and discuss them with other students in your tutor group so that you can learn from each other. Do not be concerned if other students have undertaken skills that you have not been allowed to do (since this will depend on the individual organisation s policies) or if all of the skills in your skills log cannot be completed on your adult placement. If there is something that you particularly wish to achieve on a placement include this in your action plan (appendix 2) and ensure that you have your mentor s agreement that this is a skill that you can undertake on that placement. Using this workbook Each section will include a number of activity boxes: ES These are sections in which you are asked to undertake a specific activity or reflection. Your answers should ideally be discussed with your mentor and included in your portfolio where appropriate. Each section identifies a list of resources that you will need to undertake the activity(s). NB. Many of the activities require the use of the Internet. Boxes with red borders relate to the first patient identified. Boxes with blue borders relate to the second patient. Adult Insight Sept 16 2

3 SECTION 1: Beginning the journey This section looks at the beginning of the patient s journey into an adult setting. To help you complete this section you will need: Internet access Discussions with patients and staff If patients are admitted to hospital, they reach the start of their admission by many different routes. List the routes by which patients are admitted to an acute hospital; does this differ to admissions into inpatient mental health services? Mentor Signature. Some patients need longer-term physical nursing care, which often takes place in the independent sector. List the routes by which patients are admitted to a longer-term nursing care setting e.g. Nursing home; does this differ to admissions into longer-term mental health services? Which route of admission was used for the patients you have identified? Patient 1: Patient 2 Adult Insight Sept 16 3

4 Mentor Signature. SECTION 2: Assessment and care planning To complete this section it will be useful for you to have: This workbook, you will find a nursing care plan form for you complete at Appendix 1. An anatomy and physiology textbook Access to the Internet A foundation nursing practice book with a section on pain assessment. Pharmacology textbook Research articles At this point you should revise: The anatomy and physiology of the musculo-skeletal system. The anatomy and physiology of the pancreas. Pain assessment. People require healthcare for a variety of reasons and initial contact with health services may be via a number of routes. Regardless of the mode of entry to the healthcare system it is important to reassess the patients holistically to allow for individualised care planning. Assessing a patient with a physical condition is equally as complex as assessing those with a psychological or mental health difficulty. People do not fit neat categories. All branches of nursing need to consider the physical, psychological and social dimensions of those in their care and to recognise the strong interrelationship between mental and physical health. People with mental health issues have a vulnerability to physical illness and those with physical disease are susceptible to mental health problems. It is common to feel sad or discouraged after a heart attack, a cancer diagnosis, or if you are trying to manage a chronic condition like pain. However, there are some risk factors directly related to having another illness. For example, conditions such as Parkinson s disease and stroke cause changes in the brain. In some cases, these changes may have a direct role in depression. Illness-related anxiety and stress can also trigger symptoms of depression. (National Institute of Mental Health) Explain what the terms Holistic Care and Individualised Care mean to you. Adult Insight Sept 16 4

5 Mentor Signature. Many adult nursing care settings use the Activities of Living model developed by Roper, Logan & Tierney (2000) to guide assessment. The Activities of Living (ALs) are: Maintaining a Safe Environment Communicating Breathing Eating and Drinking Eliminating Personal cleansing and dressing Controlling body temperature Mobilising Working and Playing Expressing Sexuality Sleeping Dying Consider each of the ALs and how they relate to a patient you are caring for on the ward (Patient 1)? Use this to identify patient focused problems on the attached care plan (appendix 1) Consider each of the ALs and how they relate to a patient you are caring for on the ward (Patient 2)? Use this to identify patient focused problems on the attached care plan (appendix 1) Adult Insight Sept 16 5

6 Study the assessment documentation used at your placement to admit a patient and note if all of the ALs are included. Reflect on how this compares to assessment carried out in your own discipline. Student s reflection Assessment and care planning for pain. Physical (and psycho-emotional) pain or discomfort is a common feature of many peoples experience of healthcare. Good communication is essential in pain assessment. Consequently assessment of pain is critical in patient welfare and wellbeing. Pain affects patients physically and emotionally, so successfully managing the pain they experience is a key component of their recovery. Swift, A, 2015 Nursing Times 11 (41): When pain is assessed as a high priority. Which of the ALs would be most affected? Mentor Signature. What may be the psychological impact of a patient s pain? Adult Insight Sept 16 6

7 Mentor Signature. Read, and make notes from at least one research article that explores issues relating to pain assessment e.g. the effectiveness of your chosen tool, how they can aid analgesic treatment or discrepancies between nurses and patient s perceptions of pain. Are there any disadvantages to this tool? Assessment and care planning for diabetes. Before you begin the next section, you should complete the following activity: Access What are the differences between Type 1 (Insulin dependant diabetes) and Type 2 (non-insulin dependant diabetes) Using a pharmacology textbook, identify two drugs that may be prescribed to control Type 2 diabetes. Identify your patient s needs with regards to their diabetes and write them on a care plan (appendix 1). On the same document, record what care you would plan to meet these needs. Adult Insight Sept 16 7

8 As you will have discovered, there are major differences between the two conditions. The only major link is that raised blood glucose is a feature of both types of condition, and it is not surprising that for many years similar treatment was prescribed for both. Glucose levels are now almost exclusively assessed by blood testing as opposed to the older method of urine testing. As part of an initial assessment, patients who are admitted to the acute general sector of health care are likely to have a blood glucose test performed as routine should they be identified as at risk of either Type 1 or Type 2 diabetes. Any abnormal level (high or low) will be followed up by a laboratory analysis. Patient assessment and user involvement in the care planning process Whilst on placement, assist a member of staff to assess patients following their admission to the clinical area. Reflect on the nature and outcome of this process and how it might differ from assessment in mental health settings? Mentor Signature. Look at the documentation used with patient 1. Is there evidence that the patient was involved in the planning of their care? Consider the patient s ability, motivation and opportunities for involvement. Discuss this with your mentor. Mentor Signature. Adult Insight Sept 16 8

9 Look at the documentation used with patient 2. Is there evidence that the patient was involved in the planning of their care? Consider the patient s ability, motivation and opportunities for involvement. Discuss this with your mentor. Mentor Signature. Whilst on placement note the type of specimens that are collected, the procedures for collecting those specimens, the required documentation and how results are recorded. Make some notes below. Mentor Signature. Factfile Patients with diabetes are at higher risk of mental health disorders including depression and psychotic disorders than the general population (2015) For both first and second generation antipsychotics the incidence of diabetes increased with the number of prescriptions. Additionally, the incidence of diabetes increased with the number of combined antipsychotic drugs. (Kessing, Thimson, Mogensen & Anderson, 2010) Research has shown that diabetes can increase the risk of developing both Alzheimer's disease and vascular dementia. Adult Insight Sept 16 9

10 SECTION 3: Implementation and Evaluation of care To help you complete this section it will be useful to have: A pharmacology textbook Access to the Internet NMC The Code The next stage of the nursing process requires that the problems identified at assessment and the associated care planned is implemented. As you have seen these problems, particularly the pain, affect the Activities of Living and so to restore equilibrium the problems prioritised must be treated. Using the pharmacology text book, identify one drug that is used for severe pain. What are the actions and interactions of this drug? How long is its duration of action? What are its possible side effects? Now identify two drugs that may be prescribed for moderate pain. What are the actions and interactions of these drugs? How long is the duration of action? What are their possible side effects? How can the effectiveness of the drugs on the patient s pain be assessed? Adult Insight Sept 16 10

11 In many areas of health care, the health care professionals function as a multi-disciplinary or inter-professional team. During hospital admission this team could consist of the following a Doctors Nurse Diabetes nurse specialist Dietician PATIENT AND FAMILY Plaster technician Physiotherapist Laboratory Scientist Radiographer Identify a similar inter-professional team for patient 1 whose journey you are following on your placement. What is each person doing for your patient? Adult Insight Sept 16 11

12 Identify a similar inter-professional team for patient 2 whose journey you are following on your placement. What is each person doing for your patient? SECTION 3: Evaluation of care The final phase of the nursing process is evaluation. Evaluation is about reviewing the effectiveness of the care that has been given, and it serves two purposes. First, the nurse is able to ascertain whether the desired outcomes for the client have been achieved. Second, evaluation acts as an opportunity to review the entire process and determine whether the assessment was accurate and complete, the diagnosis correct, the goals realistic and achievable, and the prescribed actions appropriate. List the ways in which different aspects of your patients nursing care can be evaluated. NB You may wish to enter these in the evaluation section of the nursing care plan at Appendix 1 of this workbook. Reflect on how this compares to evaluation carried out in your own mental health discipline. Adult Insight Sept 16 12

13 Formal evaluation of care planning is a vital step in the performance of the nurse s duty of care towards their clients. Writing an evaluation down is the proof that the nurse has, by reviewing the care plan, complied with the professional Code. The documentation could be produced in court should it ever be needed. There are also other ways to evaluate care on a less formal basis. Nursing handover is a useful opportunity to discuss a patient/client s progress and the effectiveness of treatments. Reflection also plays a vital part, whether the nurse delivering care is a student or a clinician of many years standing. Evidence tells us that supporting patients to be actively involved in their own care, treatment and support can improve outcomes and experience for patients. Person-centred care supports people to develop the knowledge, skills and confidence they need to more effectively manage and make informed decisions about their own health and care. True patient/client centred care will also allow the care receiver to play a part in their own care. Take for example pain; once it has been assessed using the visual analogue score, recorded on a care plan, and a suitable drug prescribed it is a natural action for the nurse to ask their patient whether the drug has been effective or not so the patient will play a large part in evaluating their own care. Look at the documentation used with patient 1; has their care been evaluated? Is there evidence that the patient was involved in the evaluation of their care? Discuss this with your mentor. Look at the documentation used with patient 2; has their care been evaluated? Is there evidence that the patient was involved in the evaluation of their care? Discuss this with your mentor. Adult Insight Sept 16 13

14 SECTION 4: Journey s End To complete this section you will need: Internet Access In the next activity you need to explore the implications of discharging someone from hospital. Where possible, participate in both a simple and complex discharge of your patients. Using your own knowledge of healthcare who should be notified of the discharge? Consider the physical care needs of the patients based on your assessments think about possible social care issues, emotional support as well as more specific issues such as wound care, medication and follow up appointments Who will be responsible for informing and liaising with other professionals and what will they need to be told? Talk to the people organising the discharge. Reflect on any differences between this and discharging someone who has been an in-patient in a mental health setting. Student s reflection Adult Insight Sept 16 14

15 One of the first important questions regarding your patient s discharge is; how are they going to get home? In most cases a relative or friend will be happy to help out, but they do need to be contacted to make sure that they are willing and able to do so. Think about any equipment that may be required? Have they got basic provisions at home? Are they going to be by themselves? The General Practitioner (GP) may also need to provide a certificate of sickness for your patient to produce to an employer or to the Department of Work and Pensions. Although in many ways discharge home means the patient has reached the end of their Patient Journey within the acute hospital setting, in other ways the journey is just beginning. Diabetes A potential problem for some patients under the AL of Eating and Drinking is weight. In order to help control Type 2 diabetes some patients need, in the long term, to reduce their weight. This weight reduction forms a potential problem in the AL of Eating and Drinking, During their stay in the acute general hospital, it will not have been practical to meet in full this identified potential problem. Nursing care will have begun the process, but patients will be outside their own socio-cultural environment and in artificial surroundings where their dietary intake can be closely controlled. Access Why is weight management an issue for people with Type 2 diabetes? What type of diet is recommended? How might lifestyle and employment affect a patient s ability to maintain a healthy diet? Adult Insight Sept 16 15

16 What patient education interventions might a patient with Type 2 diabetes require prior to discharge? Look at the documentation used with patient 1. Is there evidence that the patient was involved in their discharge planning? When did discharge planning start? Who has been informed of their discharge? Discuss these issues with your mentor. Look at the documentation used with patient 2. Is there evidence that the patient was involved in their discharge planning? When did discharge planning start? Who has been informed of their discharge? Discuss these issues with your mentor. Adult Insight Sept 16 16

17 Primary Care: Primary Care Trusts, and other community based organisations, are responsible for consulting with local communities on health care needs as well as delivering care to those living within a specified area. They work in conjunction with the acute sector, social services and other organisations. Some patients will require considerable follow up care once they have returned to their own home and community. Health promotion and education, care and support will take place within the local community; and at the G.P. s surgery in nurse led clinics. Many G.P. practices have nurse-led diabetic clinics. On your next visit to the G.P. see if your G.P. practice offers this service. What other nurse led services are available at G.P. practices near to your home or the hospital where you are placed? What follow-up services does patient 1 require after discharge? What follow-up services does patient 2 require after discharge? Section 5: Conclusion This workbook has concentrated on the patient journey of patients within your placement area, following the nursing process of assessment, planning, implementation and evaluation. The psychological effects of sudden change from independence to dependence can have a profound effect on an individual and their capability to maintain their own safe environment. Diabetes has also been explored. The condition may be detected on routine examination by other professionals, for example, opticians while they are examining a client s eyes. This is an increasingly common condition, which is to some extent preventable. Type 2 diabetes tends to develop slowly, especially in those with a high BMI or a family history of the Adult Insight Sept 16 17

18 condition and is often found on assessment when a client is admitted for other reasons. It is widespread and affects patients and clients of all disciplines within nursing. By visiting the Diabetes UK website and/or reading about the topic and exploring the diet and drug therapy for this condition you have gained an insight into how the condition may be controlled in order to prevent the side-effects that can develop. The prevention and treatment of Type 2 diabetes is a high priority nationally. The politico economic implications of this condition have led to the development of a National Service Framework (NSF) for Diabetes in which standards for the prevention and treatment of both Type 1 and Type 2 diabetes are outlined. By undertaking the activities outlined you should have gained some knowledge of how to assess, plan, implement and evaluate care within an adult care setting. By assisting in the care of patients and discussing the activities with your mentor you should have gained knowledge and understanding of physical aspects of care that will enable you to deliver holistic care within your own field of nursing care. I hope that you enjoy your adult placements and that you feel more confident when performing physical care skills. Useful Reading Delves-Yates C, 2015 Essential Skills for Nurses; Step by Step London Sage Howatson-Jones, L, Standing, M, Roberts, S 2012 Patient Assessment and Care Planning in Nursing London Sage May, A 2015 Adult Nursing at a Glance Wiley and Sons Chichester Peate, I.; (ed) 2010 Nursing Care and the Activities of Living Wiley Chichester Peate I, Wild K, Nair M (eds) 2014 Nursing Practice Knowledge and Care Wiley Chichester Roper, N., Logan, W. & Tierney, A.J., The Roper-Logan-Tierney model of nursing: based on activities of living. Edinburgh: Churchill Livingstone. Adult Insight Sept 16 18

19 APPENDIX 1: CARE PLAN PROBLEM / ISSUE PLANNING IMPLEMENTATION EVALUATION Insights 19

20 PROBLEM / ISSUE PLANNING IMPLEMENTATION EVALUATION Insights 20

21 APPENDIX 2: ACTION PLAN FOR ACHIEVING CLINICAL SKILLS Date Areas identified for development. SMART Outcome 1. Actions required by student. 2. Learning Resources available to support student in achievement. 3. Agreed time frame Feedback from mentor / supervisor regarding achievement / reasons for nonachievement Student signature Mentor / supervisor signature & date Insights 21

22 Insights 22