Mental Assessment: Holistic Assessment, Planning, Therapeutic Engagement, and Clinical Interpretation

Mental assessment

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Table of Contents
Table of Contents............................................................................................................................1
PART 1: Holistic assessment and planning.....................................................................................2
The Mental Status Examination.......................................................................................................2
Appearance..................................................................................................................................2
Attitude towards the examiner.....................................................................................................2
Mood............................................................................................................................................2
Affect...........................................................................................................................................3
Speech..........................................................................................................................................3
Thought process...........................................................................................................................3
Thought content...........................................................................................................................3
Insight..........................................................................................................................................3
Impulsivity...................................................................................................................................4
Reliability....................................................................................................................................4
Clinical Formulation Table..............................................................................................................4
Plan for Nursing Care......................................................................................................................4
Clinical handover.............................................................................................................................5
PART 2: Therapeutic engagement and clinical interpretation........................................................6
2.1 The Therapeutic Relationship...............................................................................................6
2.2 Cultural Safety......................................................................................................................6
2.3 Recovery-oriented Nursing Care...............................................................................................7
The nursing plan has been formulated keeping in mind the mental condition of the patient. The
various recovery principles are:.......................................................................................................7

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PART 1: Holistic assessment and planning
The Mental Status Examination
Appearance
 The patient is a 41-year-old, female, named Mary.
 Mary wore a pair of jeans and t-shirt and sandals.
 She did not apply any makeup but her hair was brushed yet greasy looking.
 The patient sat in hands clasped resting on the lap with the eyes low towards the floor
posture.
Attitude towards the examiner
 The patient was quiet and answered slowly and in monosyllables.
 The patient was often absent-minded although she had the track of time, place and
person.
 The patient was quite defensive in her answers.
 The patient spoke about her life feely with the examiner.
 The patient was adamant and believed that she was not ill.
Mood
 The patient has difficulty moving out of the bed.
 She often feels like crying even in trifle situations.

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 Most of her days she feels low, having no driving force in herself to carry on the normal
jobs.
 She always feels very tired and does not have the urge to do volunteering jobs, which she
used to do.
 She did not feel like talking to the church members or her friends.
Affect
 The patient's affect can be defined as euthymic, as she did not show any signs of extreme
behaviour nor any extreme fluctuations took place in her mood.
Speech
 The patient spoke very slowly and softly.
 The patient’s most answers were in monosyllables.
 She spoke about her daily life, the time she spent at church, her work and so on.
Thought process
 The patient thinks that she is a burden for the rest of the family.
 The patient feels unworthy and feels that there is absolutely no hope in her life for getting
better.
Thought content
 The patient has no signs of delusion.
 The patient is aware of the time, place and the people around her.
Insight
 The patient feels that she is not ill and does not want to be admitted in the hospital for her
condition.