Menthal Health Assessment – Assessment of mental health and well-being is integral to the holistic care of a critically ill patient. The assessment has a twofold purpose—first, to identify the impact of physical illness or injury on the patient’s mental health, and second, to establish the effect, if any, of mental ill health on the patient’s physical health and recovery. In addition, nurses should be familiar with the principles and functions of mental capacity assessment. During the mental health assessment, it may become apparent that the patient is at risk. this should prompt immediate referral to mental health services. The physical signs and symptoms that may be attributable to mental disorders and/or medication prescribed for a mental disorder.
- ABC Mental Health Assessment
This involves rapid assessment of mental health status within three domains.
This domain focuses on observation of the patient’s emotional state and expressed feelings. It involves objective interpretation by the nurse of the patient’s non-verbal communication, and documentation of the patient’s mood, which is a subjective finding.
This domain focuses on observation of the patient’s behaviour. It involves subjective interpretation by the nurse of the patient’s behaviour and appearance. Caution is needed when interpreting the patient’s behaviour as a sign of mental disorder (e.g. inability to maintain eye contact can be a sign of depression, but this behaviour can also be due to a social or cultural convention).
Physical signs and symptoms that may be caused by mental disorders and/or medication prescribed for such disorders :
- Sleep disturbance
- poor memory
- Impaired speech
- Muscle weakness
- Sensory disturbance—vision, hearing, smell, taste, and touch
- tachycardia or bradycardia
- Nausea and vomiting
- Increased or decreased appetite
- Weight gain or loss
This domain focuses on evaluation of the patient’s cognitive function. Within this domain there is overlap with neurological assessment. It involves objective interpretation by the nurse of the patient’s orientation to person, place, and time, and observation of any signs of confusion or change in alertness.
- Mental capacity assessment
The five key principles
- Every adult has the right to make their own decisions (i.e. a patient is assumed to have capacity unless proven otherwise).
- A person must be given as much help as is practicable before anyone treats them as not being able to make their own decisions.
- If an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision.
- Anything that is done or any decision that is made on behalf of a person who lacks capacity must be done or decided in their best interests.
- Anything that is done for or on behalf of a person who lacks capacity should be minimally restrictive of their basic rights and freedoms.
Mental capacity assessment applies to situations where a person may be unable to make a particular decision at a particular time. It does not mean an inability to make general decisions or that a loss of capacity is permanent. Assessment of mental capacity :
- Identify the specific decision to be made.
- the assessment of capacity relates to a particular decision made at a particular time, and is not about a range of decisions.
- Functional test of capacity.
- Is there an impairment of, or disturbance in, the functioning of the person’s mind or brain (this may be either permanent or temporary)?
- If the answer is yes, does the impairment or disturbance result in the person being unable to make the particular decision?
The person will be unable to make the particular decision if, after all appropriate help and support has been given to them, they cannot:
- understand the information relevant to that decision, including the likely consequences of making or not making the decision
- retain that information
- use or weigh that information as part of the decision-making process
- communicate their decision (either verbally or non-verbally).
Decisions about serious medical treatment
- New treatment
- Stopping current treatment
- Withholding treatment
- treatment that has potentially serious consequences
Mental capacity terminology
- Lasting power of attorney (LPA)—a legal document that allows decisions to be made by an identified person (the attorney) on behalf of a person who lacks mental capacity (the donor). the document is only considered legal if it is registered with the Office of the public Guardian.
- Court of Protection— a specialist court that arbitrates over issues specifically related to mental capacity. the Court of protection will appoint a Deputy when decisions need to be made on behalf of a person who lacks mental capacity.
- Deprivation of liberty safeguards (DOLS)—decision making on behalf of a person who lacks capacity can potentially deprive them of their personal freedom and choice (deprivation of liberty). Safeguards now exist to ensure that decisions are made in the best interests of the person, and that the process is legal and open to challenge.
- Independent Mental Capacity Advocate (IMCA)—an IMCA is appointed if a person who lacks capacity has no one other than paid staff to assist them with decision making about serious medical treatment.
- Advance decisions—an advance decision allows a person to refuse pre-specified medical treatment at a time when they may no longer be capable of consenting to or refusing treatment. the person must have capacity at the time of making the decision, and must clearly identify which treatments would be refused and under what circumstances. Until an advance decision has been identified and confirmed as valid, the healthcare professionals must continue to act in the person’s best interests.
Factors that affect the mental health and well-being of critically ill patients
- Communication barriers:
Endotracheal tube or tracheostomy, sedation, cognitive dysfunction and muscle weakness.
May be linked to the patient’s past medical history (e.g. mental disorder, dementia) , may be the reason for their admission (e.g. neurological injury, sepsis) , may be caused by their treatment (e.g. post-sedation delirium).
Noise levels , activity levels and intensity, privacy and dignity, unfamiliar surroundings, transfer and discharge.
References : Oxford Handbook of Critical Care Nursing (2016)