It is expected that you will develop a sense of your ability to observe client behaviour and accurately document those observations as findings on the Mental Status Examination (MSE) and risk screening tool in the correct assessment categories using correct terminology.
Students will also develop patient-focused documentation skills in reporting the identified MSE and risk assessment findings concisely and accurately within the nursing report.
From your findings, it is also expected that students will be able to identify symptoms pertaining to the client and consequently be able to develop mental health nursing specific interventions to assist the client.
- Watch the video about Harry that is located on the study desk. Record yourobservations from the interview/assessment between Harry & the mental health clinician, on the MSE form. You can minimise the MSE form while watching the clip and pause the clip while documenting.
- Once your MSE is completed, identify and record three relevant symptoms that Harry displayed during the interview, locate two evidenced based nursing mental health interventions persymptomto assist you in completing the management plan for
- Complete the symptom and intervention page. There will be three symptoms intotal identified and two interventions per symptom (six interventions) and one reference per intervention to total six
- The symptoms that you identify with your correlated interventions must be foundfrom documented evidence in your MSE
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General appearance |
The general appearance of the patient seemed to be normal. The patient was dressed properly, however the patient seemed to lack proper grooming. The hair was not brushed neatly and the patient seemed to be least bothered about undertaking efforts to groom himself. |
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Behaviour |
The patient was seen to avoid eye-contact to the maximum. The patient was not focused in the conversation. It was clearly evident that the patient was preoccupied with different thoughts. The patient lacked interest in participating in the conversation process and was seen to struggle with proper sentence construction. Long pauses in between responses revealed that the patient lacked focus and attention. The patient was seen to be anxious and maintained an unstable posture. The patient was seen to fidget and was seen to be anxious to leave the interview. |
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Speech |
The patient was observed to be rapid with his speech. The volume of the speech perceived was low and the tonality could be predicted to be monotonous. The speech was maintained to minimal level and was strictly restricted to one or two sentences. The conversation between the interviewer and the patient was seen to be forced because the patient was seen to be extremely reluctant in answering the questions. |
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Mood and Affect |
The patient reported to feel extremely happy when ‘invisible’ and also feel sad and irritated on a number of occasions during the past week. The patient reported to feel intensely sad because of his brother who he believed mixed sedatives in his food. The affect perceived was reduced and blunted. It seemed as if the patient found it extremely difficult to express his feelings. Overall the affect could be described to be stable but inappropriate as the patient was engaged in bizarre thoughts of invisibility and superpowers. |
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Thought process |
The thought process was seen to be derailed and vague. The patient was seen to be preoccupied with thoughts of supernatural powers and the speech was perceived to be halted. It appeared as if the patient had a lot going in his mind and found it difficult to maintain a sequence of the events and voice out his expression. |
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Thought content |
No episodes of hallucinations were reported by the patient. Further, no episodes of self-harm or suicidal ideation were revealed by the patient during the interview process. However, the patient was seen to possess overvalued thought content. The patient believed that he could be invisible and had supernatural powers. Further, the patient possessed destructive thoughts and revealed that he could kill his brother because he believed his brother was mixing medications in his meals and did not support his thought process. |
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Perception |
The patient reports incidences of derealisation and illusions. The patient believes that he has some unusual powers that most of the people do not know about and are unaware of. Further, he believes that the power can make him go invisible anytime he wants and he prefers to stay invisible most of the times. The patient also reports theories about the universe which indicate that the patient possesses unrealistic thoughts and perceives things at a complete different level. |
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Cognition |
It can be said that the patient lacked concentration and was occupied with unrealistic and delusional thoughts. The interview response also mentioned that the academic grades of the patient had gone down miserably. This can be linked to the degraded level of consciousness and at the same time reduced level of concentration. During the interview process, the patient was probed to answer where he was and mention the date and purpose of him being in the session. The patient revealed a positive response and hence it can be stated that the patient was aware about the surrounding and purpose of his visit. |
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Judgment |
The patient was asked about his feelings towards his brother and the patient confessed to harbour feelings of hatred towards his brother. On being asked that whether he would like to put an end to the life of his brother he answered in positive. On being asked how he would carry out the process, he said he has not thought about a proper plan but would like to carry out the process soon as he would not let anybody prevent him from being invisible. |
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Insight |
On evaluating the response of the patient, it can be said that the patient is a victim of excessive drug abuse and is on the verge of developing substance-abuse related mental disorders such as substance-induced mood disorder, substance-induced psychotic disorder and hallucinogen persisting perceptual disorder, substance-induced sleep disorder and substance-induced sexual dysfunction as per the DSM-V manual (MSI,2013). The case scenario requires immediate measures to be administered to Harry so as to prevent him from developing any serious mental health disorders. |
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Symptom |
Intervention |
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· Delusion related feelings · Over excessive substance-abuse |
· Administering one to one counselling session · Involving the patient in substance abuse rehabilitation program · Disconnecting the patient from interacting with the agency that provides the supply of drugs (Bowen et al., 2014) · Educating the patient about the harmful consequences of indulging in drug abuse |
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· Violent nature · Destructive thought content |
· To administer medication in order to control chronic aggressive behaviour (Khoury et al., 2013) · To administer sedatives and tranquilizers so as to keep the patient stable and calm so that the patient does not attempt to harm his brother in any way · Counselling session and narrative therapy to control the aggression of the patient · Mindfulness based therapy such as involving the patient in meditation program and yoga so as to maintain composure (Britton et al., 2013; Witkiewitz et al.,2013) |
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· Abnormal sleep pattern · Poor concentration ability |
· Administration of cognitive behavioural therapy to enhance the concentration ability of the patient · Administration of medications such as Benzodiazepines either orally or through injection in order to provide sufficient amount of rest to the patient thereby balancing the sleep pattern (Galanter et al., 2014). |
My name is (xx) (your name) and I am working as a registered nurse in (xx) (name of the hospital). I have been appointed as the in charge to take care of the 14 year old young teenager, Harry.
The patient I am dealing with is a 14 year old male. The patient’s name is Harry and he is a regular school going student. The patient presents serious problems related to substance abuse and requires immediate assistance. The patient is also seen to harbour feelings of delusion and destructive thought content to kill his brother. Further, the patient believes that he possesses superpowers by virtue of which he can go invisible at any point of time. The patient lacks focus and finds it difficult to concentrate in an ongoing conversation. Further the patient also reports mild complications with the sleeping pattern and has also stated to feel that his brother hates him being invisible and possessing superpowers and hence tries to add fillings to his meals. He reports harbouring feelings of anger and hatred towards his brother and plans to kill him someday. Hence, the patient can be stated to be stable but in danger of deterioration in the absence of effective intervention.
No proper medical background history is provided in the case scenario. However, the patient has reported to indulge in substance abuse as recently as the past week. The patient is seen to possess negative and unrealistic thought content primarily as a side-effect to drug abuse and at the same time is also seen to exhibit difficulty in proper sentence formation. The patient is seen to be preoccupied with thoughts of being invisible to the world all the time.
The mental state evaluation clearly depicts the vulnerable mental health status of the patient. The patient is seen to possess destructive thought content and is seen to be extremely restless and anxious during the interview response. The patient seems to be least bothered about his academic deterioration and is observed to be influenced positively by the agency that sends him cards and engages him in substance abuse. Further the patient is seen to lack the analytical skills to understand the negative implication of drug abuse. Hence, immediate intervention to control the aggressive and violent though process and effectively minimise the substance abuse trait of the patient is devised. The interventions must be effectively administered to the patient on immediate basis so as to prevent the deteriorating mental health conditions.
According to me the patient must be administered medication to control aggressive behaviour. Medications must include tranquillizers and sedatives. Administration of sedative would help in maintaining composure and assuring a peaceful sleep pattern. Counselling and rehabilitation is extremely important to help the patient with the mental health problem. I would suggest that a counsellor must be administered to make the patient aware about the harmful implication of drug abuse and also educate him about his mental state evaluation outcome. It is recommended that the patient must be admitted to the hospital immediately and the counsellor must start with the counselling session and administration of mindfulness based therapy to relieve the patient. It can be expected that the patient would start feeling better after a time period of 6 months.
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