Care Planning and Need Assessment in Mental Health Nursing

This essay explores the critical role of need assessment and care planning in mental health nursing, focusing on a case involving Mr. Joseph, a 75-year-old man with dementia. The essay highlights the importance of social contact, activities of daily living, and addressing the biopsychosocial needs of the service user. It delves into the principles of recovery, emphasizing hope, engagement, and a positive sense of self, and underscores the significance of person-centered care, ensuring dignity and respect in healthcare decisions. The assessment process includes identifying risks, such as self-harm, and adhering to legal and ethical compliance, including The Code on confidentiality (NMC 2018), Human right laws and UK disability legislation (the Equality Act). The essay emphasizes the professional's role in understanding and coping with the service user's thoughts and feelings, ultimately aiming to provide effective treatment and improve the patient's mental health and overall well-being.

MENTAL HEALTH
NURSING

Table of Contents
INTRODUCTION...........................................................................................................................3
BIOGRAPHY..................................................................................................................................3
NEED ASSESSMENT OF THE SERVICE USER........................................................................4
PLANNING CARE FOR SERVICE USER....................................................................................7
CONCLUSION..............................................................................................................................10
REFERENCES................................................................................................................................1
APPENDIX......................................................................................................................................3

INTRODUCTION
Assessing the need of service user and as per assessment, making a plan of care plays an
important role in its recovery and improvement of mental health condition improvement. This
will also ensure better care and good health condition among the service users (Fostinelli, and
et.al., 2020). With the assessment of the need of the service user, better care would be provided.
In the same way with the need assessment, the carer would be able to provide better and efficient
care and treatment to the user. Likewise, with respect to The Code on confidentiality (NMC
2018) it is highly important that the carer or the nurse would own a duty of confidentiality that,
they share adequate information to the user and the confidential information will be kept private.
The same has been followed in the present essay as well. This essay will make a focus over the
need assessment and making of care plan that will not only meet the needs but it will also assist
in the recovery of the patient. With the aspect of considering biopsychosocial need, the essay
will make focus that how with the identification of the need related with the brain changes,
functioning of body organ and various other aspects are being taken into account. The essay
would include various themes related to identification of the need of the service user so that his
basic as well as mental needs will be analysed adequately. This will be followed with the
formulation of the care plan so that along with the satisfaction of the need of the user, the
individual would be assisted in terms of its care that will lead to minimise its health issues along
with its improvisation.
BIOGRAPHY
During the mental health setting, I cared for a person named Mr joseph who had dementia(It
is noted that a pseudo name has been used to denote the patient so that The Code on
confidentiality (NMC 2018) is considered). The service user which is being selected for the
concern case study has a severe mental health issue i.e. Dementia. He was 75-year-old man who
lost the cognitive functioning including the thinking, remembering and reasoning that affected
his daily life activities. It had also affected his decision making ability and as a result of that, he
has suffered from the various family issues. Due to dementia, the service user faced difficulty in
his normal life and activities wherein it became very difficult for him to take decisions and
remember the things which sometimes created various difficulties for it. This problem is
associated with the loss of memory, issue in solving of problem and thinking difficulties. Along

with the persistence of these issues, the old man faced various difficulties in his daily life that
affected its mental ability. There are various instances related with his family wherein due to the
lack of the ability of taking decision, he was neglected and avoided in the family decision. This
had a major impact towards his mental health condition. Although dementia is counted as a
mental health condition but at the same time with the perspective of various difficulties in daily
activity and persistence of being ignored in the society, made dementia as a major issue.
NEED ASSESSMENT OF THE SERVICE USER
While making an assessment of the need of the service user it is found that, the major need
would include the need of social contact and the activities of daily living (ADLs) that will assist
the user to grab assistance with regard to the daily living activities (Ye, and et.al., 2019). In the
same way as he was being ignored and separated from its family because of the short memory
and lack of decision making which would lead to raise the need of social contact so that the need
related with loneliness and mental health would be meet. It is to be noted that while assessing
need the concept of engagement and rapport building need to be focussed. This will include the
listening without judgement, use of empathy while assessing needs, use of disclosure with
caution while assessing needs must be considered (Pomey, Denis and Dumez, 2019). Since the
present case deals with mental health issues so a consideration towards the engagement and
rapport building is essential because it is further related with the concept of ethical compliance
and consideration.
Concept of Assessment in mental health nursing:
It is the first process of nursing wherein detailed information is obtained from the
patient. With the aspect of assessment, the detailed history of patient is created along with the
identification of problem and the creation of nursing diagnosis with the most suitable care plan
(Toney-Butler and Unison-Pace, 2018). This enables the carer to know everything about the
patient. In order to access the information and history of the concerned service user who had
suffered from the dementia, a detailed assessment was performed so that the concerned
information related with the mental health condition would be obtained. This also include the
identification of the need of the user, such as his prime needs and how it is useful in the
preparation of care plan for the concerned user. In addition to this, while undertaking the
assessment, various risks were also identified in relation to the service user. Whether patient is at

the risk of harming themselves, was one of the major risks that emerged while assessment. This
is highly important to undertake because while assessing the need, it is equally important that the
patient with the mental state and the problem of dementia is protected from the risk of self -harm.
Role and responsibility in professional health assessment
The professional health assessment plays an important role in dealing with the service
user. The role of carer includes developing better understanding and coping with the thoughts,
behaviour and feeling of the service user (Gibson and Palermo, 2020). This will lead to assit the
service user in delivering best treatment and care to the patient with a due consideration towards
its needs. This will also lead to raise the understating related with mental health of the patient
(Fink-Samnick, 2021). The role would also include the diagnosis of the mental health condition
of the service user.
In the context of responsibility, the major responsibility would include the legal and
ethical compliance including the compliance towards The Code on confidentiality (NMC 2018),
Human right laws and UK disability legislation (the Equality Act) wherein it will be ensured
that, while delivering treatment of service user the required provisions will be complied. This
means it is the major responsibility that while undertaking mental health assessment, the
concerned ethical and legal compliances will need to be considered. As during undertaking of
assessment, various instances and situation emerge wherein it is highly important that the
personal need and privacy of the service user will not be harmed. Since the present case deal
with the mental health issue of Mr Joseph (pseudo name) which involve various confidential
aspects and issues. Thus, while assessing the need assessment the carer and the professional need
to be cautious towards the compliance of professional, legal as well as ethical factor so that the
privacy as well as the gathered information will be kept confidential and used only for effective
treatment.
Engagement of service user in assessment
In order to make engagement of service user, various aspects were considered that
included the focus towards the social, biological and psychological aspects. The consideration
that is needed to be considered initiates with the psychological need that would lead to enable the
mental state of the service user i.e. its thinking ability, decision making sense was identified. As

during assessment, it was fond that the service user was ignored during family decision making
and he also had a habit of forgetting things. In the same way the social need was also identified
that how with the persistence of the mental state has an impact towards the social relation (Wong
and Horan, 2021). The service user had an issue of dementia that resulted in loss of memory and
affected the decision making capacity, which further led to raise the issue of ignorance and
avoidance by its family member. This not only impacted hiss mental health but also his social
relation would also have been impacted. This has also impacted its mental state in terms of
making of social relation and engage in social activity.
Likewise, the engagement of the user was also made in relation with the biological
factors that included concentration towards the degeneration in the cerebral cortex which is an
important part of the brain that control the thoughts, memory and actions of the human body. As
the death of the brain cells in this region led to cognitive impairment that would further lead to
dementia.
Thus, the engagement of the user in relation with the assessment included the equal focus
towards the biological, social and psychological aspects.
Principles of recovery
The principles of recovery in the context of the mental illness refers to gaining and
retention of hope that will make an understating of the individual’s abilities and disabilities along
with an engagement of the individual in the active life, social identity, real meaning and purpose
of the life and the positive sense towards self (McGuire, and et.al., 2021). This is an important
phase with respect to need assessment because assessment of need will be of no worth, if the
principles of recovery will not be applied which is related with the actual recovery of the patient
and the service user. As the recovery principles will enable an individual to come to the new
phase and active state of life that will act as an important part in the preparation of action or
improvement plan which itself raise the importance of this step and concept (Ramon, 2018). Like
the assessment, the principle of recovery also plays an important role in engagement of Mr
Joseph (pseudo name) in terms of developing a hope that he will lead a healthy and active
lifestyle. This has also included an assessment of social, biological and psychological need of Mr
Joseph and thus raise its active engagement.

In the above case, the principles of recovery played an important role because the service
user was 75 years old and suffering from the mental illness of dementia wherein the principles of
recovery not only led to an identification of the need of the user but at the same time also
assisted in making an improvement plan so that required steps could be taken in order to ensure
good health and wellbeing. As per the Principles of recovery one of the principle is ‘Recovery
included support from others’ which further assisted in enabling the individual to lead an active
and positive life with a sense of development of the positive approach that further assisted with
the mental support from others including family, society and friends. In the same way as per
another principles i.e. ‘With the identification of the need of the user i.e. mental, physical and
spiritual need the service user was able to get actively engaged that further helped in its care’.
This led to enable improvised action plan related with the recovery of the service user so that , he
will able to live its life along with its need satisfaction.
Interpersonal skills and Person centred care
Person centred care:
It refers to the treatment of the patient with full dignity and respect along with ensuring
that all the decision related with its health will be taken with its full concern. This means treating
the patient and the user who is taking service with full dignity and respect along with ensuing
that an individual has full right to take decision related with the healthcare and its life (World
Health Organization, 2020). This is related with the person’s healthcare. With the aspect of
Person centred care an effective care will be provided to the patient. In the present case also the
Person Centred care will enable a keen and effective care to service user. While providing Person
Centred Care the nurses need to comply with the professional code of conduct and guidelines so
that better care and treatment will be provided (Ballard and et.al., 2018). Compliance of NICE
Guidelines by professionals and carer will also lead to meet the specific need related with
Dementia as in the case of Mr Joseph (pseudo name).
MDT approach:
It refers to a mechanism that is related with organization and coordination of health and
care services that will meet the need of patient along with complex care need too (Taberna and
et.al., 2020). Here the team will bring a set of professional expertise and skills so that the access,
plan and management of care will be performed. In the chosen case, an implication of MDT

approach and active role of carer would enable the identification of the need of Mr Joseph
(pseudo name) and thus enable effective care.
Interpersonal skills:
It refers to the ability of the provider to understand the concern of the patient, make an
explanation of the healthcare issues along with engaging in its decision making. This will make
the delivery of professional care to the service user so that its healthcare condition will be
improved. The important skills that would be counted as important includes the, verbal or non-
verbal communication, problem solving, patience, decision making, listening, negotiation and
related skills. With the persistence of these skill better care would be enabled to the user. The use
of concerned interpersonal skills plays an important role in respect to the providing efficient
Person Centred Care to Mr Joseph (pseudo name). This is because with the use of concerned
skills need of the patient will be assessed that will lead to provide effective and better treatment.
As communication is counted as one of the major interpersonal skill that assisted with the
person centred care led to make an effectiveness of it. As the Delaney, Shattell and Johnson,
(2017) said that with the aspect of person centred care personalised care if assisted with the
communication then it will lead to enhance the efficiency of care. In the same way while caring
the service user this skill helps in bringing clarity with regard to delivery of care and effective
recovery of the user. With this skill the carer was able to make an understanding of the need of
the user along with making the required plan so that its recovery take place at faster rate.
Likewise, Kokanović, and et.al., (2018) also said that apart from communication the
other interpersonal skills including decision making, patience and others will lead to further
enhance the efficiency of person centred care. While caring the service user, with the use of these
skill, not only the meeting of satisfaction of the need of the user take place but it also lead to
enabling of treatment with respect and dignity. This would assist in better decision making in
terms of making a decision of the future course of action.
Along with the implication of interpersonal skill an implication of the Peplau’s theory of
communication also plays an important role. as per this theory communication is an interpersonal
process of therapeutic interaction between the service user who is sick and the nurse who is
educated to recognize and respond towards the need for help (Forchuk, 2021). With the
implication of this theory along with the active role of nurse in case of Mr Joseph (pseudo name)

plays an important role in identification along with meeting the need of the service user. This
will lead to raise the effectiveness of the Person Centred Care in respect to the patient.
Thus, in respect to the case of service user who had issue of dementia i.e. mental illness
was treated adequately with the integration of interpersonal skills and Peplau’s theory of
communication so that the mental health of the service user was improved.
PLANNING CARE FOR SERVICE USER
Care planning:
It refers to a plan or the process in which the healthcare professionals and patients make
discussion, agree and review the concerned action plan so that the goal will be accomplish. This
is highly important because with the aspect of care plan an individual would be able to make a
better understanding of its condition and would be able to live as independently along with
ensuing more control over its life (Doody, and et.al., 2017). This is further important because
with regard to a care plan, the family of the service user would be able to make a better
understanding of the need and wishes of the user so that they can support as well.
In order to make work with the values, respect and as per the need of the service user the
mental health nurses need to make an understanding of their various roles and responsibilities so
that the changing needs of the people and the group would be able to meet. This means during
care planning of mental health, nurse needs to work in a way that they can make understanding
of the service user’s experiences along with valuing it and giving respect to them. This will lead
to provision of more effective care to the patients so that they would be able to make a better
recovery. Likewise, with the key role of nurses in terms of recognizing dementia among
hospitalized service user with the assessing of sign during the course of nursing admission
assessment. Under such situation the nurses will orient the client along with enforcing positive
feedback. They can discourage suspiciousness of other and avoid cultivation of false idea. This
will further be supported with the NICE guideline which said that adequate training need to be
provided to carer and professionals so that they can support people living with dementia. The
guideline of NIC need to be followed by nurses and carer alongside the individual need, values
and preferences of the patient. As per NICE guideline all problems in relation with medicine or
medical device used for treatment need to be reported to Medicines and Healthcare Products
Regulatory Agency (Guidance., 2018). In addition of this, it is also to be noted that as care plan

would include the steps in which the future action will be agreed by both the professionals and
the servicer user and if it will be assisted with the respect, value and exploration of the
experience of the service user then it will lead to raise the improvisation of care with regard to
the patient.
Planning of care for service user and the concept of collaborative care plan
While making a plan of care for the service user various need along with a high focus
towards the biopsychosocial needs of the service user were focussed upon. This means while
making a plan of care for the service user his mental state and needs were identified. This means
that throughout the care plan, the biopsychosocial needs that is concentrated towards the
approach that healthcare professionals viewed the patient as experts who also have care for
themselves. This raised the effectiveness of the care plan with respect to the improvisation of
mental health of the user. Planning for care was related with the making of future actionable
steps that was further directly linked with the principles of recovery because it made a direct
contribution towards recovery of the patient in terms of making a focus towards the
biopsychosocial needs along with other need assessment. This helped him to lead a normal and
active life. This means while planning for care of the service user the various needs including the
social, emotional, mental and other needs were also considered and accordingly adequate actions
were taken that further assisted in recovery of the service user in the chosen case and link to the
principle of recovery. As under principle of recovery in relation with mental illness an
understanding of patient need will be made followed with taking of step towards the ensuring of
active life which will remain same in case of care plan also that is associated with the need
identification and ensures active lifestyle.
Collaborative care plan:
It refers to the care plan in which the values and personal preferences of the individual is
prioritize along with the live experience of mental health issue and the carer, family and kinship
groups. This will enable the understanding about more informal information about the service
user so that the outcome of the personal care will be enhanced (Lake and Turner, 2017). In the
chosen case of service user with the mental health issue of the dementia, the needs were
addressed with the collaborative care plan in which along with giving priorities towards the user
preferences more informal information was also identified which further enhanced the service

user’s health condition with the development of positive approach towards life. With the concept
of collaborative care plan the need of patient i.e. Mr Joseph (pseudo name) will be meet in terms
of assisting towards decision making and enabling of emotional support. The collaborative plan
focus towards the personal preferences along with mental issues of Mr Joseph and thus assist in
meeting its mental support need.
Evidence based intervention:
Cognitive stimulation:
This is one of the main intervention that is related with dementia that provide a wide
range of enjoyable activities that will provide general stimulation for thinking and concentration
with the involvement of small group. As per this intervention, the discussion and wide range of
activities are focussed that will lead to the enhancement of social and cognitive functioning of an
individual (Woods, and et.al., 2017). This is an important intervention that assists the patients of
moderate to the severe dementia so that the of social and mental health of the patient will be
improvised. However as per the studies it is also found that the use of cognitive simulation
although proves to be highly useful but its effect is moderate to small which means it is not
highly effective in use (Kim, and et.al., 2017).
The rationale for choosing this intervention was the inclusion of those activities that
would lead to assist the service user in improvisation in its mental health. In the case, the service
user was suffering from dementia in which with the state of ignorance from its family and social
groups the user felt more stressed. But with the inculcation of this intervention in case of service
user followed with the organization of fun activities and social group get together, led to
improvement in his health in a better manner. This can further be supported with the Nice
guidelines which shows that the use of the cognitive intervention proves to be highly effective in
dealing with the individual having mild to moderate dementia (NICE guideline [NG97], 2018).
Cognitive rehabilitation:
It refers to the intervention that is designed to make an improvement in the cognitive
function through strategy training or repeated practice of cognitive task. This is related with the
adoption of external environment that is assisted with the improvement of the abilities of patients
to use aids so that they can overcome impairment. Under this, the functional goal which are
relevant with the patient of dementia are identified and work on it so that the health condition of

the patient will be improved. This will lead to make an improvement in memory, attention,
problem solving skills. This will lead to play an important role in making a recovery from
dementia. However, it is affected with the aspect of avoidance, emotional dysregulation and
other aspects.
The reason for selecting this intervention was related with the aspect that the service user if
associate with the cognitive rehabilitation would lead to accomplishment of its functional goal
which will further help in dealing with dementia situation. In the same way with this intervention
the need and goal of the service user including the state of mind or the social need were also met
so that better recovery of the user was quite ensured. This is further supported with the NICE
guideline which shows that the adoption of cognitive rehabilitation will lead to improve the
ability of individual living with moderate to mild dementia (NICE guideline [NG97], 2018).
With the aspect of multimodal framework or therapy this can further be justified that use of
more than one model or the therapy will lead to make a direct and high impact towards the
dementia and its treatment. This is because it lead to assist an individual to get the benefit of
more than one therapy like the combination of cognitive rehabilitation and stimulation which
will make a delivery of effective treatment in respect to an individual.
In the selected intervention of cognitive stimulation and rehabilitation the involvement of
service user, carer and the external body played an important role in selecting the intervention for
the chosen case. As the intervention including the care plan or the treatment procedure which
will be applied over the service user, thus the role of service user and its state of wellbeing is
important. Likewise, the intervention in relation with the service user need to be made identified
and decided by the professional which shows that the role of professional is also important.
Likewise, as it is implemented by the carer so without its active role the intervention will not be
able to implement.
CONCLUSION
From the above report it can be concluded that, making an assessment of the needs of the
individual and its consideration plays an important role in health improvisation of the patient.
This means with the need assessment and making an inculcation of interpersonal skills within the
person centred care would lead to make an improvement in the mental health of the service user.
In the same way it is also understood that with the making of care plan or the collaborative care

plan, the carer would be able to make adequate attention towards the functional and
biopsychosocial need which would lead to assist the service user to accomplish its goal. In the
same way it is also summarized that how with the selection of most appropriate framework and
intervention with respect to dementia, the mental health of the user will be improved. This will
also raise the efficiency of the care plan that will further make a contribution towards the health
improvement of the service user.

REFERENCES
Books and journals
Ballard, and et.al., 2018. Impact of person-centred care training and person-centred activities on
quality of life, agitation, and antipsychotic use in people with dementia living in
nursing homes: A cluster-randomised controlled trial. PLoS medicine. 15(2).
p.e1002500.
Delaney, K.R., Shattell, M. and Johnson, M.E., 2017. Capturing the interpersonal process of
psychiatric nurses: A model for engagement. Archives of Psychiatric Nursing. 31(6).
pp.634-640.
Doody, O., and et.al., 2017. Families’ experiences of involvement in care planning in mental
health services: an integrative literature review. Journal of Psychiatric and Mental
Health Nursing. 24(6). pp.412-430.
Fink-Samnick, E., 2021. The Social Determinants of Mental Health: Assessment, Intervention,
and Wholistic Health Equity: Part 2. Professional Case Management. 26(5). pp.224-
241.
Forchuk, C., 2021. Overview of Peplau’s Theory. In From Therapeutic Relationships to
Transitional Care (pp. 3-15). Routledge.
Fostinelli, S., and et.al., 2020. Eating behavior in aging and dementia: The need for a
comprehensive assessment. Frontiers in Nutrition. 7.
Gibson, S. and Palermo, C., 2020. Optimizing the Role of Clinical Educators in Health
Professional Education. Clinical Education for the Health Professions: Theory and
Practice, pp.1-14.
Kim, K., and et.al., 2017. Cognitive stimulation as a therapeutic modality for dementia: A meta-
analysis. Psychiatry investigation. 14(5). p.626.
Kokanović, R., and et.al., 2018. Supported decision-making from the perspectives of mental
health service users, family members supporting them and mental health
practitioners. Australian & New Zealand Journal of Psychiatry. 52(9). pp.826-833.
Lake, J. and Turner, M.S., 2017. Urgent need for improved mental health care and a more
collaborative model of care. The Permanente Journal. 21.
McGuire, A.B., and et.al., 2021. Recovery-oriented acute inpatient mental health care:
Operationalization and measurement. Psychiatric Rehabilitation Journal.
1

Pomey, M.P., Denis, J.L. and Dumez, V. eds., 2019. Patient engagement: How patient-provider
partnerships transform Healthcare organizations. Springer Nature.
Ramon, S., 2018. The place of social recovery in mental health and related services. International
journal of environmental research and public health. 15(6). p.1052.
Taberna, and et.al., 2020. The multidisciplinary team (MDT) approach and quality of
care. Frontiers in Oncology. 10. p.85.
Toney-Butler, T.J. and Unison-Pace, W.J., 2018. Nursing admission assessment and
examination.
Wong, K. and Horan, R., 2021. Needs assessment: risk, desistance and engagement.
Woods, B., and et.al., 2017. Cognitive stimulation to improve cognitive functioning in people
with dementia. Cochrane Database of Systematic Reviews. (2).
World Health Organization, 2020. Mental health of people with neglected tropical diseases:
towards a person-centred approach.
Ye, J., and et.al., 2019. Physical restraint in mental health nursing: a concept
analysis. International journal of nursing sciences. 6(3). pp.343-348.
Online reference
Guidance., 2018. [Online]. Available through <https://www.nice.org.uk/guidance/ng97>
NICE guideline [NG97]., 2018. [Online]. Available through <
https://www.nice.org.uk/guidance/ng97/chapter/recommendations#interventions-to-
promote-cognition-independence-and-wellbeing>
2

APPENDIX
Care plan: Resolving issue of ignorance in family decision making:
Problem
statement
Intervention
action
Date of review
of care plan
Outcome Date and
Signature
I’m avoided and
neglected in
family decision
making
Set together with
family when the
decision has
been taken
Ongoing Avoidance and
neglecting of
Joseph in the
family decision
making will be
minimised and
its involvement
will raise
Jan and Joseph
Present views of
own during
family
discussion
Monthly
Look towards
past decision
Monthly
Keep diary and ongoing
3

note everything
so that family
will involve in
decision making
4