This reflection essay discusses the scope, nature, and rationale for assessment of Alison video case study with particular reference to components of MSE.
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Mental Health Assessment Clinical Reflection – Alison Video Case Scenario Nursing assessment is an important aspect to provision of appropriate mental nursing care. Assessment is the first step of treatment process and involves gathering information about a client for the purpose of making a diagnosis (Hunter, & Arthur, 2016). Nurses use mental status examination (MSE) assessment as a tool to understand how a mental patient think, reason, feel and remember (Johnsen, Slettebø, & Fossum, 2016). Nurses also require clinical reasoning skills to detect impending client deterioration and make a decision that positively impact patient’s outcomes (Petersen, 2016). Mental health nurses need to undertake MSE assessment and adapt clinical reasoning cycle to appropriately identify patients’ issues and prioritize them to improve their situation. The following reflection essay discusses the scope, nature, and rationale for assessment of Alison video case study with particular reference to components of MSE. The video case scenario is about a patient by the name Alison Wells who is a 38 year old woman who is seeing her GP Dr. Taylor because of low mood. Alison is divorced and has two children one 11 years while the other one 9 years. She works in the local supermarket and her sister had noticed she seemed fed up for a couple of months. Alison feel that things have been piling up and it seems she has not been able to cope with them. Immediately after a brief introduction the GP started to gather information about Alison condition. The GP starts by taking the patient history that involves the patient describing facts about her condition. The GP requires Alison to explain what has been going on that allows the patient to describe her condition. This initial stage helps the GP to put things into context by either describing or listing facts about their condition. The GP asks the patient about her mood. The patient mood is prolonged disposition or state of emotions based on mental condition (Knorr, Tull, Anestis, Dixon-Gordon, Bennett, & Gratz, 2016). The patient states that most of the time she is fed up and in the morning she sees things being black. The GP aims to collect cues or information about the mood status of the patient to use it for diagnosis (Dalton, Gee, & Levett- Jones, 2015). The GP asks the patient if she feels tearful and miserable to try and relate to the patient’s condition. The patient has tearful episodes that are caused even by small things such as
falling sugar. The GP also collected information about the patient’s change in behaviour. Alison confessed that she was not keeping her hair and stuff as usual and that her boyfriend was complaining. The patient was active and used to go swimming and playing but now she spends most time sitting on the sofa. The patient energy levels cannot keep up with her job and she does not go to work every day. This shows that the patient’s activity levels are unusual (Chakkamparambil, Chibnall, Graypel, Manepalli, Bhutto, & Grossberg, 2015). The patient has difficulty sleeping and wakes at nights that make her exhausted in the mornings. In terms of cognitive, the patient has problems of concentrating and she states that she cannot concentrate for more than 10 minutes as the mind goes to something else (Morimoto, Kanellopoulos, Manning, & Alexopoulos, 2015). The patient has good short term and long term memory and can recall about her children, their genders, and age. The patient also has intact insight and is able to acknowledge the possibility of a mental health problem. The GP was therefore able to collect symptoms and signs that included feeling down, no energy, problem with sleeping and eating, problem with concentrating, not enjoying things, struggling a bit with kids, and difficulties in the relationship with Dave. In the second phase, the GP takes past psychiatric history. The GP seeks to find out the patient’s medical history. The patient outlines that she had episodes in the past where she used to try for “no reason” when the husband left. The patient says that she took paracetamol medicines and glasses of wine to overcome the situation. Though the patient did not seek medical attention at the time, she feels it was silly to taken the medications just to have sleep and she is glad that she was still alive. The GP reviews the patient history to collect more cues for making decisions. According toKeeley et al (2016), reviewing the past psychiatric history determine if there is anything that can affects patient’s overall condition in the planned care. Therefore, past psychiatric history is a necessary cue when collecting patient information for clinical decisions. In the third phase, the GP makes risks assessment of the patient and her surroundings. The patient holds that she cannot do anything bad to her kids because she loves them very much. The patient also states that she cannot take drugs that harm her. The GP also assesses patient’s thoughts of harming. The patient also states that her children make her feel good and the things they do give her pleasure. In terms of a support structure in case of a risk, the patient has a sister,
a boyfriend, and couple of friends who can help. The condition cause minimal risk of harm to the patient. From the MSE assessment the GP finds out that the patient has symptoms suggesting that she has depression. The GP interpreted the information collected, distinguished relevant from irrelevant information, discovered a relationship and formed an opinion that the symptoms of Alison are as a result of depression. The GP was able to process information from cues collected to identify the specific patient’s condition. The facts and inferences show that the patient had depression that there is need for it to be addressed to avoid the condition advancing or leading to more symptoms. In summary, mental status examination (MSE) is a crucial tool to assessing mental status. The clinical reasoning cycle enable to use information collected and process it to make clinical. The GP in the video collects patient’s appearance and behaviour, mood, thoughts, and insights information that provide cues for the condition. The processing of the information collected showed that the patient has symptoms of depression. Therefore, it can be concluded that a mental nurse need to use mental status examination tool and apply clinical reasoning cycle skills to diagnose and make decisions on the mental condition of the patient.
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