Mental Health Assignment: Patient Assessment, Risks, and Care Plan

This assignment presents a mental health assessment of a patient named Marion, detailing her appearance, behavior, affect, mood, speech, thought processes, perception, cognition, insight, and judgment. The assessment is based on NSW HEALTH documents. The assignment identifies key risks associated with mental health issues, including suicidal thoughts, agitation, and substance use. A care plan is then proposed, addressing the clinical issue of stress, with the goal of helping the patient manage stress and maintain a normal life. The rationale for the care plan focuses on engaging in physical activity, encouraging quality sleep, and taking control of the situation. The assignment also includes an evaluation of the interviewer's approach during the patient interview, suggesting improvements for building rapport and ensuring patient privacy and efficient questioning.

MENTAL HEALTH ASSIGNMENT
Name of Student
Institution Affiliation

Mental status examination: modelled from NSW HEALTH documents
APPEARANCE
Marion is the name of the patient being examined. She is a middle aged woman of about
35 years largely recognizable by fair skin tone and a bun hairstyle. Marion is clean and smartly
dressed in a white checked top and a long brown skirt. At the time of the interview, she had
come to the clinic in one of her routine visits. She had come earlier because of her alleged effect
of halting the use her Clozapine medication. Apart her complaint about her weight gain, she has
no any other visible symptoms.
She maintains an upright posture throughout the interview process, constantly using
gestures such as the movement of hands and shoulders to illustrate points and answer the queries
asked Anne, the Nursing staff attending to her. Additionally, Marion has a Mesomorph type of
body based on her appearance during the interview. It is largely difficult to determine her height
due to the fact that she remains sited throughout most of the interview process, she can be
classified in the middle height category based on a rough estimate. Notably also, she maintains
an eye contact with the interviewer thorough out the interview process. She has no visible tattoos
or piercings on her body. However she has a pair of glasses.
BEHAVIOUR
Marion is generally friendly and easy to build rapport with. Also she is actively engaged
from the start of the interview to the end. Besides she remains cooperative throughout the
interview often answering questions appropriately and in a conclusive manner. There are no
visible psychomotor activities during the interview. She however has a positive attitude about the
interview, her doctor, her interviewer and the clinic at large.

AFFECT
Her affect can be described as restricted. Generally, Marion is able to restrain her
emotions, although she has a lot going through her head. She does not openly show it. It is not
easy to notice how she is currently feeling by looking at her.
MOOD
According to the client, she has been well ever since she stopped talking her tablets but
has not been feeling well in the last few days. Her mood can be described as an ambivalent
mood. She explains that she has mixed feelings to an extent where she cannot tell whether she is
feeling sad or happy .Her mood fluctuation is a little bit deep. She explains how she feels as if
she has ants in her brain and feels as if people are looking ate her on trains and things. The
intensity of the mood changes is also demonstrated by her decision to come to the clinic.
SPEECH
One of the things easily noticeable about Marion is her articulate nature. She is not only
articulate in her speech but also audible. Also, She has an impressive quality of speech and is
able to answer questions clearly, satisfactorily and in a continuous manner. Her responses to the
questions asked are also prompt. Additionally, she flows smoothly between ideas and responses.
Finally, she does also include a rising and falling intonation in her responses
THOUGHT FORM
Generally speaking Marion’s thought form is still perfect. From her responses, she does
not show any formal speech disorders. Her responses depict a person who is able to answer
questions instantaneously without fumbling with words or beating about the bush. She perfectly
connects her ideas well in a sequential and logical manner .Also she does not offer vague or
incomplete responses.

THOUGHT CONTENT
She is largely preoccupied with her well-being as demonstrated by her arrival at the clinic
earlier than she was used to. This shows that the current problem she was facing was somehow
troubling her. She is also obsessed about what people who know her think about her current
situation. One of the dominant themes of her thought content is therefore health and well-being.
She is also concerned about her ability to go about her work responsibilities and hopes to resume
work soon.
PERCEPTION
Marion depicts normal perception. She has not shown any sign of misinterpretation,
hallucinations during the interview
COGNITION & INTELLECTUAL FUNCTIONING
Marion is not new to the place where the interview took. She had been there a couple of
times. She was alert all through. Therefore, she is absolutely oriented to the place and venue of
the interview. She clearly understands what is happening to her and is aware that she is being
interviewed by Anne. She can clearly recall all the aspects related to her current illness including
when the symptoms started and the medication she had been using .In addition she is able to
answer questions clearly and thoughtfully. She is also able to plan and implement .For example
upon the realization that her situation was not getting better she decided that she would go to see
the doctor and did exactly that during the day of the interview
INSIGHT & JUDGEMENT
The patient has not shown any signs of poor judgement or Insight .She clearly
understands that that she has a problem which urgently needs medical attention. She is also
aware about when the problem started. The fact that she chose to come to the hospital on her

own volition means that she is aware about the possible consequences of failing to seek medical
attention. She has therefor took decision which is favorable to her
(15 marks)
Identify 4 risks (5 marks). Refer to risk template for various types of risks.
There are multiple risks associated with mental health issues.
Suicidal thoughts
This occurs when an individual thinks about suicide or creates a detailed plan to commit suicide.
Suicidal thoughts are prevalent among individuals undergoing stress or depression. Suicidal
thoughts is one of the main issues, suicidal thoughts can arise from unmanaged stress or
depression (Smith et al., 2017)
Agitation
Secondly, people with mental health issues, are more likely to become aggressive towards other
individuals. Agitation may differ among individuals, for some it may come in the form of
aggression, violence, unease or tension. Agitation may cause harm to other individuals
(Blashill,Perry & Safren, 2011).
Substance use
Drug abuse refers to the use of drugs such as illicit drugs or alcohol in quantities or methods that
can harm someone or those close to him. A clear correlation exists between mental health issues
and drug abuse. This means that mental health issues are more likely to push people into drugs as
they seek temporary comfort in drugs (Smith et al., 2017).
Care plan: Modelled on clinical modules information NSW HEALTH
CLINICAL ISSUE

Stress
RATIONALE FOR CHOSEN ISSUE
Stress is a major issue in mental health. Stress can affect the well-being of the client in a number
of ways. First it can lead to persistent headaches making it difficult for the patient to engage in
productive activities .emotional problems such as anxiety have been identified as one of the
causes of stress. It is evident the patient is quite anxious about her current health condition
(Yaribeygi, Panahi, Sahraei, Johnston & Sahebkar, 2017).
GOAL/S
The ultimate goal for this care plan is to help the patient to avoid or manage stress that may arise
from her current situation. The outcome will therefore facilitation of the continue leading a
normal life to save her from potential depression.
1Engaging in physical activity every day in
the evening
2Encouraging the client to have quality
sleep
3Taking control of the situation
RATIONALES
Engaging in physical activity has been
identified as one of the strategies used to
suppress stress hormones bringing calm to the
body (Jackson, 2013).
2Lack of sufficient sleep can escalate stress in
an individual. Enough sleep will therefore
help the body to relax sufficiently minimizing
chances of high level of stress (Yaribeygi,
Panahi, Sahraei, Johnston & Sahebkar, 2017).
3Taking control of the current situation would

also require sufficiently prepared and trained.
Taking control of a situation will require a
trial of many possible options so that the most
appropriate may be taken. The client will be
guided in writing down the various available
option (Alborzkouh, Nabati, Zainali, Abed &
Ghahfarokhi, 2015).
ACTIVITY 3
The interviewer started the interview by introducing herself and informing the patient
about the privacy policy at the clinic. The introduction was good in that it helped the patient to
easily connect with the physician. Secondly, by informing her about the privacy policy at the
clinic, she build the confidence of the patient to answer all questions including those that might
require confidential information. Besides assuring the patient was safe the physician should have
told her how the information collected would be used. Finally, the interviewer need to structure
the questions efficiently to ensure that they do not consumer much clients time especially those
seeking treatment such as Marion. Finally the nurse ought to have prioritized the patient by
interviewing her after she had received the necessary care

References
Alborzkouh, P., Nabati, M., Zainali, M., Abed, Y., & Ghahfarokhi, F. S. (2015). A review of the
effectiveness of stress management skills training on academic vitality and psychological well-
being of college students. Journal of medicine and life, 8(Spec Iss 4), 39.
Blashill, A. J., Perry, N., & Safren, S. A. (2011). Mental health: A focus on stress, coping, and mental
illness as it relates to treatment retention, adherence, and other health outcomes. Current
HIV/AIDS Reports, 8(4), 215.
Jackson, E. M. (2013). Stress relief: The role of exercise in stress management. ACSM's Health &
Fitness Journal, 17(3), 14-19.
Smith, L. L., Yan, F., Charles, M., Mohiuddin, K., Tyus, D., Adekeye, O., & Holden, K. B. (2017).
Exploring the link between substance use and mental health status: what can we learn from the
self-medication theory?. Journal of health care for the poor and underserved, 28(2), 113-131.
Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on
body function: A review. EXCLI journal, 16, 1057.