Adelaide Mental Health Clinic: HLTH 1037 OSCA Assessment 2 Report

This assignment presents a comprehensive ISBAR (Identify, Situation, Background, Assessment, Recommendation) clinical handover and a Mental State Examination (MSE) for a client referred to the Adelaide mental health clinic. The client, Mr. Johan, presents with symptoms of depression, including fatigue, lack of interest in activities, and excessive alcohol consumption following a recent separation. The ISBAR details the client's history, including hypertension and social isolation, and recommends various assessments such as head-to-toe, vital, mental health, nutritional, spiritual, and cultural assessments. The MSE analyzes the client's appearance, behavior, speech, affect, perceptions, cognition, and insight, revealing a dysphoric mood, slow speech, and tendencies towards agitation. Risk issues identified include potential for accidents while driving, poor nutritional intake, and social interaction challenges. The assessment underscores the need for immediate interventions to promote mental health recovery, including referrals to a psychotherapist, psychological counseling, and mental wellness community services. This assignment demonstrates a detailed understanding of clinical handover protocols and mental health assessment techniques, providing a thorough evaluation of the client's condition and appropriate recommendations for care.

HLTH 1037 – Mental Health OSCA Assessment 2
Complete the following ISBAR clinical handover as if you were the
Registered Nurse handing this client over to the next shift
ISBAR Clinical Handover
Identify the client:
The client Mr, Johan was referred to the Adelaide mental health clinic by his General Physician, who
suspected that he suffered from depression. The Client mentions that he was presented to the General
Physician by his mother who was concerned about his increased fatigue and lack of interest in socialising.
The client reports he experiences a lack of interest in doing activities that he previously enjoyed. He also
mentions that he spends most of his time browsing through different channels of television. The client has
been experiencing fatigue and a lack of interest in addressing every day activities post his separation with
his wife three months ago. The client mentions having two daughters who are both married and are busy
with their life schedule and he further mentions about one of the daughter working as a nurse in Adelaide.
He also mentions about one of his daughter being overseas and being busy with her work. He further states
consuming more than the recommended level of alcohol as per the Australian Drinking Standards. The client
mentions about staying alone and mentions about being visited by his mother twice a week. No information
has been provided in relation to the patient’s age, residential address or cultural identity.
Situation:
The patient appears to be depressed and experience persistent low mood and affect. The patient appears to
be dysphoric and lacks interest in regular activities. The patient’s social interaction level appears to be poor
which reflects a diminished mental health status. The patient confirms a medical history of hypertension and
the current mental health status indicates an urgency to implement appropriate care interventions to
facilitate mental health recovery.
Background:
The patient confirms a medical history of Hypertension and also states to have separated from his wife three
months ago on account of relationship problems. The patient confesses to have experienced increased
detachment and lack of pleasure in engaging in activities that he liked post separation. He mentions about
continuing to work but also mentions about experiencing a poor appetite and a poor sleep pattern. The
patient further mentions to experience agitation and feel enraged while driving. The patient also mentions to
consume alcohol more than the recommended standards of drinking.
Increased alcohol consumption can negatively impact the existing medical condition of hypertension
Increased alcohol consumption can also trigger associated health issues in relation to cardiovascular
disorders and gastrointestinal disorders which can deteriorate the quality of physical health of the patient
Poor appetite can trigger malnourishment or negatively impact the normal physiological functioning of the
gastrointestinal system
Poor appetite can also interfere with the immunological response of the body and increase the susceptibility
of acquiring infection
Poor sleep pattern can trigger mental health disorders as classified by the DSM V criteria which include sleep
apnoea
On the basis of the obtained patient information and the previous medical history the above listed physical
and mental health problems can be identified which require immediate attention to promote patient
recovery.

Assessment:
Upon analysing the existing physical health status and the mental health status of the client, the following
assessments would be vital to conduct for the patient.
The assessments would include:
Head to Toe assessment: Head to Toe assessment would help to analyse any other existing physical health
issues which the patient might be experiencing
Vital assessment: Vital Assessment would help to assess the vitals of the patient with respect to
temperature, pressure, SpO2, Respiratory rate and Heart Rate which would help to identify the abnormality
and accordingly devise an appropriate care intervention
Mental Health Assessment: Mental Health Assessment would help to identify the existing mental health
issues being experienced by the patient
Nutritional Assessment: Nutritional assessment would help to identify the existing nutritional needs of the
patient and accordingly devise the most suitable diet plan
Spiritual Assessment: Spiritual assessment would help to identify the spiritual needs and preferences of the
patient and devise a care plan that is aligned to the spiritual preferences of the patient
Cultural Assessment: Cultural assessment would help to identify the culture specific needs and preferences
of the pateint and accordingly incorporate the same while devising a care plan for the patient.
Recommendations:
Request to conduct the listed assessments for the client in order to identify the holistic health care needs of
the patient
Request for a referral to a psychotherapist in order to facilitate mental health recovery
Request for a referral to psychological counselling
Request for a referral to a mental wellness community service
Mental State Examination
Appearance:
Patient attended clinic in lose clothes, (Greyish Graphic T-shirt and Navy Blue Trackpants)
Patient’s hair was unkempt
Patient appeared to be maintaining a sloughing posture while being seated on the chair throughout
Behaviour:
Patient appeared to be fidgeting on multiple occasions and clubbing his hands together
Patient appeared to avoid eye-contact throughout the video
Patient’s facial expression was blunted
Patient appeared agitated
Conversation/Communication/Speech:
Rate of speech appeared to be slow

Quantity of speech appeared to be minimal
Volume of speech appeared to be quiet
Affect/Mood:
Patient’s facial expression appeared to be dysphoric
Patient’s overall demeanour appeared to be disconnected
Patient’s mood appeared to be low
Patient appears to feel depressed
The intensity of the mood appeared to be flat and blunted
Perceptions:
The speed of thought form appeared to be retarded
The thought flow appeared to be linear and coherent
No sign of abnormal beliefs, obsessions, overvalued ideas or suicidal thoughts were identified
Presence of violent thoughts in terms of reacting violently to others was detected
No presence of hallucinations, pseudo-hallucinations or illusions were identified
Cognition (Including thoughts, memory and orientation):
Patient was oriented to time and place
Patient appeared to be attentive
No problems related to short term memory issues were identified
No data in relation to Mini-mental state evaluation
Insight & Judgement:
Patient confirms to experience depression
Patient wishes to avail help with the course of treatment
Patient is thorough and consistent with judgment
Rapport:
Poor quality of rapport
Poor eye contact identified
Risk Issues (if identified):
Tendency to react negatively or in an agitated manner while driving
Prone to encounter accident
Poor nutritional intake
Poor Sleep pattern
Increased anxiety
Poor quality of social interaction