Title: Assessing nursing needs and planning care for a patient with Post-Traumatic Stress Disorder (PTSD)
Biography
In accordance with the Nursing and Midwifery Council
(NMC) Code (NMC, 2018), the patient will be identified as “David”
to maintain confidentiality. Consent was consistently obtained from the patient
during the provision of care and before compiling this case study.
David, a 37-year-old male, was referred to the mental health clinic by his
general practitioner due to concerns about his mental health, it is evident
that referral
in nursing practice plays a crucial role in improving patient outcomes and
facilitating interdisciplinary collaboration (Hagle et al.,
2023). David had a lived experience of a specific mental
health condition – Post-Traumatic Stress Disorder (PTSD). He had been
experiencing symptoms for the past two years, following a traumatic event. His
symptoms included recurrent nightmares, flashbacks, hypervigilance, and
emotional numbness. These are classic symptoms of PTSD as defined by the
American Psychiatric Association (2013).
David was initially assessed in the outpatient mental
health clinic. This is important to identify pathological
health anxiety and guide the management of patients with functional disorders
and it helps in engaging patients in psychiatric care (Zhang et al.,
2020; Tyrer et al., 2021). Given the
severity of his symptoms and the impact on his daily life, the mental health
team decided to admit him to the clinic’s Day Program for further evaluation
and treatment. He was later diagnosed with PTSD, as confirmed through
standardized assessment tools including the Clinician-Administered PTSD Scale
(CAPS) (Weathers et al., 2018). The CAPS is considered one of the
most reliable and widely used measures for assessing PTSD symptoms and their
severity, allows for a comprehensive evaluation of PTSD symptoms and the impact
they have on the individual’s daily functioning, and it assesses the presence
and severity of 17 symptoms of PTSD that are described in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) and it well documented that it
has been used to assess the efficacy of various treatments of PTSD (Kayrouz et al.,
2018; Bisson et al., 2019).
Feedback from the lecturer:
You should be considering if his symptoms are consistent with the ICD-11 criteria/code for PTSD.
Well done for submitting a draft of your essay for formative feedback. You submitted different sections of your essay without specifying exact part of your essay you are struggling with. This implies that you will not receive robust feedback on any specific part of your essay. You have chosen a good case study for this essay. You need to refer to the assignment guidelines for this essay and ensure that you present your essay in line with the required outline under the following sub-headings: Introduction, Biography, Assessing the needs of the service user, Planning care for the service user, Conclusion, References and Appendices (if applicable).
Introduction- A brief introduction to the assignment is required at the start of your essay. You need to signpost the reader to the key themes to be discussed in the essay. You need to state how you have adhered to the NMC Code on confidentiality (NMC 2018) throughout.
In your biography section, you should provide the reader with a brief information about the patient’s background and about his life- family, education, job, etc. You should not make any stereotyping assumptions about the patient. You should personalise the individual by using a pseudonym. You should also convey a sense of knowing the patient by providing information on how you met or had a caring encounter with the patient. Do not focus your discussion on the patient’s medical condition (diagnosis). Provide information and context that will suggest to the reader that you understand something about the patient beyond his/her mental health problems.
In your assessment section, you need to demonstrate your understanding of the concept and scope of assessment in mental health nursing process and reference your sources. You need to your understanding of how this is done in practice. It is required for you discuss how David was engaged in his assessment. It was not clear who conducted David’s assessment. Please do not give the impression that you conducted this assessment. In reality (in practice), risk and nursing needs assessments are completed by RMNs (your PA/PS) or by a student nurse under their supervision (with consent from the patient). Some aspects of what should be discussed in this section are missing. Please revisit your assignment guidelines. The following aspects have not been highlighted: (a) evaluate the professional, legal, and ethical factors involved in mental health assessment (b) how principles of recovery were utilised during the engagement and assessment of David (c) the communication theories and skills used effectively to engage and build a therapeutic rapport and provide person-centred care for David (d) good practice examples you have seen of engagement and promoting recovery (e) identify two or more of David’s needs that need to be care planned in the next section (f) impact of biological, psychological and social aspects on him (g) the role of the mental health nurse in assessment (and care delivery).
Your discussion on care planning needs significant improvement. You are required to demonstrate understanding of the definition of care planning and how mental health nurses work with patients in a way that values, respects and explores the ways they experience their mental health condition. Discuss how David’s care plan was formulated, who was involved in the process and consider if his care plan is linked to the principles of recovery. How might the principles of recovery be used in care planning Consider if David’s care plan was developed collaboratively with him/his family/carer and did his care support and address all his needs. Remember that in this section, you are required to identify and focus on two of David’s needs. Then evaluate evidence-based interventions and provide rationale(s) for the choice of specific interventions to address these two needs. You will need to correctly reference your sources. You can also refer to relevant policy guidance and frameworks to demonstrate an awareness of these interventions and their efficacy, to link theory and practice. Consider the extent of service user’s/carer’s/other professionals (multidisciplinary, multi-agency) involvement in choosing interventions to meet David’s needs. Provide some information on the importance of collaboration in mental health nursing, identify who nurses collaborate with. Briefly explore the barriers and facilitators of successful collaboration in care planning. Consider the issue of relational power in health care. How are decisions around patient’s care made? For clues to these, think about what happens in MDT and CPA meetings in inpatient mental health wards. on the wards.
Your essay should end with a conclusion, which summarises what you have discussed in your essay.
Please use reference from the UK such as RCN, NMC and WHO, NICE and so on.
Use reference from 2018 till date.
The reference list can be above 30. like 50.