For the purpose of this essay the author has been asked to discuss the nursing care of a patient

for the first 36 hours following admission to an acute psychiatric unit. During the course of
the admission procedure a full assessment will be undertaken, there are many issues in this
case study but not all can be discussed in detail. Assessment includes an interview with and
observation of a patient by the nurse and considers the symptoms and signs of the condition,
the patient's medical and social history, and any other information available. Among the
physical aspects assessed are vital signs, skin colour and condition, motor and sensory nerve
function, nutrition, rest, sleep, activity, elimination, and consciousness (Mosby, 2009).

A nursing assessment should be done holistically; it is a process that requires decision making
based on gathering all relevant information using a set of guidelines that can help a nurse
develop a care plan for that patient (Barker, 2004). The identified outcomes that will be
prioritised for this assessment are the patient’s use of amphetamine and managing her
withdrawal symptoms, her aggression and her suicide risk. The assessment covers only the
first 36 hours therefore it will be short term interventions that will be used initially.

Mary has been brought the Acute Psychiatric Unit against her will. A person can be admitted
involuntary under the Mental Health Act 2001 if you have a mental disorder, if you are at risk
of causing harm to yourself or others or that your decision making abilities are diminished
and your condition could get worse if not admitted to hospital for treatment. We as nurses
have to ensure that the procedures involved in admitting someone involuntary are carried out
correctly. The Mental Health Act 2001 is the law that must be followed when giving care and
treatment to people with mental illness. The Mental Health Act, (2001) brings Irish mental
health law into line with the European Convention (Mental Health Commission, 2001). There
are procedures that must be followed to admit you to hospital against your will and a number
of people can be involved. In this case the Gardaí are involved in the admission of Mary.
They were called to Mary’s house because she was physically and verbally aggressive
towards other people in the house. In this instance within the law of the Mental Health Act
(2001) the Gardaí have arranged for her to be examined by a doctor and that doctor has
recommended that Mary needs to be admitted to hospital therefore she has been brought by
the Gardai for involuntary admission (Mental Health Act, 2001)

Assessment
Mary has arrived to the acute unit in a very agitated state. As a nurse caring for Mary
following admission it is very important that meeting the patient for the first time the nurse

pg. 1
introduces herself and advises on what procedures are to follow such as tests to record basic
physiological needs such as Blood pressure, temperature, weight (Cox,2010). It is essential
that you have good communication skills and let the patient tell their story first (Lloyd &
Craig, 2007). The nurse then needs to arrange for Mary to be seen by the consultant
psychiatrist on duty (Mental Health Act, 2001). This consultant will carry out a Mini Mental
State examination. According to Meei-Fang et al (2007) the Mini-Mental State Examination
(MMSE) is the most frequently cited cognitive screening instrument, it is a 30-point
questionnaire used to detect cognitive impairment and assess its severity (Folstein et al 2001).
Mary is quite agitated and aggressive and carrying out a 30 point questionnaire may add to
this agitation therefore it is important that the nurse advises the consultant of this and suggest
that it may be more effective for the consultant to carry out an 11 question measure that will
test five areas of cognitive function: orientation, registration, attention and calculation, recall
and language. This will only take 5-10 minutes to administer therefore it can be done more
efficiently and cause less stress to the client. In assessing her client the nurse’s role is
gathering information on patients from many sources including observation, interview,
written information and discussion, for example observing a patient in seclusion or a patient’s
sleep pattern, measuring temperature/blood pressure (Cowman, 2001).

According to Gordon, 2010 there are 2 phases of an assessment; these involve undertaking a
nursing history and a physical examination. Taking a nursing history gives the nurse a
description of a client’s functional or dysfunctional pattern. This history ideally should come
from the client or close family members or friends (Gordon, 2010). In this instance Mary is
very agitated and angry therefore getting her to disclose a full history may prove difficult so
her aggression will need to be managed immediately. Mary appears to be having suicidal
thoughts, she has an injection site that appears to be infected, according to her housemates she
has been using amphetamines, cocaine, alcohol, heroin and cannabis and she is displaying
symptoms of psychosis but according to Harris and Batki (2000) amphetamine use can cause
drug induced psychosis, therefore giving a possibility of a dual diagnosis. She is very pale and
thin and seems exhausted also therefore evidence of malnutrition seems likely, this often
happens when there is substance abuse because the patient may have been trying to cover up a
mental illness (Abayomi and Hackett 2004). Unfortunately Psychiatric units have moved
away from routine physical assessment on admission eventhough it is evident that people
with mental illness are vulnerable with respect to their nutritional needs (Abayomi and
Hackett 2004). There are many other symptoms evident with Mary but for the purpose of this

pg. 2
essay there will be three areas that will be discussed in detail, these areas are managing
Mary’s aggression in order to assess her and put together a care plan for her, her risk of
suicide and to manage the amphetamine withdrawal for the first 36 hours.

As there is evidence of needle marks and Mary’s eyes appear widely dilated, along with the
suggestions from housemates that she has been using amphetamine, according to the NICE
guidelines it is vital that as part of comprehensive assessments, urine and blood tests are
carried out to confirm this (NICE, 2008). Alternative tests may be required but research has
found that amphetamine urine test screens have poor sensitivity and should not be a routine
component of assessment. Because acute management is needed for Mary, serum sample test
results are not available immediately and should not be routinely requested. It is initially a
clinical diagnosis from the nurse that will identify drug toxicity (Green et al 2008). According
to Clinical guidelines from New South Wales some of the symptoms of Amphetamine use are
suppression of appetite which may explain her weight loss, paranoia, aggression, inability to
sleep, mood swings (NSW Health, 2000). Mary has been walking the streets over the past
week which shows irrational behaviour and this is putting her at risk of harm to herself or
others (NSW Health, 2000). Long term users of Amphetamines may sometimes present with
an acute psychotic episode, we are not sure how long Mary has been using amphetamines but
she has no history of a psychiatric illness, therefore evidence based literature does suggest
that the amphetamines are causing this psychosis (Leamon et al, 2002). It is critical that the
nurse has knowledge of this as Mary will begin to undergo withdrawals within 24hrs, these
withdrawal symptoms are severe some of which are severe dysphoria, irritability, anxiety,
hypersomnia and paranoia. Mary needs to be nursed in a quiet part of the ward to avoid any
unnecessary stimulation and will need constant reassurance from nursing staff that she is in
hospital. Also during withdrawal some reports have stated that there is risk of suicidal
ideation and attempts (Scott, 2007) therefore observation will be required to help prevent this
happening. It is well established that subjects with psychosis are at greater risk of substance
misuse and suicide than members of the general public (Scott, 2007).Mary already has some
thoughts of suicide so it is vital that she is observed as there is evidence that early
intervention can reduce this risk (Bell et al, 2003). It is likely that Mary will “crash” at some
stage within the 36 hours, this lasts 1-2 days therefore it is vital that the nursing assessment is
carried out before this happens. Associated with the “crash” is exhaustion, long and disturbed
sleep, hunger and depression (NSW Health, 2000). Managing Mary’s withdrawal will require

pg. 3
high observation, keeping her safe and if she becomes highly agitated she may require
sedation which can be prescribed by the consultant (Gray et al, 2007).

As mentioned earlier Mary is very aggressive and feels that there is nothing wrong with her. It
has been said in the past that the combination of a mental illness and substance abuse can
enhance the possibility of aggression (Duxbury and Whittington, 2005). Aggression has been
defined as any verbal, non-verbal or physical behavior that can be threatening to the
individual or others (Foster et al 2007). It is vital that Mary’s aggression is managed in an
effective way to enhance the chances of a comprehensive assessment. Maintaining a safe and
therapeutic environment is a principal and critical nursing responsibility (Bisconer et al 2006).
Using verbal conversation in a calm manner rather than using more severe methods such as
seclusion or restraint has been proven to have a more positive effect on aggressive patients
(Duxbury, 2002). While working with Mary the nurse needs to de-escalate her aggressive
behavior on the unit but in order to do this she needs to get an understanding of what is
causing it and learn about the factors that may increase the chances of Mary to act in an
aggressive way, this is why a comprehensive history is taken (Foster et al, 2007). The
promotion of therapeutic relationship is necessary if aggression needs to be managed
effectively and it is also very important that the nurse does not label Mary as being “mad” or a
“drug addict”(Duxbury, 2002). De-escalation is one of the most effective ways of managing
Mary’s aggression; it is an important part of the therapeutic process. There are other methods
of managing aggression such as medication, restraint, seclusion or time out. Every individual
case is different and these methods should be thought about in each case, some may look at
restraint and medication as very restrictive and may contribute to the anger (Cowin et al,
2003). Reducing aggressive behaviour can be achieved by finding a calm personal space,
avoiding any triggers that may cause escalation, identify and reduce any stressors and provide
a safe environment (Cowin et al, 2003). While the therapeutic relationship between Mary and
her nurse is young, the nurse must be aware of approaching her with caution, not startling her.
She should be careful not to provoke her and be aware of her facial expressions and posture,
also using calm respectful language and open-ended sentences and questions will all help in
reducing the aggression and promoting the relationship (Cowin et al, 2003). The nurse should
remove any dangerous objects from Mary as she has mentioned that she considered suicide.
Mary is quite agitated and is very suspicious therefore involving her in a discussion on how to
avoid seclusion and restraint is a particularly useful if the topic arises during the course of
admission (Cowin et al, 2003). This is also a good opportunity to give Mary an option to

pg. 4
become a voluntary patient under the Mental Health Act, 2001 as she may be more relaxed
and cooperative. The nurse will carry on with the rest of the assessment; she will be assessed
for the level of suicide risk.

It has been identified that substance use has been one major risk factor for completed suicide
in patients with psychosis (Verdoux et al, 1999). Dedicating care and supervision to one nurse
is one of the most common methods used in managing the troubled and hostile behavior of
acutely ill psychiatric clients on admission, this helps the therapeutic relationship and gives
better outcomes in treatment, it also helps in avoiding absconding and may be useful in this
case as Mary has mentioned that she is not willing to remain on the unit (Power et al, 2003).

In assessing the risk of suicide with Mary it is vital that the nurse has up to date education on
the risk assessment tools that are available. In recent years an education intervention known
as Skills Training on Risk Management (STORM) has become widely used (Gask et al,
2006). STORM focuses on assessment and management methods for patients with suicidal
ideation and/or feelings of hopelessness (Gask, 2008). Storm enhances nurse’s skills in
assessing the level of suicide risk (Appleby et al, 2000). Establishing rapport with your client
is very important as it will make them feel more comfortable in disclosing important
information (Bowers et al, 2000). Explaining to Mary what the interview is for and telling her
that everything will be kept confidential is necessary to make her feel at ease. It’s important to
ask Mary about any current mental health problems, substance use, relationship problems,
social isolation, her physical health, any issues with college or her living arrangements as this
information will help with assessing possible precipitating risk factors. It’s also important to
note that if the client does not want to speak that it is ok to have some level of silence until
she feels ready (Mental Health Trust NHS, 2001)

Many studies that have indicated that specific areas appear to be related to the increased risk
of suicide for example hopelessness, evidence of a plan, depression, and recent relationship
breakdown; therefore it is very important that these are explored in more detail within the
assessment (Cutliffe & Barker, 2004). Exploring hopelessness is necessary as it is one of the
best predictors of suicide; if Mary discloses a degree of hopelessness the nurse needs to ask
specific questions about thoughts of suicide (Appleby et al, 2000). When a client admits to
thoughts of suicide investigating the availability of means to attempt suicide is very important
at this stage as this will help to assess suicidal intent (Mental Health Trust NHS, 2001). Mary
is quite young and research has stated that young people with early psychosis are at

pg. 5
particularly high risk of suicide. However evidence also states that early intervention can
reduce this risk. Despite this, first episode psychotic patients attending mental health services
still remain at risk and since this is Mary’s first admission to a psychiatric unit it is vital that
early intervention and management is given (Power et al, 2003).

Following Mary’s detoxification and stabilization of her mental state, it should then be
possible to educate Mary on the adverse effects of her substance misuse and the likelihood of
relapse of her mental illness should she continue to use amphetamines (Leamon et al, 2002).
We have discussed the assessment and management of her amphetamine withdrawal
remembering that she will require ongoing monitoring throughout the 36 hours as reports
have stated that there is high risk of suicidal ideation and attempts during withdrawals
therefore observation will be required to help prevent this happening (Scott, 2007). Mary’s
aggression is a barrier to carrying out the assessment so an immediate plan is required to de-
escalate her anger to enable the nurse to complete the assessment. Methods of calming Mary
down were discussed but research seems to identify that de-escalation is one of the best
methods of managing aggression (Cowin et al, 2003).We also identified the suicidal risk
assessment which is necessary for Mary because she had stated that she has considered
suicide, this requires diligence by the nurse is identifying the level of risk and whether Mary
has a plan or means of attempting suicide. It has been identified that substance use has been
one major risk factor for completed suicide in patients with psychosis (Verdoux et al, 1999).

In conclusion a nursing assessment is a vital component of developing a care plan for a

patient during admission. It is necessary to gather all the facts relating to that individual
during the assessment and not to make any judgments on the person.

pg. 6