HLTH 1037 - Mental Health OSCA Assessment 2.

HLTH 1037 – Mental Health OSCA Assessment 2
Complete the following ISBAR clinical handover as if you were the
Registered Nurse handing this client over to the next shift
ISBAR Clinical Handover
Identify the client:
The client Mr, Johan was referred to the Adelaide mental health clinic by his General Physician, who
suspected that he suffered from depression. The Client mentions that he was presented to the General
Physician by his mother who was concerned about his increased fatigue and lack of interest in socialising.
The client reports he experiences a lack of interest in doing activities that he previously enjoyed. He also
mentions that he spends most of his time browsing through different channels of television. The client has
been experiencing fatigue and a lack of interest in addressing every day activities post his separation with
his wife three months ago. The client mentions having two daughters who are both married and are busy
with their life schedule and he further mentions about one of the daughter working as a nurse in Adelaide.
He also mentions about one of his daughter being overseas and being busy with her work. He further states
consuming more than the recommended level of alcohol as per the Australian Drinking Standards. The client
mentions about staying alone and mentions about being visited by his mother twice a week. No information
has been provided in relation to the patient’s age, residential address or cultural identity.
Situation:
The patient appears to be depressed and experience persistent low mood and affect. The patient appears to
be dysphoric and lacks interest in regular activities. The patient’s social interaction level appears to be poor
which reflects a diminished mental health status. The patient confirms a medical history of hypertension and
the current mental health status indicates an urgency to implement appropriate care interventions to
facilitate mental health recovery.
Background:
The patient confirms a medical history of Hypertension and also states to have separated from his wife three
months ago on account of relationship problems. The patient confesses to have experienced increased
detachment and lack of pleasure in engaging in activities that he liked post separation. He mentions about
continuing to work but also mentions about experiencing a poor appetite and a poor sleep pattern. The
patient further mentions to experience agitation and feel enraged while driving. The patient also mentions to
consume alcohol more than the recommended standards of drinking.
Increased alcohol consumption can negatively impact the existing medical condition of hypertension
Increased alcohol consumption can also trigger associated health issues in relation to cardiovascular
disorders and gastrointestinal disorders which can deteriorate the quality of physical health of the patient
Poor appetite can trigger malnourishment or negatively impact the normal physiological functioning of the
gastrointestinal system
Poor appetite can also interfere with the immunological response of the body and increase the susceptibility
of acquiring infection
Poor sleep pattern can trigger mental health disorders as classified by the DSM V criteria which include sleep
apnoea
On the basis of the obtained patient information and the previous medical history the above listed physical
and mental health problems can be identified which require immediate attention to promote patient
recovery.