Nursing Assessment of Alison: Clinical Reflection on Mental Health

This report provides a comprehensive clinical reflection on the mental health assessment of Alison, a 38-year-old woman experiencing low mood, as presented in a video case scenario. The report details the GP's assessment process, emphasizing the gathering of patient history, mood evaluation, behavioral changes, and cognitive function. It highlights the use of the Mental Status Examination (MSE) to collect cues and symptoms suggestive of depression. The report further explores the GP's risk assessment and the patient's past psychiatric history, including previous episodes and coping mechanisms. The analysis underscores the importance of clinical reasoning cycle in interpreting information, forming a diagnosis, and making informed decisions. The report concludes by emphasizing the critical role of MSE and clinical reasoning skills for mental health nurses in assessing and managing patients' conditions, ultimately leading to improved patient outcomes. The provided references support the evidence-based practice discussed within the reflection.

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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 to Keeley 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.

References
Chakkamparambil, B., Chibnall, J. T., Graypel, E. A., Manepalli, J. N., Bhutto, A., & Grossberg,
G. T. (2015). Development of a brief validated geriatric depression screening tool: The
SLU “AM SAD”. The American Journal of Geriatric Psychiatry, 23(8), 780-783.
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based
education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced Nursing,
The, 33(2), 29.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical placement:
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Johnsen, H. M., Slettebø, Å., & Fossum, M. (2016). Registered nurses' clinical reasoning in
home healthcare clinical practice: A think-aloud study with protocol analysis. Nurse
education today, 40, 95-100.
Keeley, J. W., Reed, G. M., Roberts, M. C., Evans, S. C., Medina-Mora, M. E., Robles, R., ... &
Andrews, H. F. (2016). Developing a science of clinical utility in diagnostic classification
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Knorr, A. C., Tull, M. T., Anestis, M. D., Dixon-Gordon, K. L., Bennett, M. F., & Gratz, K. L.
(2016). The interactive effect of major depression and nonsuicidal self-injury on current
suicide risk and lifetime suicide attempts. Archives of Suicide Research, 20(4), 539-552.
Morimoto, S. S., Kanellopoulos, D., Manning, K. J., & Alexopoulos, G. S. (2015). Diagnosis and
treatment of depression and cognitive impairment in late life. Annals of the New York
Academy of Sciences, 1345(1), 36-46.
Petersen, S. W. (2016). Advanced health assessment and diagnostic reasoning. Jones & Bartlett
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