NUR2200 - Adult Mental Health: Consumer Assessment & Nursing Report

This assignment presents a consumer assessment and nursing report for an 18-year-old male, Harry, who was brought to the emergency department due to erratic behavior and suspected drug use. The mental state examination reveals symptoms of delusion, paranoia, and mood swings. Interventions focus on providing companionship, preventing drug abuse, and aiding social interaction. The nursing report utilizes the ISBAR tool to document the patient's identification, situation, background, assessment, and recommendations for intervention, highlighting the patient's deteriorated mental health status and self-harming tendencies. The report emphasizes the need for mental and medical intervention, counseling, and guidance to help Harry regain control of reality and resume a normal life. The document concludes with a reference list of relevant research articles.

STUDENT NUMBER:
Student Name: Student Number:
Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family name:
Given names:
Date of birth:
Sex:
MENTAL STATE EXAMINATION
General
appearance
The patient appeared to be silent, irritated, not-interested in the session.
He appeared to be excited on the onset of questioning.
Behaviour The patient’s behaviour appeared to be silent and dreamy. His
behaviour appeared to be absurd as he went on to answer questions.
While initially he answered the questions patiently, later became
aggressive.
Speech The speech of the patient was rather dreamy and absurd in nature. He
spoke in a delusional manner which reflected his mood swings.
Mood and
Affect
The patient’s mood appeared to be highly fluctuating as he answered to
the questions in the interview. His mood reflected remote connection to
reality. He sometimes reflected violence and conviction to his belief.
Thought process The though process of the patient appeared to be paranoid and
delusional. He had unclear understanding of reality.
Thought content Thought content of the patient was connected to him being invisible and
possessing special powers. He has engulfed in paranoiac thoughts that
appeared totally psychotic in nature.
Perception The perception of the patient reflects distorted mental orientation. His
perception appeared highly confused, psychotic and derision.
Cognition Report by the patient’s mother reflects his incapability in cognitive
capabilities. His decline in cognitive capabilities is seen from
deteriorating school performance, inability to speak appropriately,
perform ordinary human functions.
Judgment The patient seemed to have lack of judgemental capability as is
understood from his speech. He lacks capability to link or draw
connection between discussions or make a logical conclusion.
Insight The patient did not reflect any capability to depict insight regarding his
personality. His delusional and unrealistic speech made at the interview
was the proof.
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STUDENT NUMBER:
SYMPTOM INTERVENTION
Delusion and
mood swings
 Providing companionship to help develop sense of reality and remove
delusion (Kyaga, Lichtenstein, Boman, Hultman, Långström & Landen,
2011).
 Prevention of drug abuse through psychological counselling and
mentoring.
Feeling sad and
detached
 Providing assistantship and company to remove the feeling of
loneliness.
 Guiding through sessions to develop a sense of belonging (Schrank,
Bird, Rudnick & Slade, 2012).
Anger to violence
and paranoia
 Aiding in developing social interactions and removing isolation
(Corrigan, Druss & Perlick, 2014).
 Engaging patient in self-care and engaging in activities.
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STUDENT NUMBER:
NURSING REPORT
The findings related to the patient has been documented by making use of ISBAR tool.
Identification of patient is done earlier and his name is Harry, 18 year old school boy. While I
am conducting interview as a nurse for planning appropriate intervention techniques
(Klainin-Yobas, Cho & Creedy, 2012). The situation in which the interview is conducted as
Harry was caught and brought by the Police at an Emergency Mental Examination. It was
urgent as he was found standing in middle of the road amidst cars in semi-naked condition.
Background examination revealed, the patient Harry depicted use of drugs and was in a
delusional mental state. He had blurred psychotic and cognitive capabilities. Assessment from
the interview it was found that he had no understanding of reality and showed anger, sadness
with confused behaviours. It can be understood that Harry was suffering from a state of
paranoia. Evidence based nursing reflects deteriorated mental health status from the
assessment form and considerable mental health risk possessed by the patient. His behaviours
were not expected from a youth of 18 years and his behaviours reflected self-harming nature.
As he was caught from middle of the road as he tried to stand in middle of the road amidst
speedy cars. Further he had no control over his emotions as he thought that everyone was
trying to harm him. From prolonged drug or other substance abuse he had lost connection
with reality (Zhang & Jääskeläinen, 2014). Moreover, as he was not in taking any food he
lacked in nutrition tremendously, he also agreed to having lost weight in recent period. Such
loss in nutrition in the body can lead to mental disabilities and continuing status of the same
in case he does not resume in taking food. He lacked proper sleep during the night, which
was not normal as his brain functions could become delusional easily from lack of sleep. He
needed a normal routine and guidance through which he could resume a normal life and gain
back his control of reality. The interview revealed that he had no social connection and
suffered loneliness. He had enclosed himself and made up his own world, which makes him a
patient of delusional disorder. He made up a world where an imagery agency was sending
across to him passwords and directing him things to do. He made up imaginary stories for his
own brother as well, and viewed him as his enemy. He planned aggression towards anyone,
who would stop him from doing his acts (Kakuma, Minas, van Ginneken, Dal Poz, Desiraju,
Morris, Saxena & Scheffler, 2011). Post evaluation of the situation, I want to request
appropriate nursing intervention and medical intervention be conducted on Harry. Harry
needs mental and health care for recovering from his current situation. He needs counselling,
guidance with appropriate health treatment.
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STUDENT NUMBER:
REFERENCE LISTS
Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma
on seeking and participating in mental health care. Psychological Science in the
Public Interest, 15(2), 37-70.
Kakuma, R., Minas, H., van Ginneken, N., Dal Poz, M. R., Desiraju, K., Morris, J. E.,
Saxena, S. & Scheffler, R. M. (2011). Human resources for mental health care:
current situation and strategies for action. The Lancet, 378(9803), 1654-1663.
Klainin-Yobas, P., Cho, M. A. A., & Creedy, D. (2012). Efficacy of mindfulness-based
interventions on depressive symptoms among people with mental disorders: A meta-
analysis. International journal of nursing studies, 49(1), 109-121.
Kyaga, S., Lichtenstein, P., Boman, M., Hultman, C., Långström, N., & Landen, M. (2011).
Creativity and mental disorder: family study of 300 000 people with severe mental
disorder. The British Journal of Psychiatry, 199(5), 373-379.
Schrank, B., Bird, V., Rudnick, A., & Slade, M. (2012). Determinants, self-management
strategies and interventions for hope in people with mental disorders: systematic
search and narrative review. Social science & medicine, 74(4), 554-564.
Zhang, D., & Jääskeläinen, J. (2014). Critical Events and Mental Health.
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