Comprehensive mental health nursing reports play a pivotal role in delivering effective and tailored care to individuals facing mental health challenges. This blog will explore why mental health nurses complete a comprehensive nursing report. We will also view an actual case study on Sally, a 29-year-old Australian female with a diagnosis of Bipolar Affective Disorder. So, let’s dive in.

Comprehensive Mental Health Nursing Report?

These reports provide a holistic understanding of the individual’s condition, encompassing the clinical aspects of their diagnosis and considering social, economic, and environmental factors. This comprehensive perspective allows nursing healthcare professionals to develop targeted interventions that address the unique circumstances and needs of the individual.

Nursing Reports Are Crucial For Several Reasons.

Treatment Planning: The information gathered in a comprehensive mental health report forms the basis for developing an effective treatment plan. By considering various aspects of the individual’s life, healthcare professionals can create targeted interventions that address specific challenges and promote overall well-being.

Collaborative Care: Comprehensive reports on mental health facilitate collaboration among healthcare professionals, including psychiatrists, therapists, social workers, and other support staff. This collaborative approach ensures that all healthcare team members are informed about the individual’s needs and can work together to provide integrated care.

Client-Centred Care: A comprehensive report helps healthcare professionals tailor their interventions to align with the client’s values and preferences, increasing the likelihood of treatment adherence and success.

Risk Assessment and Management: A thorough mental health report includes an assessment of potential risks, such as self-harm or harm to others. This information is critical for developing a risk management plan to ensure the safety of the individual and those around them.

Long-Term Planning: Comprehensive reports contribute to long-term planning for the individual’s mental health care. This includes setting realistic goals, monitoring progress, and adjusting the treatment plan based on the individual’s response to interventions.

Communication with Stakeholders: The report is a communication tool between healthcare professionals, clients, their families, and other relevant stakeholders. Transparent and comprehensive documentation promotes understanding and collaboration among all parties involved in the individual’s care.

Legal and Ethical Considerations: Thorough documentation is essential for legal and ethical reasons. It ensures that healthcare professionals adhere to ethical standards, maintain confidentiality, and meet legal requirements for record-keeping. This documentation can also be valuable in audits or legal proceedings.

Quality Improvement: Comprehensive reports contribute to ongoing quality improvement initiatives within healthcare organisations. Analysis of outcomes and the effectiveness of interventions helps identify areas for improvement in mental health care delivery.

Meet Sally. To understand her treatment plan, let’s look at a comprehensive mental health nursing report and care plan (the patient’s name has been changed for confidentiality).

Patient Information:

Name: Sally Smith (name has been changed for confidently)

Age: 29

Gender: Female

Nationality: Australian

Diagnosis: Bipolar Affective Disorder

Social History: Lives with her father, father supports her financially, binge drinks alcohol weekly on weekends, and uses recreational drugs – previous cocaine use and marijuana use.

Background:

Sally is a 29-year-old Australian female who has been diagnosed with Bipolar Affective Disorder. She resides with her father and works part-time at Myer. Sally’s mental health condition has implications for various aspects of her life, including her employment, relationships, and daily functioning. She is currently under the care of the mental health service and is being case-managed to address her specific needs.

Clinical Presentation:

Recurring episodes of depression and mania characterize Sally’s bipolar disorder. She experiences periods of intense sadness, low energy, and feelings of hopelessness during depressive episodes, followed by periods of elevated mood, increased energy, and impulsive behaviour during manic episodes. These mood swings impact her ability to maintain stable employment and interpersonal relationships.

Living Situation: Sally lives with her father, who has been supportive throughout her mental health journey. However, it is essential to assess the dynamics within the household to ensure a stable and nurturing environment for Sally’s well-being.

Employment: Sally is currently employed part-time at Myer. Monitoring her work performance is crucial, as bipolar disorder can affect one’s ability to maintain consistent employment. Collaborating with her employer and ensuring reasonable workplace accommodations will be essential for the success of her job.

Summary A 29-year-old female was admitted to the mental health ward less than a week ago after discharge for a 6-week-long admission for her relapse of her Bipolar Affective Disorder.  She continued her medication but declined oral Abilify due to the side effect of drowsiness, which prolonged her illness episode. (Abilify is a brand name for a medication called aripiprazole. It is an atypical antipsychotic drug that is primarily used to treat various mental health conditions).   

Her symptoms on the initial Emergency Department assessment included auditory hallucinations, hearing voices, external, derogatory, distracted by paranoid thoughts of being unsafe at home, and worried that people or her family might harm her.  She also was suffering from insomnia and appeared to be depressed on the doctor’s review. Sally was admitted to the ward under the Mental Health Act.

What Is The Mental Health Act?

The term “Mental Health Act” typically refers to legislation enacted by a government to regulate the provision of mental health services and the rights of individuals receiving mental health care. Mental health acts vary from country to country and, in some cases, from state to state or province to province. These acts are designed to ensure the fair and ethical treatment of individuals with mental health conditions while also balancing the need for public safety.

Mental health acts typically outline the criteria under which an individual can be involuntarily admitted to a psychiatric facility. This often involves a demonstration that the person poses a risk to themselves or others due to their mental health condition.

Rights of Individuals: Mental health acts specify the rights of individuals receiving mental health care. This includes the right to receive treatment in the least restrictive environment possible, the right to be informed about their treatment, and the right to confidentiality.

Consent and Capacity: The acts address issues related to consent for treatment, especially when individuals cannot make informed decisions about their care. This may involve using substitute decision-makers or legal processes to determine treatment decisions on behalf of the individual.

Duration of Detention: Mental Health Acts typically specify the maximum duration for involuntary hospitalization and the conditions under which it can be extended.

Legal Safeguards: Legal safeguards, such as the right to legal representation, appeal processes, and review boards, are often outlined in Mental Health Acts to protect the rights of individuals.

Advocacy and Review: Some mental health acts establish mental health review boards or tribunals to independently review and oversee involuntary admissions and treatment decisions.

Community Treatment Orders (CTOs): In some jurisdictions, mental health acts include provisions for community treatment orders, allowing individuals to receive treatment while living in the community under certain conditions.

It’s important to note that the specific details and provisions of mental health acts can vary widely, and individuals should refer to the legislation applicable to their jurisdiction for accurate and current information. These acts are intended to balance the rights of individuals with mental health conditions, the safety of the public, and the ethical provision of mental health care.

During her admission, Sally became very unwell, she wanted to be discharged, She attempted to abscond several times, presented with no insight into her illness, and became aggressive toward staff and her family. However, after 7 days, Sally became more future-focused, gained insight, and trusted family, friends, and staff.  Let’s take a look at Sally’s Nursing Care Plan.

Sally’s Nursing Care Plan:

Medication Management: Ensure Sally is compliant with her prescribed medications. Regular medication reviews with the psychiatrist are necessary to adjust doses as needed. Monitor for potential side effects and report any concerns promptly.

Therapeutic Interventions: Implement a combination of individual and group therapy sessions to address Sally’s emotional and cognitive challenges associated with bipolar disorder. Incorporate psychoeducation to enhance her understanding of the disorder, triggers, and coping mechanisms. Build a therapeutic relationship with Sally, enhancing trust from her family and staff and insight into her illness.

Case Management: Regular case management meetings to assess Sally’s overall well-being, living situation, and support network. Collaborate with Sally’s father to ensure a supportive and understanding home environment.

Employment Support: Liaise with Sally’s employer to create a supportive work environment, including flexible scheduling when needed. Monitor and address any workplace stressors contributing to mood fluctuations.

Family Involvement: Involve Sally’s father in the treatment process, providing education on bipolar disorder and coping strategies to support Sally effectively.

Community Engagement: Encourage participation in community activities or support groups to foster a sense of belonging and reduce social isolation.

Crisis Intervention Plan: Develop a comprehensive crisis intervention plan in collaboration with Sally, outlining steps to take during periods of heightened mood or severe depression.

Monitoring and Evaluation: Regularly assess Sally’s mood, daily functioning, and overall quality of life. Adjust the care plan accordingly based on ongoing evaluations and feedback from Sally, her father, and other involved stakeholders.

Psycho-education: Teach Sally the importance of not taking illicit drugs and encourage her to use a journal/Gratitude journal to help her keep track of her triggers, appointments, and mental well-being.

Follow-up: Regular follow-up appointments with the mental health team to track progress, address emerging issues, and make necessary adjustments to the care plan.

This comprehensive care plan aims to address Sally’s unique needs, considering the multifaceted nature of bipolar disorder. Regular collaboration between healthcare professionals, the patient, and her support network is crucial for successfully managing her condition.

As we can see, a comprehensive mental health nursing report is a foundational element of client care. It provides a detailed and organised overview that guides treatment planning, supports collaboration among healthcare professionals, ensures client-centred care, and addresses legal and ethical considerations.

The information gathered in these reports forms the foundation for treatment planning. By examining various facets of an individual’s life, healthcare professionals can design interventions that are not only clinically sound but also aligned with the person’s values and preferences. This client-centered approach enhances treatment adherence and overall success.

Comprehensive documentation serves legal and ethical purposes, ensuring adherence to standards, maintaining confidentiality, and meeting legal requirements for record-keeping. It communicates between healthcare professionals, clients, their families, and other stakeholders, promoting transparency and understanding. It ensures client-centered care, addresses legal and ethical considerations, and ultimately contributes to the overall quality of mental health care delivery.

” Within the provisions and safeguards, compassion ensures the rights of individuals are upheld, their voices heard, and their healing journeys treated with the dignity they deserve.”

Molly

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