Mental Health Nursing: Mental Status Examination and Risk Assessment

The report provides an overview about a mental status assessment done for a client with mental issues and critically evaluates the approach used to develop rapport with client during the mental status examination and risk assessment. Mental status examination and risk assessment for Ms. Ketty was done as part of clinical assessment process to analyse different domains of behavioural issues for client and diagnose type of mental health disorder for Ms. Ketty.

Running head: MENTAL HEALTH NURSING
Mental health nursing
Name of the student:
Name of the University:
Author’s note

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Introduction:
In the field of mental health and psychiatry, mental status examination is an important
component of patient interview as it helps to classify and interpret type and severity of mental
disorders in patient. Apart from the use of clinical skills to complete the mental status
examination, skills related to establishing rapport with client during the assessment and use of
appropriate questions enhance the quality of therapeutic relationship. The report provides an
overview about a mental status assessment done for a client with mental issues and critically
evaluates the approach used to develop rapport with client during the mental status examination
and risk assessment. This would help to develop understanding regarding multifaceted elements
that influence therapeutic relationship in mental health nursing.
4 P information about client:
Pre-disposing factors:
Ms. Ketty (hypothetical client) is a 35 year old lady who came to the mental health clinic
presenting with symptoms of poor mood, irritation and suicide ideation. The review of patient
information revealed Ms. Ketty used to work as bank employee and she left the job two months
back. She lives alone in her apartment and her elder sister lives nearby. Her mother died because
of cancer two years back and her father died when she was 10 years old. After her mother’s
death, she was in depression for five-six months and has to take anti-depressant to cope with her
mother’s death. She was in stable mental status after getting job in a bank. However, since two
months, her mental state worsened and she left her job too.
Precipitating factors:

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The current issue for Ms. Ketty is that her symptoms of poor mood and irritation have
continued since the past one month. She restricts herself in one room throughout the day and
does not interact with anyone. She also tried to attempt suicide on two occasions. Because of her
worsening mental state, her sister has come to be with her and support her. One of the major
issue is the development of suicide ideation which was never seen before even while reviewing
past history of depression. Hence, to prevent risk of suicide and harm to Ketty in the future,
contacting mental health clinic was important.
Perpetuating factors:
Since the death of Ketty’s mother, she has become very isolated. Getting no emotional
support and attachment from family members and living alone is one of the perpetuating factors
has deteriorated client’s level of mental health and well-being. She is 35 years old and poor
relationship experiences in the past is also a reason for her dissatisfaction with life.
Protective factors:
Being employed and economically independent after getting a job was a source of
strength for her as her job helped her to positively cope with her mother’s death. However,
relationship issues with boyfriends disturbed her so much that her feelings of low mood and
irritation affected her job performance. She was finally fired from her job. This event worsened
her mental state. Her elder sister is only her source of support and strength now. However, since
she is married with two children, her elder sister finds less time to visit Ketty. Her elderly sister
is now staying with her because of her two suicide attempts and poor mental condition.
Mental status examination:

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Mental status examination for Ms. Ketty was done as part of clinical assessment process
to analyse different domains of behavioural issues for client and diagnose type of mental health
disorder for Ms. Ketty. The following are the details for mental state examination done for Ms.
Ketty:
Appearance and general behaviour: Assessment of appearance and general behaviour was done
by observing client and asking self-reflecting questions like ‘Is the client well-dressed or is the
clothing appropriate for the occasion?’. Ms. Ketty was found wearing dull clothes and her hair
looked tangled too. Her clothes were tidy, however her nails were very dirty. She was very
restless and anxious.
Motor activity:
Speech: Speech pattern of client was assessed by means of observation methods. During the
interaction, Ms. Ketty was found to have monotonous speech and low volume of speech.
Mood and affect: Mood and affect was assessed by asking questions like ‘How are you feeling
now?’. Ms. Ketty was found to be irritated, depressed, anxious and hopeless. She faced
difficulty in initiating a conversation.
Thought processes: Thought process was inquired by asking general questions like ‘Do you
know what is affecting you right now’. The response of patients was irrelevant and she had
vague idea about her future life.
Thought content: Thought content was evaluated by inquiring about ideas and beliefs of client
related to her current mental problem. For example questions like ‘Why do you detach yourself

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from social gathering?’ and ‘Do you have any unshared beliefs?’ were used to conduct mental
status assessment. No delusion was found, however suicide ideation was present.
Perceptual disturbances: Perceptual disturbances were judged by analysing whether client has
experiences any hallucinations and illusions or not. No disturbance related to hallucination was
found. However, extreme feelings of detachment from the surrounding people or environment
existed.
Sensorium and cognition: This was done by assessment throughout the interview regarding
orientation and concentration of client. Ms. Ketty had good abstract reasoning, however her
concentration was poor.
Insight: Insight of Ms. Ketty was determined by asking questions that defined client’s awareness
and understanding about illness. She was regarding her mental state; however she had poor
insight regarding the way to manage her illness.
Judgment: Client’s judgment level was inferred throughout the interview by critically evaluating
Ms. Ketty’s understanding about ways to manage his or her behaviour. Judgment level of Ketty
is poor and she has negative coping styles to deal with her life issues and stressors.
Risk assessment:
Risk assessment for patients with depression is important to identify the likelihood of
harm to self and others. Major depression is one of the significant risk factor for suicide and risk
assessment process provided health care professionals the opportunity to identify at risk
individual and intervene at the right to prevent future events of suicide or harm. For the risk
assessment of Ms. Ketty, the square risk assessment tool and the brief risk assessment form has

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been used. The main advantage of using a risk assessment tool is that it helps in checking for
known risk factors of suicide, eliciting suicide ideation and also identifying whether patients is at
imminent risk of suicide or not (Singhal et al., 2014). In the context of risk assessment for Ms.
Ketty, the square risk assessment tool helped to obtain data related to severity of harm to self and
others.
As Ms. Ketty was found to suffer from extreme depression, comprehensive risk
assessment for the client was important to determine whether her condition can cause harm to
her or others. The square risk assessment tool was to conduct risk assessment. The square risk
assessment tool identifies risk in mentally ill patient by parameters like risk of harm to, level of
problem with functioning, level of support available, history of response to treatment and attitude
and engagement to treatment. The outcome for each of the parameters was as follows:
Risk of harm to: Significant level of harm to self was identified based on current thoughts/past
impulsive actions and harm to others.
Level of problem with functioning: Serious impairment was found in the area of social and
occupational functioning. This can be said because severe impairment affected both her
occupational performance and social engagement.
Level of support available: Her level of support available was found to be minimal as only her
sister was involved to provide support and Ms. Ketty had no contact with family members.
History of response to treatment: During her past episodes of depression, she received moderate
response to treatment.
Attitude and engagement to treatment: Moderate response to treatment found in the past.

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From the risk assessment using the square risk assessment tool, moderate risk of harm to
self has been identified. This is evident from the fact the fact Ms. Ketty was involved in past
suicide attempts. Her recurrent episodes of depression and feelings of hopelessness are also
significant markers for suicide risk. Ng, How and Ng (2017) argues that pervasive thoughts of
hopelessness and additional psychiatric co-morbidities like substance abuse, poor physical
health, social isolation and having stressful life event are also risk factors of suicide. Few of the
psychiatric co-morbidities were also found for Ms. Ketty as she expressed stressful life events,
social isolation in the past.
The risk assessment revealed significant impairment in social and occupational
functioning of Ms. Ketty suggesting the severity of problem for patient. She has limited area of
support in her life. Living alone and social isolation is regarded as one major risk factor
contributing to suicide ideation for the client. Many research studies have confirmed the
association between loneliness and suicide ideation. Pereira and Cardoso (2017) gave the insight
that loneliness, social anxiety, higher level of depressive symptoms and lack of trust in others are
the common symptoms identified in people with suicide ideation. For Ketty, death of her parents
and marriage of her elder sister limited her attachment with families. She could get very short
episodes of attachment with family members who affected her interpersonal relationship and
social engagement. Schinka et al. (2012) also established association between loneliness and
suicidality by explaining that loneliness leads to suicidal thoughts and suicidal behaviour.
Lack of parental support is one major disadvantage and risk factor identified for Ms.
Ketty which increases life stress as well as suicide ideation for Ms. Ketty. Kang et al. (2017)
supports the fact that youth suicide is a major social problem and lack of protective factors like
parental support also increases suicide attempts for patient. Supportive relationship with parents

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helps youth to manage multiple stressors. However, being deprive of social support affected
mental health and well-being for Ms. Ketty. As Ketty’s depression has affected her occupational
and social functioning and contributed to suicide ideation, it is evident that she is at moderate
risk of self-harm. Her safety should be prioritised and psychological intervention is important to
treat her depression and promote mental health and well-being for the client.
Evaluation:
Patients with depression avoid engagement in social occasions and interacting with
people in social situations. They like being alone and asking to many questions also increase
their irritability and emotional outcomes. For mental health care professional, dealing with
clients with suicide ideation and depression is a challenging task. Their symptom of irritability
and violence during social situation can act as a major while conducting mental health
assessment (Turecki & Brent, 2016). As Mrs. Ketty was a client with depressive symptoms and
suicidal ideation, it was evident that challenges may be encountered while conducting mental
status examination and risk assessment. Hence, several strategies related to counselling skills for
developing rapport with client and use of appropriate line of question was used to conduct the
mental status examination and risk assessment process.
While initiating the mental status assessment process, one of the major focus was to build
rapport with client. This was because Ms. Ketty avoided social engagement and it was imminent
that collecting information from her related to her mental health condition would be difficult.
The method that was applied to build rapport included use of effective communication skills and
displaying respect and empathy to client (Kiosses et al., 2015). The initial approach was to use
values of empathy and communication skills to make the client comfortable and develop trust

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with the client while conducting the assessment. Non-verbal expression of empathy such as
forward lean, direct body orientation and head nodding was used to give the client the feeling
that their well-being was important. The advantage of using non-verbal expression of empathy
was that it reinforces the message to client that the clinician or the staff conducting assessment is
sensitive to understand their concerns (Lorié et al., 2017).
The conversation was started with client first by initiating conversation with non-
threatening topics and avoiding use of direct questions related to her mental health condition.
This helped to avoid situations of irritations for clients in the first instance of communication. To
ensure that Ms. Ketty feels included but not interrogated during the assessment, the rapport
building strategy was to mirror the body language of client. Non-verbal strategies to build
rapport included maintaining rapport by matching non-verbal signals including body positioning,
eye contact, tone of voice and facial expressions with the client (Hershkowitz et al., 2015). Bodie
et al. (2015) explained that eye contact is an indication of active listening skills. Abbe and
Brandon (2014) supported the fact that mirroring patient’s perception and body language during
mental examination enables building therapeutic relationship with client and ensure that client
disclose all information willingly without any resistance. Similar rate of speech and vocal tones
ensured that client do not feel interrupted during the assessment. This would help to establish
common ground and ensure that client is at ease to provide the message. The value of empathy
and reassurance was constantly used so that the client feels confident and develops the trust to
disclose all her problem. Malin and Pos (2015) also supports the fact that empathy significantly
promotes alliance building while working with clients with depression. Utilization of cognitive
and emotional functions while responding empathically to clients help to convey understanding
and increase interaction with patients with depression.

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To ensure that the client provides correct information related to her mental state and not
become irritated too, open ended questions were used. The advantage of using this strategy was
that it provided Ms. Ketty the freedom to respond to the question as per her will. She could give
long answers or she could have given very brief response too. Pietkiewicz and Smith (2014)
argues that open-ended questions encourage clients to talk at ends and also use prompts. Oberjé
et al. (2015) supported the fact that open-ended questionnaire is a reliable tool too capture
behaviour change information from patient. However, this approach might limit collecting useful
data if the client gives very short answers. Too avoid such situation, the strategy of referring
back to what the client had said would help client disclose more about their condition without
feeling interrupted. Rautalinko (2013) gave the evidence that reflective listening and open-ended
questions improves the evaluation skills of counsellors. Similar approach can also work for
health care professionals who are conducting assessment in mentally ill patients. Paraphrasing
and summarizing also helps to verify information, extract more information and demonstrate
engagement in the conversation. Hence, open-ended questions and communication skills like
back questioning is a useful strategy to extract information from difficult clients.
The alignment to recovery oriented practice was done during the risk assessment process
by ensuring that two-way communication process existed during the assessment. This was done
by agreeing with client’s response in certain occasion as well as providing honest feedback
regarding things or perception which is not correct. Chester et al. (2016) expressed that patients
should be empowered and motivated to change their behaviour by honestly showing them their
weakness and giving the encouragement that new course of actions would help them to
overcome the stressors in life. Recovery oriented practice was also followed by giving the
knowledge to client regarding the need to take control of their health.

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Conclusion:
The report gave an insight into the process used to conduct risk assessment and mental
status examination for patient with depression. Ms. Ketty contacted mental health care service
following episodes of depression and past suicide attempts. The mental status assessment gave
the indication that patient is suffering from major depression. The risk assessment process
revealed social isolation and lack of social support as major risk factor for suicide ideation. The
process used for rapport building and conducting risk assessment with client gives the insight
that communication strategies like eye contact, mirroring body language, appropriate voice tone,
empathy and respect is essential to collect information from client without any issues or
challenges.

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