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The case study of a client the author met during her placement period in one of the NHS trust.


This essay is based on the case study of a client the author met during her placement period in one of the NHS trust.Confidentiality will be maintained to protect the clients’ sensitive data as stated under Data protection Act (1998).Therefore, a pseudo name will be used and hospital name withheld throughout the essay.

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This is in collaboration with NMC (2008) Code of Professional Conduct. The author will discuss about assessment strategies used by the team to assess the client. The essay will develop by identifying factors contributing to client mental health concerns and in addition the author will look at agreed care plans. Discussion on own contribution and those of others in implementing and evaluating agreed care plan actions will be revisited as well. The author will also reflect on mental health education and practice carried out with the client and his family. In conclusion the author will summarise the case study by reflecting on how she experienced the procedures of her treatment from assessment throughout to recovery plan.

Richard (pseudo name), is a 20 year old white male who was admitted in one of the NHS acute wards in England under Section 3 of Mental Health Act (MHA, 1983). He is known to the service since the age of 13 and has been diagnosed with schizophrenia. This was his sixth admission and he has been to a mental rehabilitation and recovery unit twice during his previous admissions and presently he is under care of Community Psychiatric Nurse (CPN). He is known to be escorted by police on all his hospital admissions.

Richard grew up under the care of his mother who was single with different men coming in her house. She was unemployed and lived on benefits in a two bedroom council flat since Richard was two years. The area was crowded, multicultural with a high rate of drug, theft and violence crimes (UpMyStreet, 2011). As he grew up, he played with friends raised from the same financial/economic and social background as his, in the Council Estate in which he resides. Drinking alcohol excessively and smoking any sort of cigarettes is common in his home and his neighbourhood. As a result Richard was easily influenced into excessive drinking and smoking. He began using the little money he was given by his mum to feed his habit. His friends smoked cannabis and all sorts of drugs and it did not take long for him also to join them in smoking it.

According to Rausch and Young (1991, Pg 4) cannabis is “a depressant drug with hallucinogenic properties”. This reality catches up with him as he increasingly gets accustomed to cannabis. Around the age of 14, he started using illicit drugs like Heroin and crack cocaine. According to Edlin and Golanty (2009, Pg 377) these drugs stimulates the nervous system. What this means is that when a person is under the influence of these drugs, even though it is a crime on its own, can easily go to the extreme of anything he/she is performing or have wrong judgements that may easily result into another crime. Richard had family history of Mental Health; both his grandparents died of Alzheimer’s Dementia. According to epidemiology studies people with family history of mental health have high risk of having mental health in future.

Richard was admitted after the CPN and his mother were concerned about his behaviour, for example, walking naked around the house; not attending to his personal care; very withdrawal; laughing inappropriately; low moods; responding to voices and not taking his prescribed medication. They tried to bring him into Hospital informally but he refused as he had no insight into his condition, therefore, CPN informed the Approved Mental Health Professional (AMHP) who then arranged for mental health assessment and brought him formally under section 3 of Mental Health Act 1983 (MHA 1983). On admission, he was under influence of drugs and was not able to stand properly; therefore, he sat on a wheelchair to avoid risk of falling. He looked untidy with long uncombed hair, wearing dirty clothes and appeared to be in need of using the toilet. The author and other nurse took him to the toilet/bathroom and were able to get the urine sample which was sent for test and confirmed that illicit drugs were present. Whilst in the bathroom, he was assisted to have a bath and get changed into clean clothes. This also gave the author and other nurse opportunity to do Body map. He was responding to both visual and auditory voices. He could not maintain eye contact. Every time staff looked at him he puts his head down.

During body map, it was found that his fingers and toes appeared purple with wounds. This was documented on Body Map Form (See Appendix 10a). The nurse said that the type of wounds is common to people who inject themselves with drugs. However, he sat on a scale to weigh him and his height taken as per assessment procedure. His weight was 48kg and height 1.78m (See Appendix 10b). According to Body Mass Index (BMI) Richard was 15.1 under weight. Understanding this from his lifestyle, it appears that he was living on a poor diet because most of his money went towards drugs instead of food, clothing and toiletries. Vital signs such as Blood Pressure, Temperature, and Pulse were taken and recorded (See Appendix 10c). Night Staff reported that Richard becomes restless during the night asking to leave hospital. On doing this he turns to be aggressive presenting with threatening manners. Richard was reminded that he was under section 3 (MHA 1983) and nurses read his rights for him to remind him that he was not able to leave the ward without section 17 which requires Consultant’s approval (See Appendix 10d for patient’s rights). All these behaviour according to Patrice (1994) are drugs unforeseen effects.

Through involvement with the Multi-Disciplinary Team (MDT), the author got an opportunity to participate in the assessment, for Richard’s needs, planning of his care, implementation and evaluation of the planned interventions.

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According to Ward (1992) assessment is a form that the nursing team use to measure what clients can do independently and their coping strategies. Walsh and Kent (2001 Pg 140) argued that assessment is about looking at a “patient as a whole” that is “physically, socially, biologically and psychologically”. During the assessment different assessment tools, approaches, observation techniques were used by different members of the team depending with their conceptual frameworks or models of practice. The team was comprised of the Author, Psychiatric Doctor, Physiotherapist, Occupational Therapist, Registered Nurse, Psychologist etc. However, all these were to fulfil holistic nursing care.

Schultz and Vibeck (2002) views assessment as the initial step carried out during first stage of admission. Care Program Approach (CPA 1991) was used to assess Richard. According to The Sainsbury Centre for Mental Health (2000), CPA has a goal-achieving feature. It gives an efficient framework for a coordinated care provision and resource allocation. In this, a patient is allocated a key worker; a detailed assessment to each client’s needs is clearly stated and the client is involved in the recovery plan. However, interview was done, which involved Richard and his mother. They were assessed on their needs, for example housing, finance, physical and mental health status, past and current medication, education, sleep pattern and coping strategies. During the interview the author and other team members maximised their knowledge and skills, especially communication skill. According to Porritt (1984, Pg 3) communication is the main way by which human beings interact and can be viewed as a social process.

It was witnessed that Richard was hallucinating; had paranoid ideas; restless; confused at times; presenting flat moods. He was denying to what was taking place at the same time avoiding eye contact and crying. All these were influenced by drugs he took. Ross (2001) describes this as common to people who are depressed.

The team was highly experienced and understood how to deal with these factors that might impinge assessment. Active listening skills were brought into use, for example: reflecting everything Richard had said and clarifying with him; at other times paraphrasing and also asking him to summaries; speaking simple, clear and straight forward without use of jargon (Porritt, 1984). Good distance from him and sitting posture was maintained professionally for him to feel relaxed and engaged into the discussion (Egan, 2002). When talking, they squarely faced him, with open gestures and smiling. Suitable questioning strategies were utilized, for example, open and close ended questions. One example of this type of questions he was asked was as follows: “What is your daily routine?” However, the author/student had limitations and boundaries to work on, therefore, during interview the doctor was asking questions and the author was documenting the answers on assessment form instead of asking questions as well. She had to maintain that and maximise understanding, acquiring skills and knowledge. According to McGuire and Priestly (1985, Pg7) “a knowledge of your own limit immense great benefit in itself and may be indispensable for solving some kinds of problems”.

Literacy and numeracy skills were involved in the process when calculating points scored and lay down in a form of a scale. These were documented on assessment forms and the author’s mentor double checked to assess if they were well completed to the standard. These were to meet the NMC Code of Professional Conduct on documentation and record keeping (2008).

It was concluded that the trigger for all His problems was substance misuse; therefore, he was referred to Drug Clinic for detoxification and was to be prescribed methadone depending on the level of drugs in the blood. Stopping drugs completely could result in death by acute causes ((Prof ) Jones, 2004). Mirtazepine 15mg once daily, Zopiclone 7,5mg once at night and paracetamol 500mg three times daily was prescribed.

Risk assessment was carried out using Threshold Assessment Grid Tool (TAG see Appendix 10e). According to DOH (2002), this tool assesses client potential risk to him or others, that is, looking at clients past history of violence; self harm or others; patient social network and neglect. TAG simply assesses the severity of service user’s mental health problems (Slade, 2000). It was noticed that Richard was at risk of blood transported diseases, for example, HIV and Hepatitis. Blood test was done and Richard was informed that the results were negative. Advice was given that the blood test will be repeated again after six months as HIV studies refer this period of months as window period. Level three observations commenced, where the staff had to monitor him on one to one. Close monitoring was important on Richard because he was depressed and was on antidepressant medication, therefore, suicidal thoughts were most likely to affect him (Carolyn et al, 2008).

Care planning is one of the requirements of CPA. According to Hogston and Simpsons (2002), care planning is a process that provides a “road map” to guide everyone involved with patients’ care. Richard and his mother participated in planning. According toSeaback (2006) patient involvement make them feel empowered, valued and committed to goals sat out. However, Maslow Hierarchy of needs triangle indicates that “basic, low level needs should be satisfied first”. Following this triangle, needs to be met were housing, weight building, job, personal hygiene, sleeping pattern, compliance with medication and dealing with suicidal thoughts. Due to word limit of this assignment, three of these will be discussed and others written in appendix (1 to 9).

Since the problem was triggered by substance misuse, this can be viewed as the umbrella of all other needs, thereby makes health promotion the top priority. A health promotion care plan was devised involving Richard and his mother. This was done according to DOH (2004) that, “the care plan is to be individualised and tailored to meet each client’s needs “. It involved educating Richard about his illness and researches about substance misuse. Richard and his mother agreed that he was going to attend Drug- Misuse-Team clinic to get more help on detoxification and how to quit drugs. Therefore, a referral was sent to Drug-Misuse -Team, who came to assess and take him on board. The author sort consent from the mentor (Richard’s key worker) to work collaboratively with them in order to achieve this assignment and get insight into planning and delivering a teaching session on substance misuse.

According to Body Mass Index, Richard was under weight therefore, food and fluid chart were put out to record the intake (See Appendix 10f). Whitney and Rolfes (2008, Pg 579) suggest that, the prolonged use of drugs causes dehydration, loss of appetite which result in loss of weight which can lead to malnutrition and swallowing problems. Staff members were informed and communication book completed to make sure Richard has adequate diet and fluid. Weight chart was put in place for him to be weighed weekly (See Appendix 10g). Dietician was contacted to come and give advice on which foods to offer Richard. She came and carried out assessment with Richard and advised staff to offer him soft diet as he was likely to have problems with swallowing (Whitney and Rolfes, 2008). This was to be reviewed weekly during Multi-disciplinary Meetings. Food supplements in the form of fort sip, fort cream and Calogen were prescribed; this was in line with Stanfield and Hui (2009) who notes that these food supplements help building the body but they must be taken alongside with meal not as a substitute.

To meet his social needs Richard agreed to work collaboratively with the Social Worker who planned to find accommodation in a different area from his friends. His care co-ordinator was to monitor him effectively whilst at home to prevent further relapse and discouraging him to associate with friends who abuse drugs. Welfare state benefits began to be processed whilst he was still in hospital. In the care plan Richard agreed to go back to college in order to achieve his goals because he wanted to find a job. According to Radomski and Latham (2007), education is the “primary goal to dysfunctional people as it increase their self esteem, work experience, outdoor activities and prevent risk of exclusion”. He also agreed to take some voluntary work whilst he was still in hospital and Occupational Therapist (OT) was to come and collect him twice weekly as soon as he was ready to start. During his community activities the consultant completed Section 17 Mental Health Act (1983) which was there to allow Richard to go outside the ward for four hours a day. These care plans were to be monitored daily and evaluated every now and then as Richard progressed.

Within six weeks after admission, changes began to be noticed on his behaviour and appearance. Reflecting to progress, he began to put weight which proved that the supplements were working, therefore, weight care plan was changed from weekly weight to fortnightly. However, food and diet chart continued as it was still important to find out how much he eats and drink. The food supplements were discontinued after the Dietician’s assessment in which it was reported that he was progressing well and proper diet was encouraged. In the process, he was maximising the use of gym to build up his muscles. Evidence in progress was witnessed when he began to use his own initiative to attend to his personal needs independently; therefore, his care plan pertaining to personal hygiene was reviewed and reduced to supervision. The Social Worker got him an apartment that was close to his mother and his benefits were processed. He began receiving weekly payments which he collected accompanied by staff. He was able to buy his toiletries, clothes and other foods preferred. When Richard started activities with OTs improvement on his capability and potential to do things better was witnessed. Initially, he required a wheelchair when going out because he was assessed as weak and at risk of falls, however, this was discontinued and a wheelchair was no longer needed to mobilise him. Richard was advised to increase his activities as he enjoyed participating. He got a place at the local college to study carpentry.

His medication was reviewed and changed; Zopliclone and Paracetamol were to be given as per his request (PRN) because he was sleeping well at night and no more headaches as before. The author also reported progress on teaching session conducted with Richard as presented in the later part of this assignment.

Analysing the introduction of receiving benefits weekly while in hospital, Staff members witnessed some incidences (although few) were service users smuggle drugs into hospital. Giving Richard money appeared to be a risk because he might use it for buying drugs. However, this was an issue dealt with in advance, in the Criminal Law Review (1992) Police have right to stop and search anyone in possession of controlled drugs under Misuse of Drugs Act 1971 which also gives hospital staff same powers to do stop and search to detained patients. Therefore, the stop and search use to be conducted by staff and police once every now and then and all drugs, alcohol, dangerous weapons found were to be confiscated. However, the reason for stop and search was always explained to patients to avoid breaking the therapeutic relationship between client and nurses which is build upon trust, respect, genuineness and empathy.

On substance misuse care plan, all staff had a responsibility to educate Richard on health promotion. The author working collaboratively with the mentor planned the teaching sessions which focused on developing an understanding for Richard and family that drugs are detrimental to their health. The author put together session plan (see appendix 8). At this point the greatest dilemma was that, the author had no experience in teaching sessions of this nature. However, support was available from the mentor when needed

Blais (2002) views teaching as a system of activities whereby learning occurs. Hinchcliffe (2005, Pg 63) added that, “learning is any event that brings about relatively permanent change in behaviour resulting from either experience or practice”. To achieve a meaningful session the author usually began by defining the purpose of the lesson to the group. Each and every individual were given chance to participate, contribute and criticise the session. Information for teaching was gathered through current research, evidence based practice ideas, clients experience and other professionals as recommended by NMC Code of Professional Conduct (2008) that, one “has to keep his/her knowledge and skills up to date and deliver care based on current evidence”. According to Jarvis and Gibson (2001) rehearsing helps develop confidence and reduce nervousness, therefore, rehearsals were done with the mentor before the final session. This helped to boost confidence and to correct and polish work before presenting it to Richard and group.

In implementing the teaching session, the author used the activist strategy, according to Nicklin and Kenworth (2000) this is a teaching theory that allows clients perform more activities to motivate themselves and enjoy the learning experience. These activities were group work that includes discussion, listing substances and identifying relapse signatures. To make this teaching theory effective some resources were used, for example, flip charts, simplified diagrams and video clips. All these helped to draw attention as some realised that the symptoms they were experiencing were similar to what they saw on the teaching resources. They responded by answering each other’s questions. This proved that they were listening to teaching session. At some point they debate which made the session more enjoyable. Use of leaflets was avoided in the session because most of them including Richard got a lot of leaflet information teachings from drug misuse clinic.

During the session, the author had to use skills such as maintaining the tone of average voice because lowering it was going to give wrong signal to clients that information given was questionable. Raising the voice could be associated with threatening manner or shouting (Porritt, 1984). Listening was a skill used a lot to attract clients into discussion. In doing this, the author avoided repetition of phrases; hesitation; was facing them and maintained eye contact in order to communicate effectively without reading from the script (Egan, 2002). At the beginning of the lesson, the author advised clients to maintain confidentiality in case some clients disclosed important information and at the same time encouraged them to maintain respect and dignity in line with NMC code of Professional Conduct (2008).

An evaluation tool (see appendix 9) was designed by the author to get feedback from Richard and group. Some expressed that too much material was used, for example, flip chart and handouts. Some pointed out that they could not keep in memory words used especially in flipcharts. Few of them believed that drugs have no effect on mental health despite all education they got; they still believed mental health comes like any other disease, for example, diabetes. Generally, most were good comments such as “It was informative, well taught, the session was well timed and of good length, the teaching was helpful in personal life, the session reflected real experience in life, etc”.

According to authors’ work experience and opinion, giving up drugs is up to individuals not what clients are told. With the view of hospitals, there is a number of health care professionals who smoke cigarettes but they are quite aware of the effects. Mcdowell and Spitz (1999) argued that people give up on their own will as the substance misuse cycle is like any other recovery cycle and that varies depending on individuals.

Reflecting to the whole case study, the author was impressed to see what she knew in theory put in practice, for example, individualised care. Hinchcliff (2005) argued that reflection is the way in which everyone revisits the events that happened and how these could have been done differently. Therefore, the author hereby suggests that Richard would not have relapsed if the government’s welfare state system was fit for purpose. Evidence in the text shows that Richard grew up and lived in a community associated with poverty and social exclusion. It was also mentioned that the Social worker got an apartment for him in a better area. This means that the state is failing other places by inadequately supporting them. After detoxification the social input offered to Richard were sufficient enough to avoid his admission into hospital. That kind of social input and support was suppose to be given to Richard from birth to present. In short prevention is better than cure. Furthermore, it is encouraging that Richard and family were involved in all aspects of care. Richard was able to take a lead which was useful because it encouraged him to work toward his goal. The only skill to endeavour apart from what the team used so far is Focus Solution Therapy (Simon and Nelson, 2007) as it also encourages clients to focus on their goals instead of the problem. Richard remained in hospital.


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Hogston R and Simpson (2002) Foundation in Mental Health Practice. New York: Macmillan

Jarvis, P. and Gibson, S. (2001) the Teacher Practitioner and Mentor: in Nursing, Midwifery, Health Visiting and Social Services, 2nd Edition. Cheltenham: Nelson Thorns Ltd.

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Nicklin, P.J. and Kenworth, N. (2000) Teaching and Assessing in Nursing Practice: An Experimental approach 3rd Edition. London: Brailliere Tindall.

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Slade, M. (2000) What outcomes to measure in routine mental health services, and how to assess them – a systematic review. Australian and New Zealand Journal of Psychiatry, 36, 743 -753

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Appendices provided here are:

Appendix 1 Personal Hygiene- care plan

Appendix 2 Sleep- care plan

Appendix 3 Medication-care plan

Appendix 4 Mood- care plan

Appendix 5 Suicide-care plan

Appendix 6 Section 3 Mental Health Act- care plan

Appendix 7 Observation –care plan

Appendix 8 Lesson plan

Appendix 9 Evaluation Tool

Appendix 10a Body Map- Assessment Tool

Appendix 10b Body Index- Assessment Tool

Appendix 10c Vital Signs- Assessment Tool

Appendix 10d Section 3 Mental Health Act (1983) Patient’s Rights

Appendix 10e Threshold Assessment Grid- Assessment Tool

Appendix 10fFood and fluid Charts- Assessment Tool

Appendix 10g Weight Chart- Assessment Tool

Where information is deleted or omitted is done deliberately to protect confidentiality of the source




1 Richard to be assisted by one staff with his personal hygiene needs daily.

2 Staff to encourage him to use preferable deodorant.

3 Staff to encourage him to wear clean clothes daily.

4 Staff to encourage him to shave every now and then.

5 Staff to encourage him to brush his teeth and comb his hair daily when attending to his personal hygiene needs.


1 For Richard to be able to attend to his personal hygiene needs independently.

2 For Richard to look presentable all times.

3 For Richard to continue practising this skill when discharged.




1 Richard to be commenced on sleep chart to monitor his sleep pattern.

2 Staff to offer him warm milk drinks before bedtime to help him sleep, but avoid caffeinated drinks

3 Staff to offer him warm bath priory to bed.

4 Staff to keep him occupied with activities during the day and discourages him to sleep until evening.

5 Staff to monitor any side effect of his current medication to his sleep pattern.


1 For Richard to have long sleep hours.




2 Richard to take all his prescribed medication.

3 Staff to educate him on importance of taking medication.

4 Staff to educate him on his prescribed medication.

5 Richard to discuss with the Doctors on other routes if he does not want oral medication.

6 Staff to monitor concordance with medication and observe for side effects and therapeutic effects.


1 For Richard to have knowledge on his prescribed medication.

2 To maintain recovery.

3 To prevent further relapse




1 Staff to have one to one session with Richard once daily.

2 Staff to monitor his mood and document daily.

3 Staff to encourage him to participate in ward activities.

4 Staff to encourage him to interact with fellow peers.

5 Staff to use de-escalation skills when Richard becomes aggressive, restless or when he ask to leave.

6 Staff to use lock door policy when Richard threatens to leave the ward, document the incident and then inform the doctors.

Expected outcome

1 For Richard to be able to ventilate his feelings and thought to staff.

2 For Richard to be able to interact with fellow peers and staff.

3 To maintain his safety and others




Staff to monitor Richard on one to one observations
Staff to monitor side effects of depressant medication
Staff to educate him on depressant medication
Team to review his medication regularly
Richard to have psychologist input
To be referred to Therapy and Recovery Unit for CBT and Relaxation

Expected outcomeTo prevent further relapse

To prevent suicide or harm risk
To help Richard achieve optimal function
Richard to recover and maintain treatment




Staff to read Richard’s right to him
Staff to give him medication as prescribed
Staff to inform him on lock door policy and observation levels
Richard to have a signed Section 17 when he wants to go outside the ward.
For the care plan to be reviewed weekly by the team.
Mental Health Coordinator to be informed of Richard section status as well as family

Expected Outcome

For Richard to be able to understand his rights
For Richard to follow the section guideline at all times
For Richard to be in a position to get support and guidance in appealing if they is a need.




Staff to maintain Richard’s observation level
Staff to increase observation level if appropriate
Staff to record appropriate observation
Staff to inform MDM of any change as appropriate
No one should observe for longer than two hours at any one time


Staff to provide information for ongoing behavioural and risk assessment including specific behaviours and triggers
Staff to monitor all changes in behaviour
Staff to enhance the safety of Richard’s behaviour at risk including: suicide attempts; harm to others; self injury; risk of absconding and potential risk of neglect



TOPIC: Substance Misuse and Mental Health

Target audience: Patients, Staff, Family

Date: 20 / 05 / 2010Time: 14.00 hrs

Venue: Meeting Room Expected Duration: 1Hour


To enable clients to:

a) Understand what the meaning of the terms “substance misuse”.

b) Understand the difference between the benefits of prescribed medication and the intoxication of illicit drugs

c) List the different types of substances likely to be abused

d) Discuss the effects of substance misuse on mental health

e) Identify their own relapse signatures

f) Identify ways of getting help.


Handouts Discussion

Flip ChartsGroup Work

Overhead projector watching a Video

Television and video player Lesson Evaluation

Video tape



Circle the appropriate answer

1) Objectives clear. Yes / No

2) The teaching material was useful. Yes/ No

3) The teaching material was easy to understand. Yes / No

4) Discussions and group activities were useful. Yes / No

5) The language used was easy to understand. Yes / No

6) The presenter was speaking clearly.Yes / No

7) The subject well researched.Yes / No

8) The subject brought new things I did not know. Yes / No

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