Mental Health Assessment and Nursing Report for Harry

Student Name: Asmeet Singh Student Number: U1113219
Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN: 86425677
Family name: Smith
Given names: Harry
Date of birth: 07/06/2000
Sex: M
MENTAL STATE EXAMINATION
General
appearance
18 year old Male, Appear to be in the stated age, Caucasian, Tall and
normal build up, medium Hair, Appropriately dressed at the time of
interview
Behaviour Agitated at start and Resistive to answer, uncooperative at times,
Restless (Continuous movement of hands), keeping eye contact to
minimum.
Speech Rate of speech: Normal, Volume: Soft , Quantity: normal, Quality:
accent
Mood and
Affect
Appears anxious, concerned and agitated while interview when asked
second time about his brother. He also showed restricted and normal
Affect at times in interview.
Sudden mood changes as per his mother as well
Thought process
Appears to have racing thought, Illogical thought process
Thought content Delusion: Stating about an agency which are sending him codes to
follow, which in result make him invisible.
Persecutory: He thinks that his brother is trying to take away his power
of invisibility.
Grandiose: He thinks that his ability to become invisible is of great
importance and other people does not realise that.
Paranoia: His jealously towards his brother and wanted to kill him
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Perception Hallucination visual: His brother is releasing gases in air and adding iron
fillings in his food which according to Harry, reduces his ability to go
invisible.
Hallucination Auditory: He can hear voices of agencies and they are
talking to him.
Cognition Alert, oriented to time & place, responding to verbal commands, Good
memory recall of past events and little impaired while recalling recent
events,
Judgment Impaired as his ability to rationale decision is compromised.
Insight Diminished as he does not think that he has any mental health issue.
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SYMPTOM INTERVENTION
Thought disorder as
evidenced by visual
hallucinations
The interventions on the hallucination and delusion symptoms presented by
Harry would be:
Use professionalism and best practices of compassion and integrity to talk to
the client and strategize on managing and controlling baseline hallucination
symptoms (Geddes, Ehlers, & Freeman, 2016).
Another is developing coping mechanism and helping the client to practice
using mechanism such as self-instruction and decreased stimulation to enable
him cope with hallucinations.
Insomnia: evident
by poor sleep
The intervention I would employ to alleviate insomnia for Harry would be to
relieve the anxiety linked to chronic (ongoing) insomnia through cognitive-
behavioural therapy (Gilsenan, 2012).
Focussing on reducing noise and interruptions to promote sleep at night is
another intervention (Kamdar et al., 2013).
Anxious as evident
by
Effective nursing interventions for the anxious client would require tailoring
them to the individual client (Biddiss, Knibbe, McPherson, 2014). Small
interventions such as turning on or off devices (Paganini,
Teigelkötter, Buntrock, & Baumeister, 2018) can alleviate the client’s level of
anxiety. Harry’s fear of getting visible after a strong self-conviction of being
invisible, would need a validating his fear and encouraging him to do better.
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