Mental State Examination and Nursing Report for Harry Smith

This report provides a detailed analysis of Harry Smith's mental state examination and nursing report. It includes symptoms, interventions, and risk screening tools for his treatment.

Student Name: Student Number:
Adult Mental Health Services
CONSUMER ASSESSMENT
Date:20/09/2018
Time: 1900 hrs
URN: 86425677
Family name:
Given names: Harry Smith
Date of birth: 07/06/2000
Facility: USQ Clinic
Sex: Male
MENTAL STATE EXAMINATION
General
appearance
After complete evaluation according to the case study the mental situation
of Harry is identified. As per the interview, it seems clear that the general
appearance of harry is that he is suffering from depression anxiety. He is
hallucinating and his body gesture seems a bit irrelevant. During the
discussion, his appearance seems to be a little stressed and he is simply
residing in his make-believe world.
Behavior Behaviour is a part of the nonverbal communication. During the interview,
Harry's behavior was a little stressed. His behavior expressed anxiety and
sense of reality was missing in his behavior. He was totally talking about
his imaginary world where he could become invisible (Boursnell, 2011).
1

Speech
During the interview process, Harry had no problem with speech. His
speech was clear and he was clearly speaking about his make-believe
world. According to the speech, it seems he has lost grasp on reality and is
thinking that his imagination is the actual reality.
Mood and
Affect Mood-Harry has some mood swings. According to the interview for most
of the time, he was in a good mood and talking about his imaginary world
with the interviewer. His mood was decent during the interview process.
Affect- Harry was completely natural when giving the answers, In some
sensitive question, he was fumbling which makes it clear that he is losing
grasp on the reality.
Thought process
His thought process was quite irrelevant from the reality. According to the
interview, Harry is not thinking in a rational way as he is showing
symptoms of hallucination. His memory is not appropriate as he is not able
to give proper information in some question (Boursnell, 2011).
Thought content Harry's thought content was totally irrational as he hallucinated that he can
become invisible. According to an interview, he did not show any suicidal
2

tendency, on the other hand, he had a thought of killing his own brother.
Perception Harry has lost his control over reality. He is not able to perceive the
practical situation properly. His perception is not working properly due to
different mental disorders like depression, anxiety, and hallucination.
Cognition
According to the interview, Harry has shown cognitive impairment. He is
not able to assess or evaluate his present situation and is showing signs of
memory loss.
Judgment
The evidence suggests that Harry’s mentally unstable at the moment. He is
showing signs of hallucination are showing cognitive impairment. Proper
mental nursing care should be taken to improve the mental state of Harry
(Hough & Bailar-Heath, 2010).
Insight The interview process helps to get really good insight about the holistic
condition of Harry. It is really helpful for assessing the problems of Harry.
3

SYMPTOM INTERVENTION
Depression
Cognitive behavior: Cognitive behavior is a most effective way for Harry's
fast recovery. He requires empathetic behavior, mental; support and a friendly
attitude from the caregivers and family to recover him from his present mental
state.
Medication: Proper medication is effective requi8remnet for the treatment
procedure. An intake of Nefazodone and sertraline medicines must be given to
him for his speedy recovery.
Hallucination
Counseling: Care, apathy, sympathetic behavior and respect are a most
essential criterion for mental counseling. A smooth communication must be
developed with Harry so that he can understand the friendliness of the people in
front of him. It is capable to increase his mental strength (Hough & Bailar-
Heath, 2010).
Routine management: Proper routine must be maintained for the treatment of
4

a patient suffering from hallucination syndrome. Harry must be provided
sufficient fresh foods, water, fruits, and antiseptic drugs for his mental
development
Anxiety Stress management: Stress can be managed by effective implementation of
anti-anxiety practices. It includes proper diet maintenance, sufficient water,
regular physical exercises, listening to soft songs and regular meditation.
Motivation and medication: a person suffering from anxiety requires
sufficient mental support and motivation to get out of his anxious feelings. He
must be motivated for a better lifestyle and requires sufficient anti-anxiety
medicines for his situational betterment (Boursnell, 2011).
5

NURSING REPORT
The clinicians must provide Harry with an effective mental care treatment for his speedy
recovery. Harry is suffering from the symptoms of hallucination, depression and unusual
anxiety. The healthcare staffs must be sympathetic towards Harry to reconstruct his cognitive
decline (Hough & Bailar-Heath, 2010). The risk screening tools with which Harry can be
treated in a better way are as follows:
Advance health directive: Health directive factors generally analyze the stress and suicidal
tenancy of the mental patient. However, Harry did not have a suicidal tendency.
Aggressive factor assessment: this assessment helps to identify the violent behavior of the
mental patient. Harry had a violent behavior as he wanted to kill his brother and used his
force to stay away from the police and care staffs
Vulnerability assessment: The vulnerability assessment highlights the traumatic situation of
the mental patient. Harry was in a traumatic situation as he had no control over his words and
activities (Boursnell, 2011).
Absconding factors: The involvement of the patient in any absconding issue signifies the
absconding factors of the risk tool assessment.
Responsibility for the parents: Parents must play an active part in mental health treatment.
Harry requires empathy, love, counseling and mental support from his parents in order to
come out from present mental instability.
6

References
Boursnell, M. (2011). Parents With Mental Illness: The Cycle of Intergenerational Mental
Illness. Children Australia, 36(01), 26-35. doi: 10.1375/jcas.36.1.26
Hough, S., & Bailar-Heath, M. (2010). A Clinical Neuropsychological Approach to Memory
Rehabilitation: Building on Aspects of Cognition, Behavior, and
Situation. Psyccritiques, 55(7). doi: 10.1037/a0018355
.....
7