Assessment;
Analysis
Assessment type;
Treatment Plan
Word limit/length; 2000 words
Overview
Theory is useful as an underpinning to care for consumers, but it’s important to be able to move the theory into action. In the following case study you will have the opportunity to demonstrate that you can take what you have learned and apply it to real-world scenarios
Learning Outcomes
This assessment task is aligned to the following learning outcomes:
1. Appraise a range of complex acute care conditions engagement and interventions
2. Design a package of Trauma Informed Care applicable to acute mental health settings.
Assignment detail ***VERY IMPOTANT FOR YOU TO FOLLOW
Review and analyse the following scenario and create a holistic wellbeing assessment and treatment plan for the individual based on the principles of ‘Trauma Informed Care’. The plan you develop must be supported by critiqued evidenced-based research, with links between physical and mental wellbeing created and justified. Implementation processes of the package/plan must also be designed with specific reference to overcoming inhibiting factors in the consumer’s experience.
The Scenario
Mark was brought into the Emergency Department by a friend who said Mark told him that he was feeling unsafe. His friend advised that he had to leave and didn’t have time to stay. Mark is a 23- year-old Caucasian male. As you greet Mark, you note that he is around 6ft, has dark shoulderlength hair, and has a stocky build with weight held in his abdominal region. Mark presents as unkempt, wearing track pants, torn plain t-shirt and thongs. His feet appear to be unwashed, and his fingernails and toenails are dirty and unmanicured. Mark has limited eye contact and does not respond to your offer to shake his hand. You explain to Mark that your role is to offer support and help him. You further explain that this is done by listening to his concerns and working with him to identify helpful interventions whilst supporting him in keeping safe.
You ask Mark to share some information about himself. Mark explains in a regular rate and softly spoken voice that he has recently separated from his partner Annie and doesn’t know how to live without her. They had been together since he was 17. He explained that they have a four-year-old son together who now lives with Annie. Mark advised that Annie kicked him out of the house because she was sick of him drinking and passing out on the lounge. When she was packing up his stuff, she also found a few bottles of vodka around the house, about which she got upset. He advised that he is now staying with his mates or sleeping in his car. He also reported that he had been picked up by police and charged for high range drink driving a few days ago. Mark states that he hasn’t slept properly in a week.
Mark stated that he works as a labourer doing whatever needs to be done on the job site; however, that job is off and on again. He advised it was the only job he knew and that he didn’t like working out in the heat and that his back had started to hurt. Mark said the only thing he likes about work is going to the pub with the boys for drinks after a day’s work. Even though he knows he shouldn’t, Mark said he sometimes needs a drink before he finishes work to help him get through the day. He doesn’t get as much work now as he did when he was younger and most of his money goes on alcohol and to Annie to help with their son.
His friendship group is limited to the guys he met at the pub and on the worksite. He lost touch with his old school friends when he moved away from home. His parents live in a small rural town, and he doesn’t have anything to do with them. He described his upbringing as really rough and that his father used to drink heavily and would hit his mother when drunk. Mark recalled not having enough money for food or new clothes because his Dad was repeatedly fired from several jobs. He recalled his Dad ended up in the local lock-up for a few days for assaulting a man who confronted him about how he spoke to Mum at the pub. Mark shared how he tried to stop his Dad hitting his Mum but stated that his Dad ended up just hitting him too. Mark believes he was a disappointment to his parents, he feels that his Mum loves him but knows his Dad can’t stand the sight of him and nothing he did was ever good enough. Mark said he missed his Mum but knew he couldn’t go back.
The only thing he liked about growing up in the country was that it taught him how to handle guns. He has a rifle that he hasn’t used in a while as he has no one to go ‘roo shooting’ with.
Mark explained that he hated to leave his Mum but needed to move away from his Dad. He met Annie online when he was in year 11 at school and moved in with her. He didn’t finish school. Mark said that they got along well at the start, and Annie loved him so much. He and Annie did everything together, and then he started work as a labourer. Mark began to drink more, and Annie got upset with this. Mark said that Annie didn’t understand that that’s how he prefers to wind down after a hard day at work. They argued even more, when their son was born. Mark said that everything changed when he came along. He said that Annie told him that he had a problem with drinking and needed to stop.
Mark described his mood as really low, and this is congruent with the way he presented. He added that he felt hopeless and couldn’t do anything right. Mark stated, “I don’t know how I am going to live without Annie; she was my best friend.” Upon assessing the risk of self-harm, Mark stated he had thought about suicide when he was younger, but his uncle talked him out of it. He had a friend who died due to suicide when he was 15, and Mark saw what that did to his family “tore them up”. He further said that he had thought recently about suicide after breaking up with Annie and that the feelings come in waves. He said he had strong feelings again when the police charged him. Mark said he always talked to his uncle about these things as his uncle ‘really understood me’. His uncle passed away from cancer when Mark was 18.
Mark denied having experienced any hallucinations or other altered sensory perceptions. Mark believes he is ‘a loser’ and stated he was afraid he would turn out just like his old man (father). Mark didn’t appear to have any long-term memory impairment; however, he does describe blackouts when he can’t remember how he gets home from the pub. This has been increasing in recent months. He is orientated to place but cannot recall the day, date or time.
You ask Mark what he might need and what might help. His response includes that he hit rock bottom when he got caught drink driving and knows he needs to stop drinking. He would like to get back with Annie and have more time with his son. He also wants to increase his energy – he stated, “look at me, I have no energy, I can’t even be bothered having a shower”. He said his friend brought him here as he told his friend that he couldn’t take much more and wanted to end it all. However, he did add that he doesn’t feel like that all the time and that he currently feels safe talking to you. Mark said he would like a new job and always wanted to work as a mechanic. He also needs somewhere to stay while he works it out with Annie
TASK
*****VERY IMPORTANT TO HELP IN STRUCTURE THIS ASSIGNMENT****
Part A – Approx. 1500 words
Concerning the assessment of Mark provided in the scenario, outline what additional information you would obtain and why to complete a comprehensive and holistic assessment. Ensure you include information for an evaluation of risk.
Part B – Approx. 500 words
Write a letter to Marks GP explaining that you assessed Mark, summarise your findings, what your brief interventions and recommendations were and why, and include any further followup Mark may require from the GP. Keep in mind that Mark will be provided with a copy of the letter, and he should be able to easily read and understand what you consider the problems are and what needs to happen.
Letter Requirements:
1) Outline the critical biological, psychological and social health issues that need to be addressed in this episode of care — paying attention to past trauma/experiences and how they may have contributed to the Marks current presentation.
2) Highlight anything that needs to be addressed to keep Mark safe.
3) Outline your plan of care of brief therapeutic interventions to holistically address/resolve the health problems, referencing the latest evidence and authoritative guidelines.
4) Provide any recommendations that the GP may address to assist Mark in further improving his health, again with reference to the latest evidence.
