Mental Health Assessment

This document provides a mental health assessment of a patient with schizophrenia, including their appearance, behavior, affect, mood, speech, thought form, thought content, perception, cognition & intellectual functioning, and insight & judgement. Risk factors and a care plan are also discussed.

Running Head: MENTAL HEALTH ASSESSMENT
MENTAL HEALTH ASSESSMENT
Name of the student:
Name of the university:
Author note:

1Mental Health Assessment
Mental status examination: modelled from NSW HEALTH documents
Activity 1-
APPEARANCE- Dimitri is a young man who looks physically fit and has long black hair.
He is tall and has a lean body structure. He had a bad hygiene as he was continuously biting
nails. He has no tattoo or piercing in his body. He does not groomed at all.
BEHAVIOUR – His behaviour is different from the normal person. He faced difficulty in
building rapport with the psychiatrist. He is not able to connect with the doctor. He has lack
of concentration and hence not able to concentrate on the psychiatrist’s words. He is also
suffering from psychomotor complication, he gets distracted very easily due to voice
hallucination.
AFFECT- Therapy session helps him in identifying his issue and mental complication. He
hates being judged for his mental issue and get frustrated. He seems very confused regarding
his problems. He shows good congruence with the doctor, when the doctor advised him to get
hospitalized for some time.
MOOD- His mood remain fluctuated. Due to schizophrenia he feels scared. He was not able
to convey his words to the nurse due to his mood fluctuation. He showed delayed response to
the nurse’s question.
SPEECH- He suffers from speech disability and is not able to complete a sentence
appropriately. He starts blabbering in the middle of the conversation. He looks confused
while speaking and gets distracted by the hallucination.
THOUGHT FORM – He was not able to correlates things. He was not able to frame his
sentence and remain confused.

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THOUGHT CONTENT – He gets engrossed in his own feeling while speaking and shows
lack of concentration.
PERCEPTION - He have auditory hallucination, due to which he remain depressed and
confused all the time. He is not able to focus in his work because of the hallucination.
COGNITION & INTELLECTUAL FUNCTIONING- he is not well oriented. He gets
distracted easily with minimum self-confidence. He has knowledge of calculation, but gets
distracted because of low confidence.
INSIGHT & JUDGEMENT- After the session it was observed that, he had minimum
confidence in himself. He gets auditory hallucination, due to which he remains confused and
depressed. He has only one friend, Cheryl. He gets scared by the idea of travelling outside.
He is not able to complete sentences and starts blabbering in the middle of the conversation.
Identification of Risk Factors
Health deterioration due to voice hallucination (Wang et al., 2016) - Dimitri is a young
man who is suffering from mental complication. He is suffering from schizophrenia, he
thinks that there is someone who is continuously talking to him. Due to that, he remains
distressed all the time and was not able to concentrate at his work. He gets scared by the idea
of being alone. He has lost his self-confidence. All the factor stated above are responsible for
his deteriorating health.
Isolation (Meier et al., 2014) - he has only one friend, Cheryl. He has isolated himself from
everyone and has no social circle. As a result of isolation, he is getting into depression and
his health is becoming mire deteriorated day by day. When more information about his
friends was asked during the session. He said that he has only one friend and he does not feel
any need to make more friends. He has compromised with the situation. He likes to be alone
and does not want more friends, which is a risk factor for his deteriorating health.

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Fear of being judged (Giacco et al., 2018) - During the interview session, nurse asked him
several question related for his life, hobbies and his medication. He thought that the doctor
thinks he is crazy and that is why the doctor is asking so many questions. He hates being
judged as a person suffering from mental illness and told the doctor that he is not crazy. All
these things is making negative impact on Dimitri’s health and making it worse.
Threat of harming others (Fervaha et al., 2014) – When nurse asked him about attacking
others or harming himself during the session. He explained that he will not harm himself even
the voice suggests him to do so, but if anyone will try to harm him he will attack in order to
protect him. Further he justified his statement by saying that, it is normal to attack someone
in order to protect themselves.
Activity- 2
Care plan: Modelled on clinical modules information NSW HEALTH
CLINICAL ISSUE - The clinical issues in the case that Dimitri witnesses are very critical.
He has been facing psychological issues known as schizophrenia. He has been facing this
problem from past few years. He was on medication for some time and during this period he
was hearing less voices. But as he stopped taking medication, he is again listening to the
voices and now in increased frequency. Other issues he had was lack of concentration, during
his session he was not able to concentrate or bring interest to the session with the doctor. He
also had disability in speaking, as half of he was blabbering. His words were not clear.
RATIONALE FOR CHOSEN ISSUE- The impacts of the issues that Dimitri has been
living with, has a major impact on his social and mental health condition. He has gained a
habit of talking to the voices even when he is in middle of his work or maybe in public place.
It affects his social condition, people witnessing him will conclude him as a mental patient
(Scott & Connell, 2017). Because of the judgment, he will face discrimination in social

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world, he might lose his job and friends. The speaking issue also makes it difficult for him to
communicate with others. People with residual speech errors are found to witness an
increased threat of social, emotional as well as academic difficulties comparative to other
people (Cunningham et al., 2017). It makes it tough for him to explain what he wants to say
and difficult for people to understand what he wants to express. People with depression and
lack of concentration often have a feeling like they can’t focus in providing and obtaining
directions or knowledge, which creates a major misunderstanding in workplace or between
people. Relationships are also affected because of the same, as people feel left out and
avoided (Jain et al., 2015). The lack of concentration also affects him in a major way, he has
no concentration ability because of which he is not yet successful in writing anything till date.
He has been trying to write a novel, but because of his issues he is not able to succeed in his
work and life.
GOALS- From the above stated issues of Dimitri, the goal that needs to be achieved is that,
proper interventions needs to be applied so that he overcomes the issues and get better in his
health condition.
INTERVENTIONS - 3 ONLY
1. Building therapeutic relationship
(Hayward et al., 2017)
2. providing exercises and sessions (van
der Steen et al., 2018)
3. Providing speaking and
communication sessions (Nazligul et
al., 2017).
RATIONALES
1. This will help Dimitri to overcome his
mental issue and for which the nurse needs
to understand what he experiences and
what the voices he hear are directing him
to do. So that, a nurse can understand the
situation and use the voices the patient
hear to provide treatment according to
them (Westermann et al., 2015).

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2. Concentration can be increased by
performing aerobic exercises and sessions
such as interactive sessions with
councillors and performing exercises such
as meditation, yoga or may be listening to
music or art (Stanton & Happell, 2014).
This will help Dimitri to improve his
concentration power and reduce
depression.
3. This helps the patient to learn how to
communicate and speak in a proper
manner (Tahir et al., 2016). The therapy
provided for the speech disorder will help
Dimitri to talk and express himself in a
much better and clear way.
Activity 3-
From the interaction of nurse and client, complication of the client is identified. He
has schizophrenia. He is not able to focus on a single thing for longer time and along with
that, he has speaking issue (Boyle, 2014). He is not able to construct sentence properly.
Positive effect of the nurse and client interaction.-
1. The complication of the client is identified. From the interaction it is observed that he
has schizophrenia. He also gets blanked out in the middle of the conversation.

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2. Risk factors such as, fear of isolation, risk of harming others, fear of being judged and
health deterioration are identified.
3. From the interaction his background, hobbies and other issues are identified which is
helpful in designing nursing care plan.
4. Nurse agreed him to get hospitalized.
Negative aspect of the interaction
1. The nurse is not able to take all the information and starts assuming things on her own. As
a result he was not able to share more information with her.
2. During the interaction he feels uncomfortable with so many questions and gets irritated.
After getting irritated with so many, he justified that he is not crazy.

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References
Boyle, M. (2014). Schizophrenia: A scientific delusion?. Routledge.
Cunningham, B. J., Washington, K. N., Binns, A., Rolfe, K., Robertson, B., & Rosenbaum, P.
(2017). Current methods of evaluating speech-language outcomes for preschoolers
with communication disorders: A scoping review using the ICF-CY. Journal of
Speech, Language, and Hearing Research, 60(2), 447-464.
Fervaha, G., Zakzanis, K. K., Foussias, G., Graff-Guerrero, A., Agid, O., & Remington, G.
(2014). Motivational deficits and cognitive test performance in schizophrenia. JAMA
psychiatry, 71(9), 1058-1065.
Giacco, D., Laxhman, N., & Priebe, S. (2018, May). Prevalence of and risk factors for mental
disorders in refugees. In Seminars in cell & developmental biology (Vol. 77, pp. 144-
152). Academic Press.
Hayward, M., Jones, A. M., Bogen-Johnston, L., Thomas, N., & Strauss, C. (2017). Relating
Therapy for distressing auditory hallucinations: a pilot randomized controlled trial.
Schizophrenia research, 183, 137-142.
Jain, F. A., Walsh, R. N., Eisendrath, S. J., Christensen, S., & Cahn, B. R. (2015). Critical
analysis of the efficacy of meditation therapies for acute and subacute phase treatment
of depressive disorders: a systematic review. Psychosomatics, 56(2), 140-152.
Meier, S. M., Petersen, L., Pedersen, M. G., Arendt, M. C., Nielsen, P. R., Mattheisen, M., ...
& Mortensen, P. B. (2014). Obsessive-compulsive disorder as a risk factor for
schizophrenia: a nationwide study. JAMA psychiatry, 71(11), 1215-1221.
Nazligul, M. D., Yilmaz, M., Gulec, U., Gozcu, M. A., O’Connor, R. V., & Clarke, P. M.
(2017, September). Overcoming public speaking anxiety of software engineers using

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virtual reality exposure therapy. In European Conference on Software Process
Improvement (pp. 191-202). Springer, Cham.
Scott, J., & Connell, M. (2017). 6.1 Hallucinations in Adolescents and Risk of Mental
Disorders and Psychosocial Impairment in Adulthood: A Birth Cohort Study.
Schizophrenia bulletin, 43(Suppl 1), S8.
Stanton, R., & Happell, B. (2014). A systematic review of the aerobic exercise program
variables for people with schizophrenia. Current Sports Medicine Reports, 13(4), 260-
266.
Tahir, Y., Chakraborty, D., Dauwels, J., Thalmann, N., Thalmann, D., & Lee, J. (2016,
March). Non-verbal speech analysis of interviews with schizophrenic patients. In
2016 IEEE International Conference on Acoustics, Speech and Signal Processing
(ICASSP) (pp. 5810-5814). IEEE.
van der Steen, J. T., Smaling, H. J., van der Wouden, J. C., Bruinsma, M. S., Scholten, R. J.,
& Vink, A. C. (2018). Music‐based therapeutic interventions for people with
dementia. Cochrane Database of Systematic Reviews, (7).
Wang, R., Aung, M. S., Abdullah, S., Brian, R., Campbell, A. T., Choudhury, T., ... & Tseng,
V. W. (2016, September). CrossCheck: toward passive sensing and detection of
mental health changes in people with schizophrenia. In Proceedings of the 2016 ACM
International Joint Conference on Pervasive and Ubiquitous Computing (pp. 886-
897). ACM.
Westermann, S., Cavelti, M., Heibach, E., & Caspar, F. (2015). Motive-oriented therapeutic
relationship building for patients diagnosed with schizophrenia. Frontiers in
Psychology, 6, 1294.