Mental Health Examination Findings

Nursing
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1 Mental health examination findings
Ans. General appearance and behaviour: Mrs B is 85 year old women who is well groomed
and having short hairs.
Abnormal motor behaviour: There is no such abnormal behaviour presented from side of Lady
while interview
Level of consciousness awareness: She was conscious while interview as she was moving her
hand and also responding to the
Cooperativeness and rapport: She was cooperative while interview but sometimes she get
irritated and confused over the discussion with the clinician which make it quite challenging to
establish the rapport.
Speech and language: Speech volume was normal and her ascent was for Australian English.
Emotional state: She was sometimes irritated with clinician and sometimes she was normal. She
shows range of emotions during interview
Thought Stream: The thought stream was normal and don’t having any kind of pressure
speech.
Thought Possession: Not much explored while interview
Thought form: Mrs B found to have less association as at several point of time she was
answering in different manner to the questions which are not relevant.
Thought content: Mrs B was seems to be suspicious and having certain kind of paranoid
thought as she was mesmerizing that “they know why they do it”, “they say I deserves this”
Perception: While interview she was not asked about any kind of perpetual disturbance but she
but found to having acute confessional state as she found observing unseen object, remain lost
while interview.
Cognition: The cognitive assessment was not formally done while interview and report from
staff regarding the assessment was quite confusing and required to be done again.
Insight : As Mrs B was cognitively impaired and confused there was a limited insight about
hospital admission.
Judgement: The judgement remain impaired due to impaired acute and cognitive confusion.
2 Other assessment information that can be gathered by nurse?
Ans From the interview analysis it has been found that the majority of information has been
gathered from, the patient regarding his current mental and physical condition along with the
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previous medical; history diagnostic formulation, medication she use to consume and past
experience in her life. The most common cause of confusion could be dementia and other causes
such as depressive disorder, single episode, psychotic features etc. are sign of mental illness that
need to be treated (Taube-Schiff and et. al., 2019).
The nurse must perform the cognitive screening as baseline and perform a valid delirium
screen to prepare a care plan for the lady. But there are certain information that can be further
gathered by the nurse in order to prepare a more effective care plan for Mrs B. This mainly
includes the sleeping and rest cycle of Mrs B this is so because the sleeping pattern and the
quality sleep that a patient take have a huge influence over their physical as well as mental state
and help in keeping them healthy (Gutiérrez-Colosía and et. al., 2019).
Other then this the daily routine of Mrs B is required to observe to determine such as food
and fluid chart for determining nutritional and fluid intake. Other than this the nurse must get
involve within communication to patient as well as her family to determine the actual factor
which make her anxious in certain situation so that proper cure must be provided to them and
help her in getting ease with her fear which is essential for her health (Stergiopoulos and et. al.,
2018).
3 The diagnostic formulation after information synthesising
Ans. The diagnostic formulation within psychiatry involve analysis of information and preparing
a care plan to deliver to patient. The diagnostic formulation mainly includes a discussion over the
diagnosis made to evaluate all the information in deeply manner and discussion made with
doctor to ensure that each of the information can be linked appropriately (Miller, Hameed and
Sukhera, 2020).
Mrs B was found to have a acute confusion and having certain of the psychotic factors
which are required to be treated well and as early possible. She is having certain medical history
where she is found to have hypothyroidism coronary artery disease, atrial fibrillation,
hypertension, hypercholesterolemia, and gastroesophageal reflux disease. Other than this she was
also found to have recurrent urinary trac infection, osteoporosis, constipation. There are not such
physical issues in her body except constipation, but she is having a cute confessional state,
observe unseen object, remain lost and in illusion (Jefferson and Sifferd, 2018).
Other than this the aetiological factors is also considered within the case that help in
determining the actual cause of the disease or origin from where it actually starts. This support in
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