Who is the person [service user] that you are going to write about? What did you know about them before you met them? When/ where did you meet? What were your first impressions of each other? What skills did you use to engage with this person? On reflection are there things that you could have done differently or better?
Did you talk about this person in supervision? What skills did you use to present this person’s case? On reflection are there things that you could have done differently or better in terms of your presentation? What did you learn from your experience and did you get feedback?
Case Presentation [1200 words]
Subjective perspective – how does the person see their situation? Use quotes. Do they agree with their diagnosis, treatment or care plan? How do they see their future? What are their priorities. Who is around them that is important –friends, family, carers?
What is their primary mental health diagnosis? When was this given, by who and why? Does the diagnosis relate to recognised criteria – if so, cite these. Outline the treatment they are currently receiving including accurate representation of drug treatments, doses and the purpose of these treatments. Are there psychosocial therapies being used?
Is this person being seen in the community or as an inpatient? If, so what kind of service is it? What is their MHA or MCA status [and have they been subject to treatment under these in the past?] Outline their history of treatment by and engagement with mental health services. What are the main aims of their current care plan?
What are this person’s strengths? What positive factors might influence the future for them?
Historical Background [600 words]
Tell the person’s life-story as much as possible using their own words and perspectives. If, possible append a timeline to support this. Think about their life in biological, psychological and social terms, considering factors from each of these categories that may have affected their journey and experiences. How have life events affected their education, employment, social circumstances [and skills], physical wellbeing and relationships.
Demographic Context & morbidity data; what evidence can you provide to offer context here? Think about social inequality, stigma, life expectancy, disability[200]
Physical wellbeing [600 words];
What are the person’s physical wellbeing needs or risks? How are these [or might they be] affected by their treatment or their mental health? Are they receiving any treatment currently for physical health needs [including side effects of medications?] What aspects of their physical wellbeing may need future monitoring [and why]? How can nurses work collaboratively with the service user and carers to promote health and wellbeing? How can SMART care planning and assessment tools be used? Examples might include;
Use of alcohol, nicotine or street drugs.
Weight / Diet / Exercise
Sleep
Analysis [1000 words]
Baseline measurements, timeframes and goals- is the current care plan SMART? What assessment tools have been used and what is the current picture that emerges from them? How have these informed the care plan? Do these assessments, measurements and goals reflect the interaction of biological, psychological and social factors to promote recovery? Are there assessment tools that you think could be used? Are there interventions that you think could be used? Is the care plan consistent with current policy and guidance? How will the person and the service know if the plan is working? How will the person be supported to maintain optimism and deal with setbacks? What is their experience of interventions that have helped or not helped in the past?
Conclusion [300 words]
If you could work with this person in the future, how could you contribute to their recovery? What skills, support and resources would you need? What further research could you do? How could you promote autonomy and a sustainable recovery for this service user?
Last Completed Projects
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