The focus of this assessment is quality of life and specifically this paper considers how malnutrition affects quality of life of community settings’ patients. According to the Scottish Governments publication “Older people living in community – Nutrition needs, barrier and interventions: a literature review”, malnutrition is an umbrella term for undernutrition, overnutrition and imbalance diet intake (The Scottish Government, 2009). Malnutrition has previously been described in the various ways (The Scottish Government, 2009). However, for purpose of this assessment the following term will be used as defined by World Health Organisation (WHO) “the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions” (see European Nutrition for Health Alliance, 2005).

According to Saunders, Smith and Stroud (2010) 2 per cent of the UK population is underweight: Body Mass Index (BMI) is lower than 18.5 kg/m. However, they agreed that patients could be still at risk of malnutrition whatever their BMI is (Saunders, Smith and Stroud, 2010).

Malnutrition, as well as other factors, has negative effect on the person’s quality of life (The Scottish Government, 2009). In the UK, hospitals admission rate and mortality were greatest in patients with BMI below 20 (kg/m2) (Teo and Wynne, 2001). During nutrition screening survey in the UK various settings it was found that malnutrition doubles risk of mortality in the hospital patients and triples morality in elderly patients in hospitals following discharged (RCN and NPSA, 2009). Care Homes’ nutrition survey shown that 30 per cent of service users recently admitted to care homes were at risk of malnutrition (RCN and NPSA, 2009).

According to Hickson (2006), malnutrition may be secondary to certain health conditions which is increasing risks for patients to become malnourished and those risk factors will be discuss later in this assessment (Hickson, 2006 and Teo and Wynne, 2001). However, European Nutrition for Health Alliance (2005) argued that malnutrition should be classified as independent disease (European Nutrition for Health Alliance, 2005), its due to undernutrition has a negative effect on all organs systems such as muscle-skeleton, cardiovascular, respiratory, gastrointestinal, endocrine systems and in addition, malnutrition has a psychosocial effect (Saunders, Smith and Stroud, 2010).

It was found that undernutrition could cause following health conditions: in the healthy individuals and has advance exacerbation effects upon existent illnesses or injuries, reduced psychological wellbeing (increase anxiety, depression apathy, and loss of concentration and self-neglect) (Webb and Copeman, 1996 and Saunders, Smith and Stroud, 2010). According to Morley and Kraenzle (1995), balanced diet in general, is improving cognitive and memory performance in elderly (see Vetta et al, 1999).

Chandra (1993) found that undernutrition is depressing organism immune function (see Webb and Copeman, 1996). It could be due to impaired cell-mediated immunity and cytokine, complement and phagocyte function this most commonly could lead to developing bacterial and parasitic infections and poor wounds healing (Saunders, Smith and Stroud, 2010).

Malnourished patients have reduced muscle function, loss of cardiac muscle and reduce cardiac output, which results in impact on the renal function (Saunders, Smith and Stroud, 2010). The same individuals have reduced respiratory response to oxygen deficit by poor diaphragmatic and respiratory muscle function (Saunders, Smith and Stroud, 2010), increased risk of hypothermia, increase risk of falls and injuries (Webb and Copeman, 1996). In addition, redaction of fat and muscles mass are more obvious signs of malnutrition (Saunders, Smith and Stroud, 2010). According to Clayton (1991), malnourished elderly clients have a poor prognosis for recovery from following fractured femur, hypothermia, pressure ulceration and other conditions (Clayton, 1991). Fracture risk is high then calcium, magnesium and vitamin D intake is insufficient, during the weight loss bone mass is reducing as well (Saunders, Smith and Stroud, 2010).

Early stage of malnutrition leads to loss of digestive enzymes that result in intolerance of lactose. The colon loses its ability to absorb liquid, electrolytes, and secretions of small and large bowels, which results in diarrhoea (Saunders, Smith and Stroud, 2010).

According to Saunders, Smith and Stroud (2010), endocrine system is affected in malnourished patience. For example, chronic malnutrition will change the pancreatic exocrine function by reducing the insulin secretion (Saunders, Smith and Stroud, 2010).

An author is currently working a nursing and residential care home for elderly patients as well as nursing and social recruitment agency, which is covering biggest part of the North West of England. Being allocated in hospitals and nursing homes the author noticed that patience’s nutrition needs are being met well but where are still some areas for improvement. During the study carried out in the large the UK hospitals, it was found that 40 per cent patients admitted to hospitals were malnourished and two-thirds subsequently lost weight during their hospital stay (Teo and Wynne, 2001).

During the service users’ meeting in the care home author working in, carried out in January this year, all 14 service users have stated that they are satisfied with food they are getting. However, two patients are still at risk of malnutrition. They have been referred to the GP for dietician support. The author strongly believes that nursing home is providing adequate food to the service users. Catering manager in the UK hospitals compare to chefs in nursing home have a small budge of £11 to £15 per patients a week (Teo and Wynne, 2001). The author’s care home spends around £30 per service user a week. However, in March 2007, Royal College of Nursing (RCN) carried out survey questioning nearly 2200 of their member relating nutrition issues. Survey has revealed that 42 per cent said the food provided for patients were below overage expectancy (RCN, 2011).

In various reasons government and health profession organisations are now advising for routing screening of all patients admitted to any healthcare facilities (RCN and NPSA, 2009). In author’s opinion, the main priority for addressing this issue is promoting patience’s health and wellbeing and cutting financial cost. For example, annual financial cost of treatment malnutrition patience and any associated illnesses in the UK was estimated around 7.3 billion pounds. This figure includes treatment malnourished patience in the hospital setting, round 3.8 billion pounds and long-term care facility such as care home, round 2.6 billion (Elia M., et al., 2005).

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Causes of Malnutrition

The author is currently looking after two service users who are scoring on the MUST. All two patients are elderly from 65 to 80 years old, with different background and health conditions. Patient No 1 is 87 years old female, was diagnosed with Alzheimer’s Disease, history of Transient Ischemic Attack (TIA), high blood pressure, right wrist fracture and Dysphasia. Current BMI is 19, which was stable after referral to dietician and commencing on oral supplements, than BMI was 17 back in the October 2010. Patient No 2 is 72 years old man, diagnosed with alcohol excess, CA oesophagus, Gout, Heart Failure. Current BMI is 23, which was stably increasing over past months following admission to nursing home, than his BMI was 17. Both patients have a poor appetite at present. Nursing home’s staff cannot establish reasons for anorexia and BMI reduction in one patient.

There are number of risk factors, which could cause malnutrition among elderly population. However, the most important factor leading to undernutrition is reducing of oral intake (Saunders, Smith and Stroud, 2010). Inadequate dietary intake is depending on various factors (Saunders, Smith and Stroud, 2010), which could be divided into three main categories: medical, social and psychological (Hickson, 2006). Firstly, age related changes such as changing in appetite or sensory (Teo and Wynne, 2001). Working in the care homes author noticed, an appetite is reducing with advanced age. Some people refused or preferred to omit meals, for example, one patient does not take breakfast, then the author asked her why she is not taken breakfast that patient replied that she is not a “breakfast person”. In addition, during the study carried out in USA it was discovered that elderly population are consumed less energy intake and follow more traditional eating pattern then younger population (Teo and Wynne, 2001). Poor appetite or anorexia is a most common factor leading to malnutrition in both young and old generation (Hickson, 2006). However, during the study commenced by Roberts et al (1994), it was found that ageing seemed to affect the ability to control food intake and weight lost will take longer to re-gains in elderly men compare to young (see Hickson, 2006). In addition, according to work of De Castro (1993), older people are less responsive to stomach contents than younger people, in term of hunger (see Hickson, 2006). Anorexia may occur as process of aging as well as during underlying illnesses (Teo and Wynne, 2001 and Hickson, 2006).

Hetherington (1998) argued that changing in taste and smell could lead to loss of appetite through a perceived decline in the pleasantness of food. Loss of taste and smell could be associated with advance age and medications therapy mechanism of these changes are remains unknown (see Hickson, 2006). In author’s care environment patients prefer to eat strong flavour and taste meals such as a roast meat with gravy, bacon, fish which are being served with traditional sauces or salt and vinegar to encourage patients to their food. According to Hickson (2006), a few works have been done to find out that improving the flavour of the food can improve diet intake and follow weight increase in hospitals and community healthcare patients (Hickson, 2006). A few patients do not like vegetables, intake of which have being recommended by NHS “5 a day” complain based on the WHO (NHS, 2009).

Patient No 1 and Patient No 2 do not have own teeth which is reducing ability to chew tender food. For both patients oral problems have not been reported. However, according to Finch et al (1998), National Diet and Nutrition survey, energy consumption was lower in edentate individuals compare to individuals with own teeth (see Hickson, 2006).

Dysphasia or swallowing problem is leading concern in reducing dietary intake (Hickson 2006). The author has experienced that often care and catering staff do not understand the different between soft and liquidised diet and which diet should be given to each patients with dysphasia. Moreover, care staff that is responsible for feeding patients, needed assistant, every often do not understand the sings for swallowing problem. This concern has been addressed in the care home that the author is working in by appointed care staff for appropriate training section provided by Liverpool Primary Care Trust (PCT). According to research carried out by Mowe et al (1994), swallowing problem is showing up in 64 per cent of in-patience elderly (see Hickson, 2006). In addition, Gariballa et al (1998) argued that post Cerebrovascular Accident (CVA) patients with Dysphasia had a worse nutrition status then those patients without swallowing problems (see Hickson, 2006).

The author strongly believes that malnutrition caused by various factors combined together such as old age and health or mental health problem (Saunders, Smith and Stroud, 2010). In the UK, it was estimated that around 8 per cent of patients with chronic diseases living in the community are malnourished (Teo and Wynne, 2001). According to Hickson (2006), diseases-related malnutrition is usually associated with cancer, physical disabilities, endocrinology disorder and respiratory disease, gastrointestinal disorders, neurological disorders, sources of infection and other psychological factors such as depression and Dementia (Hickson, 2006 and Teo and Wynne, 2001). Medical factors increase the risk of patient to become malnourish through, for example, nausea or vomiting, diarrhoea or constipation, anorexia and malabsorption (Hickson, 2006).

Cultural factors or social (Vetta et. al. 1999) and food habits are also playing an important role in developing malnutrition as independent illness (Hickson, 2006). As example, an individual who had a long-term hospital stay or had no nutrition support while in the community would not used to have full nutritional meals. Moreover, individual who has been admitted to the author’s care home used to take “fast” food or sandwiches at all the time while at home, instead of cooked meals. According to Hickson (2006), there are lifestyles and social risk factors for malnutrition in elderly people are lack of knowledge about food, nutrition and cooking, isolation and loneliness, poverty, inability to shop or prepare food (Hickson, 2006).

Dementia has a great effect on individuals’ relationship with food (Alzheimer’s Society, 2011). Dementia patients or patients with low mental status appeared to lost weight due to reducing self-feeding ability, acute sense of smell and taste that is depending on severalty and progression of disease (Teo and Wynne, 2001). Berkhout et al (1998) has confirmed that weight lost in demented patients is caused by patients’ ability to feed them rather than by dementia as illness (Hickson, 2006).

According to Incalzi et al (1998), study carried out for in-hospitals patients found out that cognition is causing impairment to ability or desire to eat (see Hickson, 2006). Progressive dementia is usually associated with uncontrolled weight lost and changing eating habits (Claggett, 1989 see Hickson, 2006).

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Nutrition screening and risk assessment

In 2007, RCN commenced “Nutrition Now” campaign, which has a wide response from members of public as well as members of multidisciplinary teams. The RCN Principles for Nutrition and Hydration were published in 2007. That principals aim to help of all health professionals’ grades to improve nutrition and hydration of patience. This paper is highlighting three principles of nursing care: accountability, responsibility and management to improve the patience nutrition and hydration (RCN 2011).

Nutrition screening pathway, nutrition risk assessment are widely used which assist nursing staff to indentify the risk of malnutrition or/dehydration and appropriate actions to be taken. Risk of malnutrition screening should be a routine process in all healthcare settings (RCN and NPSA, 2009). In the author’s care home as required all service users are being screened for malnutrition on the admission and once a month or more often if required, using Malnutrition Universal Screening Tool (MUST) as recommended by government bodies and Care Quality Commission (CQC) as registration body. Part of the admission documentation is to collect and record patience’s food likes and dislikes. According to Saunders, Smith and Stroud (2010), MUST is reliable and valid screening tool in diagnostic or prediction of malnutrition (Saunders, Smith and Stroud, 2010). However, nutrition assessment was only done for patients who have been referral to their GPs following scoring, weight loss of 1 to 2 per cent per week, 5 per cent per month or 10 per cent over period of six months (Mitchell, 2003).

According to RCN and NPSA (2009), purpose of nutritional assessment is details identification of nutritional status and for special dietary plan to be formulated and implicated (RCN and NPSA, 2009). In the author’s care home, dietician or dietician’s assistant based on the information provided by staff nurse on duty normally carries out the nutritional assessment. As far as author concerns, nutrition assessment should be done by care home nurses as they are working in close contact with patients and their families on the daily basis, know better person’s food likes and dislikes. However, special nutrition trainings are not always available to the nursing home staff. This could lead to complicated nutrition issues not to be addressed as quickly as they should be due to community dieticians waiting time is usually 6 weeks.

In the author’s nursing home all necessary equipments are available such as weight scales and height measures. However, weight scales calibration has not been done which could lead to poor nutrition screening assessment (NPSA).

After completing the MUST, the author and colleagues will formulate the personalised care plan for each patient in order to meet nutritional requirements. Nutrition care plan could be based on the information or guidance provided by dietician or other health professions.

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Treatment

According to Hark and Morrison (2003), the nutrition needs of healthy older adults are mainly the same as for middle age adults (Hark and Morrison, 2003). The intake of food containing Calcium, Vitamin D, Folate, Vitamin B12 and B6 should be increased for the elderly population (Hark and Morrison, 2003). Protein intake recommendation is variable from 0.8 g/kg per day in the USA (Mitchell, 2003) to 0.75 g/kg in the UK (McKevith, 2009). However, according to Mitchell (2003), one established nutrition needs recommendation cannot be used for all ages’ population (Mitchell, 2003). In addition, patient’s lifestyle, height and weight should be taken in account (Mitchell, 2003).

There are number of fundamental support of nutrition available at present such as enteral and parenteral nutrition support (Hark and Morrison, 2003). At this assessment only oral nutrition support (ONS) will be discussed. The aim of the nutrition support is to ensure an individual gets enough energy, proteins, macronutrients and micronutrients to meet patients’ nutrition requirements (Saunders, Smith and Stroud, 2010). Saunders, Smith and Stroud (2010) argued that provision of regular meals with better nutrition content, wide menu choice and assistant with feeding should be enough to meet nutrition requirement and reduce nutrition risk (Saunders, Smith and Stroud, 2010).

Numerous studies show that nutrition support could reverse weight loss, only if underlying health conditions under control (Saunders, Smith and Stroud, 2010). However, not all patients react at the same way (Hickson, 2006). At what reasons care and treatment should take an account of individual needs and preferences (RCN and NPSA, 2009). In practice, knowledge of food preferences and past medical history, following personalised nutrition care plan, serving patients with small meals (Teo and Wynne, 2001) or using a small plate could encourage service user to finish all meal.

Currently some of the UKs’ hospitals commenced to use red tray scheme for serving the meals to patients. A purpose of using red trays is to alert hospital staff that patience with red tray is at nutrition risk and need assistance or supervision with diet intake (Bradley and Rees, 2003 see Davis, 2007).

Protection of mealtime scheme is also widely spread across the UK. The purpose of this scheme is to create an environment for hospital patients free from hospital activities and unnecessary disturbance during a mealtime. In addition, this scheme is to assist nursing staff with concentration on the meeting nutrition need of hospital patients (NS, 2007).

People with Dementia could loss an ability to use cutlery that could lead to weight loss and malnutrition. Providing those patients with available finger food could improve nutrition status (Alzheimer’s society, 2011).

Teo and Wynne (2001) argued that the possible benefits from using energy supplements in elderly patients have received little or no evaluation in clinical practice (Teo and Wynne, 2001). However, during the study carried out by Volkert et al (1996), it was found that patients consuming food supplement while in-patience and 6 months in community have develop positive nutritional status compare to group of patients without food supplements (see Teo and Wynne, 2001). The author has come across the situation then GP has refused to prescribe food supplement to one of the patience and recommended full fat milk instead. In addition, during controlled trial for six months in patients who have been discharged from hospital and prescribed ONS has no economic benefit. To compare, using ONS in community is costing more than using ONS in hospitals (Elia et al., 2005).

However, malnourished patients using could be at risk of re-feeding syndrome, which could results in death (Saunders, Smith and Stroud, 2010). Re-feeding syndrome is associated with water retention leading to fluid overload due to decay of potassium, magnesium, phosphorus and sodium in blood plasma (Mallet, 2002). Saunders, Smith and Stroud (2010) recommended that during re-feeding saviour malnourished patients potassium, phosphate and magnesium should be prescribed and thiamine (for patients with history of alcohol excess) (Saunders, Smith and Stroud, 2010).

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Conclusion

The UK elderly population is rising, currently about 16 per cent of the population is above 65 (Hickson, 2006) and by 2050 over 30 per cent European population will be over 60 which will result in prevalence of malnutrition to rise (European Nutrition for Health Alliance, 2005).

Many changing associated with aging have been documented, however, how senescence leads to the health conditions, related to aging, is still unknown (Mitchell, 2003). It was found that ageing is leading to slow reduction of weight and modification in body composition. It is due to declines in bone, muscle mass and body cell mass. Bone mass reduced due to inadequate intake of Calcium and inadequate exposure skin to the sunlight to encourage production of Vitamin D (Sahyoun, 2002). In general, people are gaining weight until they 60th birthday and after gradually reducing weight, usually 10 per cent between 70 and 80 (Mitchell, 2003). Weight loss related to aging and malnutrition should be indentified during initial nutrition assessment.

In addition, community healthcare is facing many concerns. Firstly, malnutrition remains under-recognized problem facing patients, their families and health professions (Saunders, Smith and Stroud, 2010). Secondly, according to, Hark and Morrison (2003) argued that there are no single physical or biochemical screening tools could accurate predict the nutrition status in elderly (Hark and Morrison, 2003). Food prices are constantly rising and ONS are costing too much to the local PCT. In the author’s opinion, providing service users with good quality food, offer choice of menu and snacks between meals are solution to fight malnutrition.

The significant role in education medical students and junior doctors in nutrition has widely recommended (Saunders, Smith and Stroud, 2010). However, inadequate knowledge in nutrition of nursing and care staff could increase risk of malnutrition (Saunders, Smith and Stroud, 2010). In the author’s care home nutrition in elderly is not mandatory training for the care staff. Following this assessment, the author will provide relevant care staff with information on the nutrition in elderly service users. This could be achieved through supervision sections and face-to-face talks. Moreover, there it is possible, elderly population and their families should be informed about the latest nutrition recommendations related to their age, lifestyle and health conditions and should encouraged to apply those recommendations to individuals’ lives (Sahyoun, 2002).

Discuss the importance of service user participation in the delivery of psychiatric nursing care.

Introduction

Traditionally, people experiencing mental health problems were removed from society and placed in asylums across the country, indefinitely (Thornicroft and Tansella, 2002, pp. 84-90). Patients within the mental health system were expected to take a compliant role in the management of their care and leave the decision making to the professionals. In today’s society that is not the case. In this assignment the writer will begin by exploring the publication ‘Vision for Change’ while discussing the main theme of this publication which is ‘the importance of service user involvement and the importance of empowering the service user in the mental health system of Ireland’ (Ireland, Dept of Health & Children, 2006). To empower the service user requires the control of power to be transferred from the professionals to the now known “Service User”. The writer will discuss the effect of this change and the importance of this change within the mental health system. The Mental Health Act 2001 requested the closure of many asylums and the move towards a community based model of care. The deinstitutionalisation of many patients and relocation back into the community required changes in the way the psychiatric nurse and service user operate.

Evidence has shown the importance of service user’s participation in research, education and in practice through out the mental health care system. The writer in this assignment will discuss the importance of service user participation in the delivery of psychiatric nursing care, focusing on the nursing assessment using a holistic approach.

Finally, the writer will discuss the importance of service user participation in the remaining stages of the nursing process; the nursing diagnosis, outcomes, planning, implementation and evaluation while exploring the need for a therapeutic relationship between service user and psychiatric nurse to complete the nursing process successfully.

With people experiencing mental health difficulties, who now reside in the community, it is vital that service users become involved in the development and delivery of mental health services, such as self-help services, drop-in centres, and in providing assistance with activities of daily living. The aim of this is to sensitise society to the need of integrating people with mental health difficulties back into community life.

As quoted in a Vision for Change;

“Service users must be at the centre of decision making at an individual level in terms of the services available to them, through to the strategic development of local services and national policy. To use a slogan of the disability rights movement: ‘nothing about us, without us’.

To reduce the stigma attached to people with mental health difficulties the term ‘patient’ was changed to service user, as most of the care they receive is provided in the community. The Mental Health Act, 2001 suggests ‘the term ‘patient’ is used to describe someone who is involuntarily admitted. Patient does not therefore refer to all individuals in an approved centre’. In the Vision for Change it states that ‘the correct way to describe someone with a mental health illness was to see the person before the illness, for example someone with anorexia nervosa was not to be described as ‘an anorexic’ rather than as a person with anorexia nervosa. Stereotyping in mental health is as damaging as any other stereotype (Ireland, Dept of Health & Children, 2006)’. People, who experience mental health difficulties, can be the experts through their own experience (Bee et al, 2008, pp. 442-447).

Psychiatric nurses remain the largest staff group involved in the provision of mental health care, (Bee et al, 2008, pp. 442-447). Therefore, to ensure the mental health care service abides by legislation, it is vital for psychiatric nurses to re-evaluate their role to ensure priority is given to including the service user. An Bord Altranais recommend that a holistic approach is adopted and it is listed as one of the requirements in nurse registration education programmes (An Bord Altranais, 2005). It is fundamental that the service user participates in the nursing assessment especially where the holistic model of assessment is used. The biopsychosocial model uses a holistic view, addressing the biological, psychological and social factors contributing to a person’s mental health problems. According to Boyd (2004, p.190) it proposes a person-centred treatment approach which addresses each of these elements through an integrated care plan agreed with service users and their carers and involves participation of the service user throughout the assessment. This assessment requires the service user to answer a series of questions, some being of intimate nature about themselves. This enables the assessor to obtain relevant information required in making a nursing diagnosis. To ensure accurate nursing diagnosis it is critical that the services user listens carefully to the questions asked and is completely honest when answering the questions. This process also requires the service user to be patient while the assessor records the data received. However, it is important to remember that an initial assessment can occur when a service user is first admitted into psychiatric care. According to Boyd (2004, p.194) the assessor must have empathy and an understanding of how difficult it is for a person to discuss intimate details of ones life’s to a complete stranger, even if it is in the person’s best interest.

Although the nursing assessment is the starting point of the nursing process, the writer feels that service user’s participation remains of equal importance throughout the nursing process. The freedom of information act 1997 requires that all services users can request access to any information stored about them. While, it is now a legal requirement for service users to be involved at all stages of the nursing process, the writer suggests that it is imperative that the service user is informed of the nursing diagnosis. This will empower the service user, by encouraging the service user to find relevant information regarding their diagnosis which can assist in them becoming experts of their own mental illness.

Following the diagnosis it is required by law that the psychiatric nurses discuss all details of the outcome with the service user. The psychiatric nurse needs to ensure that the service user’s values and beliefs are priority when planning the outcome. If any treatment is deemed necessary for the road to recovery, then it is compulsory that the service user is capable of understanding the effects of the treatment proposed, this requirement is stated Under the Mental Health Act, 2001:

“the service user must be capable of understanding the nature, purpose and likely effects of the proposed treatment and the consultant psychiatrist has given the patient adequate information in a form and language that the patient can understand, on the nature, purpose and likely effects of the proposed treatments (Section 56). Factors for consideration include the capacity to comprehend and decide, risks involved, patient’s wishes to be informed, the nature of the procedure and the effects of information on the service user.”

The service user must be informed of the benefits of taking the medication prescribed, for what duration the medication is to be taken and what side affects may occur when taking the prescribed medication. Forcing an unwilling inpatient to receive medication has been considered an unnecessarily coercive, traumatic, and even punitive assault on a person’s privacy. It has been stated that the patients’ refusal of medication is indicative of a gap between their experience and understanding of the medication and the intention of the prescribing physician. (Kaltiala-Heino et al, pp. 290-295) In today’s mental health care system, many service users receive treatment in the community; therefore, it is critical that services users listen to information regarding their prescribed medication while raising any concerns they may have.

Planning and the implementation stages of the nursing process are not possible without the involvement of the service user. Communication and agreement between the service user and the psychiatric nurse is necessary. Potential obstacles need to be pointed out, and methods of overcoming these obstacles, discussed. Potential risk areas for the service user needs to be discussed and a therapeutic risk assessment carried out by the psychiatric nurse to ensure the service user is not at risk or danger of harming themselves or others. Awareness of patients perceptions of their impaired quality of life gives psychiatric nurses important information for planning individually tailored interventions (Pitkänen, A. et al, 2008, pp. 1598-1606).

Finally, the evaluation stage evaluates client progress and reviews plans in accordance with evaluated data in consultation with the client. Evidence shows that the evaluation of a services users experience is of vital importance in shaping the future of service user’s outcomes within the mental health service. It also enables the psychiatric nurse to take the necessary steps required to ensure that the individual service user is satisfied with the service received. The Department of Mental Health, UK stated that the experience of service users, including those from black and minority ethnic groups, is a recognised national marker in the performance of the UK mental health services. In 2006, the UK National Service Framework (NSF) in line with the Mental Health Unit of the Regional Office for Europe carried out a systematic review of empirical service user views and expectations of UK-registered mental health nurses. Feedback from this review was both positive and negative, with service users holding mental health nurses in high regard. However; feedback also reveals that there was a strong need for nurses to be more effective in interpersonal communication and relationship building, whilst spending more time with the service user (Bee et al, 2008, pp. 442-447).

Throughout the nursing process it is necessary for a therapeutic relationship to exist between the service user and the psychiatric nurse to. Relationships are central in fostering and maintaining hope (Byrne et al 1994). Psychiatric nurses are required to have a genuine interest in services users, listening in a non judgemental way to what is being said. In a user-led study evidence has shown service users identified the importance of therapeutic relationships and how they inform patient experiences. Communication was highlighted by all participants as necessary. One participant in the survey quoted; “As soon as you come they can see that you are angry. Then someone will say, sit down, let’s talk about it, make a cup of tea.” Failure to establish a therapeutic relationship between the service user and the psychiatric nurse can result in negative patient experiences. Participants identified coercion as the main reason for failure to establish a therapeutic relationship (Gilburt, H. et al, 2008).

Conclusion:

The writer in this assignment briefly exposed the treatment of patients within the mental health care prior to the introduction of the Mental Health Act 2001 and the publication of ‘Vision for Change’. Then, the writer discussed the major changes within the Mental Health Services as a result of this act and publication. The Mental Health Act 2001, focused on the closure of many asylums and a community based model of care to be adopted, however, both the Mental Health Act and the Vision for Change also focus on the importance of service user involvement and empowering the service user. The writer demonstrates how a new psychiatric and service user role was required to adapt to policy changes within the Mental Health Service and to ensure all parties were adapting to policy requirements that aims at service user involvement at all stages, thus; empowering the service user. The writer reports how the publication ‘Vision for Change’ also hoped at reducing stigma by aiming to involve services users in developing and delivering mental health services. The writer mentioned the importance of service user involvement in research, education and practice, while focusing on the practice area by exploring the nursing process, starting with the assessment. Evidence is clear that it is not possible for a psychiatric nurse, even with the necessary skills required to proceed with the nursing process without the participation of the service user at all stages. The writer concluded this assignment by exploring evidence which reveals that service users regard a therapeutic relationship and good communication between the service user and the psychiatric nurse of high importance.

Reference List:

An Bord Altranais (2005) ‘Requirements and Standards for Nurse Registration Education Programmes’. 3rd edn. Dublin: An Bord Altranais

Bee, P., Playle, J., Lovell, K., Barnes P., Gray, R., and Keeley P. (2008) ‘Service user views and expectations of UK-registered mental health nurses: A systematic review of empirical research’ International Journal of Nursing Studies, 45(3), pp. 442-457.

Boyd, M. (2004) Psychiatric nursing: contemporary practice. 3rd edn. Philadelphia: Lippincott Williams & Wilkins.

Gilburt, H., Rose, D., and Slade, M. (2008) ‘The importance of relationships in mental health care: A qualitative study of service users’ experiences of psychiatric hospital admission in the UK’ British Health Service Research, 8(92), [online] Available at: http://www.ncbi.nlm.nih.gov/sites/entrez (Accessed: 12 December 2009).

Government of Ireland (1997) Freedom of Information Act. Dublin: Stationery Office [online]. Available at http://www.foi.gov.ie/legislation (Accessed: 6 December 2009).

Government of Ireland (2001) Mental Health Act [online]. Available at http://www.mhcirl.ie/Mental_Health_Act_2001/Mental_Health_Act_2001.pdf (Accessed: 6 December 2009).

Hall, A., Wren, M. and Kirby, S. (2008) Care Planning in Mental Health: Promoting Recovery. 1st edn. Oxford: Blackwell Publishing.

Ireland, Department of Health & Children (2006) Vision for Change. Dublin: Department of Health and Children.

Kaltiala-Heino, R. (2003) ‘Involuntary medication in psychiatric inpatient treatment’ European Psychiatry, 18, pp.290-295.

Pitkänen , A. Hätönen, H., Kuosmanen, L., and Välimäki, M., (2008) ‘Patients’ descriptions of nursing interventions supporting quality of life in acute psychiatric wards: A qualitative study’ International Journal of Nursing Studies, 45(11), pp. 1598-1606.

Repper, J. and Perkins, R. M. (2003) Social Inclusion and Recovery: A Model for Mental Health Practice. 1st edn. London: Bailliere Tidall.

Thornicroft, G. and Tansella, M. (2002) ‘Balancing community-based and hospital-based mental health care’ World Psychiatry, 1(2), pp. 84-90.

United Kingdom, Department of Health, (1999) National Service Framework (NSF) for Mental Health [online]. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4077209.pdf (Accessed: 9 December 2009).

Introduction:

Chronic inflammation is linked to sedentary life style such as Obesity, which is an important concern in human health (11,26).The experienced lifestyle of Western societies have shift toward less physical activity, and consumption more of the energy-dense food; in which this lead to increase of obese and overweight people(2,11). Generally, obese is associated with low-grade inflammatory state, which is reflected by the activation of immune system cells in adipose tissue (2). However, in England, statistics of National Health Service in 2013 shows 61.9% of adults and 28% of children which aged from 2 to 15 are overweight (36), and according to Welsh Health Survey in 2012, shows 59% of adults are obese (37). Consequently, this may increase the risk of having type 2 diabetes mellitus and cardiovascular disease (21, 2, 3,26). The contraction of the skeletal muscle lead to producing many protein, but if there is no physical activity may resulting in altering of myokines response(2,19). Therefore, this may give an evidence the association between sedentary behavior and many chronic disease. In addition, exercise play an important role in function and metabolism of many organs (21, 2,3).

Human health is an essential concern in our life. However, it is very important that we know something that nobody yet has done a research experiment, which help us to focus on something that we need to know, especially the thing which related to human health, so there is currently a gap in our knowledge about something that associated with our body. Therefore, the gap is exercise seems to cause cells such as monocyte-macrophages to produce more IL-4 regulating signaling, but as many studies have been published, showed that exercise is known to cause an increase in IL-6 not in IL-4, so they do not understand why it seem the stimulus response not matchup IL-6, IL-4 stimulus and IL-4 dependent response(2)?

In my project, I cannot replicate the experiment which was done in vivo in living mice, which was already done it, and as I am a student science and working in a biomedical science , I have to think about human(2). However, in vitro study, this review aim is to treat monocyte-macrophages with IL-6 and determine whether Dectin-1 increases, which mean if IL-4 express increase, then that people who did the experiment in mice in 2014 are correct, in which would expect that genes which controlled by IL-4 signaling will also increase(2).

The importance of macrophages and IL-6, IL-4 associated in exercise:

Macrophages are found in the body tissue, in which their function is to ingest and process of dead cells, foreign materials during response to signal of inflammatory. They are normally plasticity in which they can change their job phenotype in response to the signal of the microenvironment (4, 17, 24). Therefore, they are highly heterogeneous cells. Macrophages are released as monocyte, and within a few days, they start their function in the tissues (4, 17). In addition, when monocyte goes from the circulation, they differentiate in to macrophages (4, 17, 23, 24). Monocyte-Macrophages playing an important role in phagocytic cells (4). They are two types of macrophages such as M1 phenotype, which act as pro-inflammatory and a defense from different of viruses, bacteria and protozoa, and another type M2 phenotype, which function as anti-inflammatory and regulating the wound healing (4, 23, 24). Generally, after phagocytosis finished, M1 macrophages begin the polarization to M2 phenotype, in which that M1 phenotype loss their properties of pro-inflammatory (4, 14, 17, 22, 23) Figure (1). Nevertheless, the changes of monocytes in to macrophages in the muscle appear to be the most reaction of the immune cell after the damage of skeletal muscle (4, 23, 24). Generally, Obesity associated inflammation are a central mediator by macrophages (21, 14). So, in my project, my aim to treat and investigate the signaling in these cells by IL-6.

In chronic inflammation, there is an increase in the inflammatory activity, as the inflammatory cells such as the monocyte-macrophages detect inflammation stimuli and either they destroy them, or antigen presenting cells to make the lymphocyte to produce antibodies (21, 2). At certain period, it will cause to increase the activity which is useful to destroy the infectious agent. However, in the acute inflammatory state there is a second phase of process which return the inflammatory back to normal, so there is a load of pro-inflammatory processes and then a set of anti-inflammatory processes (e.g. IL-4), which is a signal molecules produced by cells of macrophages who is functioning is to be anti-inflammatory, in which resulting to an end to anti-inflammatory episodes to come back to normal (21, 2, 3, 4, 5, 13, 14, 20). Therefore, there is a need to increase IL-4 signaling in order to suppress chronic inflammation diseases such as Type 2 diabetic mellitus, cardiovascular disease and Obesity (19). For example, it is important to have exercise, in order to boost IL-4 signaling in monocyte-macrophages. Interestingly, IL-6 release from contracting myocytes is essential for IL-4 induced activation of macrophages (21, 2, 3).

In 2010, researcher published, the gene in which has known to be regulator by IL-4, the expression was went up, so it seem that it was increasing IL-4 signaling, but surprisingly the scientist they couldn’t find IL-4 in the blood stream in the people who have been exercising(3,14). Indeed, they saw an increasing in IL-6. As many studies showed that exercise is linked to increase in IL-6 not in IL-4, so this is the question that it need to focus in my project (21, 2, 3, 8). Another study, in 2011-2012, which state that the genes which controlled by IL-4 increase in expression, which suggest that it can have this beneficial effect, but they couldn’t find IL-4 itself, or there is no increase IL-4 itself (2,2). Basically, the measurement of IL-4 is by ELISA or by looking the amount of IL-4 that cells producing by using RT-PCR (6, 8). Last scientific studies by Mauer et al (2014), where they treated cells with IL-6 to see what result will find. Many studies showed that when we do the exercise our skeletal muscle produce IL-6, but as this study stated an increase of IL-4 also, in which the scientist surprise from this study in 2014(21, 13). They said that IL-6 causes monocyte-macrophages to increase expression of the IL-4 Receptor protein in mice (vivo), in which it can imaging that small amount of IL-4 in the circulation, but the cell have got more of the receptor of IL-4(10). As a result, this lead the cell to be more sensitive to IL-4(1).To be more precise, if a cells which is on its surface is a protein to which IL-4 will bind, and if there is a certain amount of IL-4 in the system, then it will have a certain amount of IL-4 dependent signaling within that cell. Therefore, if IL-4 increase, then it will lead to find more of IL-4 signaling, and these are IL-4 genes which resulting to increase expression (2). For this reason, this will lead to anti-inflammatory effect, in which IL-4 functioning process happen during inflammatory state. In most cases, scientist before they do not see more IL-4, in which these people in 2014 see more of the protein to which IL-4 bind(2). In addition, if the cell has more of the receptor, that will make almost more sensitive to whatever level of IL-4 depending signaling within the cells. However, these researcher did this experiment in macrophages in mice, which is an interesting, but in my side I have to do the experiment in human cells. This will make the macrophages more sensitive to IL-4, rather than producing more IL_4 (2).

IL-6 release from contracting muscle cells:

IL-6 is a type of cytokines and linked to resistance to insulin and Obesity. However, deficiency in IL-6 resulting to adult to begin Obesity, and IL-6 signaling disruption cause resistance to insulin (22). Many studies showed that IL-6 play an essential role in pro-inflammatory, therefore Obesity- associated inflammation is linked by IL-6(21, 5, 7, 10, 12, 18, 21, 22). In addition, pro-inflammatory M1 macrophages which act by IL-6 are a mediators of Obesity- induced inflammation and resistant to insulin (21, 11, 12). A published study by Mauer et al 2014, illustrated that IL-6 as a critical initiator of the macrophages M2 polarization, and it is useful in role of the prevention of obesity which is associated resistance to insulin (21, 5, 19, 22). As a result, the assumption of this find is that IL-6 acts as a pro-inflammatory cytokine (21). Moreover, the observation by Mauer et al 2014, demonstrate that IL-6 act also as anti-inflammatory cytokine in which it limit LPS ( Lipopolysaccharide )-induced endotoxemia, and not only acted to prime myeloid cells by IL-4 signaling during obesity(2). However, more than a decade ago that role was assigned to IL-6 (2).

During muscle contractions the cytokines IL-6 is the first myokines found in the blood stream (21, 5, 13, 20). Generally, healthy individual and patient with Type 2 Diabetes mellitus (T2DM) released IL-6 from human primary muscle cell cultures (21, 5, 18, 22). Nowadays, the dominant source of IL-6 production during exercise is muscle cells (21, 5, 18, 21). However, sometimes during physical activity the IL-6 level increase in the circulation without any sign of muscle damage, and macrophages is responsible for this increase. In addition, the transcription rate of IL-6 and IL-6 mRNA level is increased within 30 minutes of the start of exercise (21, 19, 21, 22). Moreover, the insulin-stimulated glucose, which is uptake in muscle cells in vitro increased by IL-6.As a consequence, treatment with IL-6 will increase the rate of glucose infusion without having any effect on the total glucose production. When human IL-6 infused into a healthy people during low-intensity exercise, in order to mimic the concentration of IL-6 during high intensity exercise, it result that glucose output was as increase as during high-intensity exercise (21, 5, 10, 19, 22).

When IL-6 increase during exercise, it followed by the appearance IL-1 receptor antagonist (IL-1ra) and anti-inflammatory cytokine IL-10 (3, 21). To make sure which cells produce the IL-6, Keller et al, used muscle biopsies to isolate nuclei, which they obtained before, during and after exercise. They used a technique of RT-PCR (3). It was showed that the nuclear transcription rate of IL-6 peaked rapidly after onset of exercise (3). In other word, the factor which associated with contraction increase IL-6 transcriptional rate, which then observed that in the monocyte nuclei, the IL-6 protein is expressed within muscle fibers(3). Studies showed that during inflammation condition, IL-6 has a role in the expression of genes and it affect the responsiveness of macrophages to IL-4 (2). However, this illustrates the role of IL-6 which limiting Obesity- associated resistance to insulin and inflammation, and it will decrease the risk of chronic disease and premature mortality (21, 2, 5, 10, 18, 22).

IL-4 triggered signaling mechanisms:

It’s a cytokine that stimulate differentiation of naïve helper T cells in to Th2 cells (8) figure (1). The mechanisms of IL-4 signaling has an important insight on the regulation of immune responses. IL-4 use IL-4R alpha as a receptor component (6, 7, 9). IL-4 activate a lot of common signaling pathways. Therefore, IL-4 is playing an important role in anti-inflammatory cytokines, and it signal through JAK-STAT (Janus kinase/ signal transducer and activator of transcription) pathway (6, 7, 8, 9, 13, 16, 28) Figure (2). However, it has many function such as activation of macrophages, chronic inflammation and healing of the wound. It produced by activated T cells, and its increase associated with allergies. In JAK-STAT signaling, which is used by different cytokines, IL-4 will bind to its receptor IL-4Rα and IL-4Rγ, followed by association to proteins called JAK1 and JAK3, which is moves away next of the receptor. Then, it bind to STAT6 protein. After that, STAT6 translocate to the nucleus, where they bind and recognize DNA sequences which have target genes that are focus for this process. However, at the end you will get mRNA transcription for these genes been produced, but only the target genes which I need to focus in my project (6, 7, 8, 9, 16, 28).

A published study by Mauer et al 2014, showed the expression of IL-4R is induced by IL-6 directly, which then primed macrophages for IL-4 dependent activation of STAT6. Generally, IL-4-STAT6 is the most inducer of the M2 polarization of macrophages, and the activation of macrophages in vitro and in vivo inhibits strongly by the ablation of the genes encoding IL-4Rα or STAT6 (2) Figure (1). Studies showed that during inflammation, the expression of IL-4Rα is unregulated in myeloid effector cells, in which is dependent on IL-6 Figure (2).

Exercise mimetic:

Exercise mimetic define as a mimetic of a natural physical activity. As we know that skeletal muscle is the largest organ in the human body. Generally, doing exercise regularly can promotes metabolic adaptions and favorable structural, particularly in the skeletal muscle (20, 25, 26, 27). Physical exercise enhances the skeletal muscle to burn calories, which is useful in many clinical condition. However, as a general rule, that nothing can fully replace exercise. As a consequence, the exercise mimetic development can enhance the beneficial effects of physical exercise in many experiment, and focused on the substance that mimic the effects of exercise without energy consumption of the actual exercise (27).

Dectin-1 and its role in the immune response:

Dectin-1 is the most important C-type lectin receptor for beta-glucan, which is naturally occurring polysaccharides that play an essential role in the innate immune system. Dectin-1 is a major receptor of the particles fungal on macrophages (30, 31, 32,33). It is a type II membrane receptor which has C-terminal, NK like (35). The role of Dectin-1 in the immune response, which include the factor production of phagocytosis and pro-inflammatory is that functioning as anti-fungal to eliminate the fungi infection (30, 31, 32, 33). The discovery of Dectin-1 as a receptor of beta-glucan gives the important of Dectin-1 in the sensing processes of beta-glucan, the signaling intracellular and cellular response induction (31). In addition, it provide the advantage of beta-glucan and its function in disease and immunity (31). Moreover, Dectin-1 is play an important role in adaptive immune response as well as immune tolerance and autoimmune disease (32). The stimulation of Dectin-1 to different cellular response through the Syk/CARD9 signaling pathway can involving in phagocytosis, production of cytokine and respiratory burst (34).

THP-1 cells:

It is one of the most widely cell lines used to investigate the regulation and function of monocyte and macrophages in cardiovascular system (29). Tsuchiya et al identified human THP-1 in 1980. However, THP-1 play an important role in the interconnection between monocyte-macrophages and other vascular cells during inflammation, especially in obesity and atherogenesis (29). Studies by Zhenyn Qin in 2011, demonstrated that TPH-1 not only resemble monocyte –macrophages which is isolated from donors with disease such as diabetes mellitus or healthy donors, but it also mimic the in situ of macrophages in obese or atherosclerotic lesions in the adipose tissue (29). Studies shows that THP-1 resemble primary monocyte-macrophages in differentiation and morphology. THP-1 is usually round cells, single with clear monocytic markers. In the culture plates, THP-1 begin to adhere by differentiation into macrophages phenotype, with change in the morphological. Generally, there are two classic agent which is used to differentiate the THP-1 in to macrophages phenotype, PMA (phorbol-12-myristate-13-acetate) and 1α, 25-dihydroxy vitamin D3. However, these classic agent used to regulate different signaling pathways, and treatment with PMA resulting to more phenotype with higher rate of adherence. In addition, treated PMA with TPH-1 cells are basically used to study the function of macrophages (29).

There are some advantages of THP-1 cells over human primary monocyte-macrophages (29). Firstly, the homogeneous genetic background of THP-1 minimizes the variability degree in the cell phenotype (29). Secondly, human primary monocyte and macrophages have problem in transfection efficiency, whereas the genetic of THP-1 by small interfering RNA to regulate the specific protein expression is easy. Thirdly, THP-1 cells could be stored in liquid nitrogen without any effect on monocyte-macrophages cell viability and features. Fourthly, the monocyte-macrophages polarized activation is divided in to M1, M2a, M2b and M2c cells. Therefore, many studies reported that THP-1 used in the fields which related to inflammation atherosclerosis and diabetes. In my project, I will use THP-1 cells and grow in a cell culture.

Conclusion:

As general rule, muscle is the largest organ in the body, and it is need to understand that it has an important impact in a field of scientific community. Therefore, physical inactivity or lack of exercise may lead to an impaired or an altered myokine response, which then resulting to have chronic inflammation, which is linked to sedentary lifestyle such as Obesity, and it will increase the risk rate of diseases, including T2DM ( Type 2 Diabetes mellitus) and cardiovascular disease (2,20). As many scientific papers showed that cytokine IL-6 produce by skeletal muscle and act as pro-inflammatory (21, 20). In contrast, IL-4 which is produce by macrophages act as anti-inflammatory. However, in my project, I have to focus on the gene that cause an end to the inflammatory episode. Consequently, if these genes increase in tissue culture experiment, it would assuming that in a real life person the same effect will happen, and that will be linked to clinical beneficially anti-inflammatory effects, in which not looking in a patient, instead I have to do my experiment in a culture cell that are act as mimic the effect of exercise.

However, the scientist until now they do not know why exercise produce wrong cytokines or wrong signaling molecules. It should produce IL-4 because of its effect of dependent depicts. Researcher by (Mauer et al 2014), give answer in mice, but I have to do my experiment in human by a cell culture. Therefore, when I will start in the laboratory, I will grow the monocyte- macrophages in cell culture, and treat those cells with IL-6 as a stimulus, and obtain RNA from these cells, and then see whether the RNA for Dectin-1 increases, in which it play an important role in anti-inflammatory.

The last paper which was reported on 2014 by Mauer et al, have been shows a weakness and strength. In that review talk about muscle, exercise and obesity, in which the strengthen is relevant to the strength to my project, but the weakness, is that they focused in skeletal muscle rather than macrophages, and this is essential in anti-inflammatory. Also the weakness, they did the experiment in vivo in mice not in human. So, as I am in a biomedical science, I have to do my experiment on human in vitro by using culture human monocyte-macrophages.

To sum up, because of the clinical importance of the subject, I propose to carry after project, in which I will test the hypothesis in vitro, if I treat monocyte-macrophages by IL-6, then it will cause expression of Dectin-1 to increases.

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