Mental Health Assessment of Mr. Johannes - Desklib

HLTH 1037 – Mental Health OSCA Assessment 2
Name of the Student
Name of the University
Author note

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:
My name is (add your name) and I work as a registered nurse in the XXX helathcare facility. While working in the mental health ward I
was assigned to take a mental health assessment of Mr. Johannes (approximately 45 year old) (MRN number XXXXX) living alone in
Australia. He was admitted to the mental health ward by her mother as she noticed signs of depression and deteriorated health conditions.
Situation:
As stated by the patient in the mental health assessment, depression is the primary problem of the patient in current situation. There are
secondary health issues, due to which physical health of the patient is also deteriorating such as increased body weight, unusual sleep
pattern, hyper pressure, anxiety, agitation, lack of concentration and high drinking pattern that affects his physical health by decreasing
his strength and immunity. His increased addiction for alcohol, negative thoughts about his self-worth and affected personal as well as
professional life (Anderson et al. 2015).
While describing his symptoms, his body language and his statements about his health conditions should be stated. In the entire mental
health assessment related conversation, patient did not make direct eye contact with me and was constantly moving his hands, eyes and
face. He was not stable to his thoughts and statements and for several responses changed his response within fraction of seconds. For
example while replying to the question about his personal life related problems affected his professional life, he changed his response
from yes to no within seconds and stated that personal problems are concern for every individual and it does not affect someone’s
professional life. Further as per the statement of the patient, he was on medication for hyper pressure and was suffering from anxiety and
agitation. he was unable to sleep properly from last three months and was suffering from binge drinking and eating due to which his body
weight increased (Dawson, King and Grantham 2013).
The client was currently living in his house where no one came to visit him except his mother as he did not wanted to disclose his health
condition to others.
As per the mental health act for determination of severity of mental health of the patient, assessor should rate several points while
conducting the mental health assessment with patient. These are level of consciousness, thought perception, attitude and insight, speech
and activity of motor sense, and cognitive abilities. In this assessment with Mr. Johannes, he was having low mood, less self-confidence,
negative thoughts, dull appearance and lack of consciousness and hence, his level of depression could be rated as moderate to severe as
the episodes lasted for three months.
Background:
As stated by the patient, he was diagnosed with depression when he was admitted to the hospital. However he was given with medication
for hyper pressure. Further, he also mentioned that due to his deteriorated physical and mental health condition, he was admitted to the
hospital by his mother.
He did not had any past medical history and this depression episodes are the only health concern he is suffering from in the current
situation. Currently he consumes medication for hyper pressure once every morning and did not mentioned any signs and episodes of
allergies. His mother is his primary carer and without her no one comes to take a visit to his home as he has isolated himself from the
entre society. Therefore, his house is his only accommodation where he performs all his activities of daily life alone. This was the health
background which was collected from the mental health assessment of the patient (Bost et al. 2012).
Assessment:
In the current situation, the patient was suffering from the severe depression due to his grievous experiences of life. He stated that he
never experienced depression before. However, due to his thought of being worthlessness, he gradually developed the symptoms of
depression. He was exhibiting different clinical signs related to the depression. He stated that he had the abnormal sleep pattern.
Previously he used to wake up at 6’o clock for work but due to negative thoughts, he had the unusual sleeping pattern. Besides, he stated
that he had anxiety and he was feeling agitated at the same time. He had a lack of concentration in the last three months. After having the
conversation, he reported that he usually had negative thoughts and he kept questioning his self-worth. He gained significant body weight
due to the negative thoughts and alcohol consumption habit. He did not have any ideas of attempting suicide but the negative thought
process of him may leads to the attempt of suicide. He was consuming the medicines of hypertension every morning on a daily basis. No
diagnosis has been planned for him and he never went through any diagnosis process. However, he suggested that communication may
help him to overcome the obstacles of life by releasing the negative thoughts. Medical experts also suggested that effective verbal
communication with any individual would help him to overcome the depression he was experiencing for the more extended period
(Eccleston et al. 2016). The thought processes of him affected his lifestyle since he was an alcoholic and eat unhealthy foods which
influence his daily activities and health. He was willing to involve himself in the treatment plan so that he can get over the negative
experience and ability to lead the quality life.
Recommendations:
In such a situation, when patients are experiencing depression, few therapies can help the patient to overcome the situation. A systemic
review and empirical studies of depression suggested that cognitive behavioural therapy is the best therapy for coping up with severe
depression. Depression usually makes people helpless about their self and subsequently affects the daily routine and lifestyle of the
patient. Effective communication with a patient in the 30 to 60 session of cognitive therapy may help the patient to boost the self-esteem
and gain the self-worth. In a majority of the cases, patients have low self-esteem due to the series of adverse events they are
experiencing. Communication with empathy and compassion would help him to gain the self-worth and confidence in coping up with
negative experiences.Moreover, he would have a sense of security, and he would be able to talk about his area of concern to the
caregiver. Moreover, the exercise daily will boost the endorphins which would give the long-term benefit to cope up with depression
(Eccleston et al. 2016). Since he had unhealthy eating habits and alcohol consumption, eating healthy would help him to get over his
problem. Incorporation of fruits, more vitamins and vegetables is the crucial part of food diet to live the standard life. Since he had the
abnormal sleeping pattern, getting enough sleep and fixed sleeping time would help him to enhance the quality of life (Anderson et al.
2015). Engaging himself with motivational therapies, motivational speech about leading life would help him to overcoming the phase of
negative experiences (Pennant et al. 2015). Taking responsibility for his own, encouraging him to live a quality life would help him to
ease the negative thoughts. Three months of communication therapy along with other change of habits would help him to manage
depression completely.