Comprehensive Consumer Assessment Report: NURS 1087 - Semester 2

This comprehensive consumer assessment report details the case of Prudence Bright, a patient presenting with restlessness, fatigue, and behavioral changes following the loss of her husband. The assessment, conducted by a psychiatric nurse, covers various aspects of her life, including personal history, family background, financial situation, and current mental state. The report includes details on her presenting complaints, psychiatric treatment history, accommodation, financial arrangements, and relationships. It also delves into her early childhood development, school progression, occupational history, relationship history, drug and alcohol use, and medical history. The assessment further analyzes her personality, cultural background, spiritual considerations, and general presentation. The report concludes with an evaluation of her orientation, thought content, mood and affect, perceptual abnormalities, attention, memory, insight, and judgment, providing a holistic view of her condition and needs. The report is designed to preserve the patient's identity by altering identifying details.

Running head: COMPREHENSIVE CONSUMER ASSESSMENT 1
Comprehensive Consumer Assessment
Student’s Name
Institutional Affiliation

COMPREHENSIVE CONSUMER ASSESSMENT 2
Comprehensive Consumer Assessment
Introduction
Prudence Bright (not her real name) was presented to the mental health department
complaining of extreme restlessness, fatigue, and lack of sleep. She is a mother of two children, a
son, and a daughter. She lost her husband six months ago and she recently started exhibiting a
change in behavior and how she interacts with other people. Prudence was reported to having
trouble with fellow workers and had engaged in two physical fights within last week while on
duty. At the same time, she was constantly sad and depressed throughout the day. At some point,
she was considering suicide and repeatedly talked about death. Based on the reports by co-
workers it was necessary for the prudence to undergo a comprehensive assessment before
diagnosis and subsequent treatment. The reason why a comprehensive assessment was needed is
that appropriate diagnosis, which depends on the nature of assessment performed, enhances the
treatment outcomes (Carson, Vesper, & Chen, 2014). This assessment report presents the
outcome of the assessment carried out. It is important to note that the details recorded in this
assessment have been altered where necessary to preserve the identity of the patient. The altered
details include names, addresses, workplaces, family details, and telephone numbers.
Consumer Details
Psychiatric Nurse Assessing Name of Student
Date September 25, 2019
Consumer Name In Full Prudence Bright
Date of Birth October 10, 1989

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Sex MALE FEMALE
√
Address Prudence Bright Flat 5/ 31 Spade Street QLD
2314 Australia
Telephone Home (02) 7 7 6 * * 4 5 6
Telephone Work (02) 3 4 6 * * 9 3 4
UR Number 9 8 5 5 6 2
Next of Kin Contact Person
Name Mellissa Bright
Relationship to the Consumer Mother
Address Mellissa Bright Flat 3/ 11 Melway Street QLD
0634 Australia
Contact Telephone Number Home (02) 1 0 6 * * 9 4 7
Contact Telephone Number Work (02) 3 9 6 * * 4 9 0
Referral Source Community support group
Other Workers/ Agencies Involved
Queensland Government (social and housing services)
Consumer Assessment
1. PRESENTING COMPLAINT

COMPREHENSIVE CONSUMER ASSESSMENT 4
The consumer has been presented to the facility because of increased agitation and a change in
behavior. The colleagues were concerned when the consumer became aggressive at work
followed by a series of moody and sad expressions. The consumer’s main concern is her inability
to understand what is happening to herself. However, the consumer did not depict any
identifiable precipitating elements or factors.
2. PSYCHIATRIC TREATMENT
The consumer does not have any form of past psychiatric admissions. This implies that she has
never been diagnosed or treated with any form of mental health disorder.
3. CURRENT PSYCHIATRIC TREATMENT
Currently, the consumer does not have any form of psychoactive medications. At the same time,
she is not undergoing any therapeutic or rehabilitation programs or interventions. The lack of
current treatment stems from the absence of any kind of previous treatment or diagnosis.
4. ACCOMMODATION
The consumer is living in a house under a mortgage plan. She has been staying there for the past
five years. The late husband was repaying the mortgage; however, the consumer was left with
this responsibility six months ago. Her job is not sufficient to pay for the mortgage while at the
same time taking care of her two little children.
5. FINANCIAL ARRANGEMENTS
The consumer is the sole financier of the family following the death of her husband six months
ago. The current debt emanates from the two-month defaulted mortgage for their house. She
works as customer care in the financial consulting business in town; however, her income is
limited and cannot meet the monthly bills and at the same time pay the mortgage.
6. HISTORY AS REPORTED BY OTHERS
There are reports from third parties. The reports came from her close friends who also happen to
be her colleagues at work. They pointed out how the consumer was okay and did not show any
signs of abnormal behavior. However, things changed immediately a few months after the death

COMPREHENSIVE CONSUMER ASSESSMENT 5
of her husband.
7. FAMILY HISTORY: GENOGRAM
The consumer comes from a family of three, two daughters and a brother. Their father died in a
collapsed mine while the consumer was at the age of 11, which implies that they were raised by
their mother. The consumer got married to Gregory her husband back in 2014 who recently
passed on after being involved in tragic road accident in April 2019. The consumer and her
husband had a daughter and a son aged 4 and 2 respectively. The consumer’s grandmother
committed suicide after battling depression caused by divorce. The consumer believes there is
bad blood in their family where married men either die prematurely or they decide to undertake
divorce.
8. RECOVERY ENGAGEMENT / RESOURCES / RELATIONSHIPS
The consumer had a positive relationship with her family and her colleagues at work. She started
experiencing a change in behavior after the death of her husband, which affected her relationship
with other people. She depicted withdrawal tendencies, aggressiveness towards other workers,
and continuous melancholy.
9. PERSONAL HISTORY
i. EARLY CHILDHOOD DEVELOPMENT
The consumer pointed out that she was delivered under normal birth and had a normal childhood
until their father passed away when she was 11 years old. This event changed the financial
position of the family and since at some point, they had to survive on social welfare programs.
ii. SCHOOL PROGRESSION
The consumer completed high school and college and managed to do a secretariat professional
and front desk courses. She pointed out that she did not have any critical encounters with truancy
or bullying.
iii. OCCUPATIONAL HISTORY
The consumer has been working with the current company since she completed her college

COMPREHENSIVE CONSUMER ASSESSMENT 6
program. The company has comprehensive compensation and work-life programs, which has
been one of the reasons for the consumer to sign a long-term contract with the firm. The
consumer has never changed jobs in her carrier. Moreover, she has never been unemployed.
iv. RELATIONSHIP / MARTIAL HISTORY
The consumer remained committed to her marriage and lived happily with their two children.
Madison who is 4 years old and Hailey who is 2 years old. She loves her children and they have
been the source of happiness in her life. However, she is afraid that after the death of her
husband she is unable to give them the life they deserve.
v. DRUG AND ALCOHOL USE
The consumer does not have any current or historical account of alcohol or drug abuse.
However, other people such as her colleagues think she might be under the influence of
something especially because of her recent aggressiveness. She believes in embracing a healthy
lifestyle devoid of drugs and alcohol or any other type of intoxications.
vi. FORENSIC HISTORY / LEGAL MATTERS
The consumer has never been convicted of any crime or for being disorderly. The consumer does
not have any proven criminal records. She clearly explained how she has been a law-abiding
citizen since her childhood. Her friends and family members also attested to this about her life.
vii. MEDICAL HISTORY
The consumer does not have any serious medical history. However, during the burial of the late
husband, she collapsed and taken to hospital. She recovered but was diagnosed with blood
pressure. She has been under a diet and lifestyle care plan and had significantly improved since
her blood pressure was stabilizing.
viii. PERSONALITY

COMPREHENSIVE CONSUMER ASSESSMENT 7
The consumer believes that life has been unfair to her and there is little she can do to turn things
around. Her family members and friends acknowledge that the consumer is used to an
introverted lifestyle and it is only possible to realize that she is trouble when things are out of
hand. Recently, she started being aggressive and sad, which contrary to her silent and all-time-
smiling personality.
ix. CULTURAL BACKGROUND
The consumer did not attest to any notable cultural background that could impact her wellbeing,
perception, or experience. However, she constantly made statements that implied she believes
that her life is in a critical condition because she no longer has her husband by her side, which
implied how she limits her strengths and abilities to overcome her present situation.
x. SPIRITUAL CONSIDERATIONS
The consumer is a Christian believer who considers her spiritual background as a fundamental
principle to guide how a person should live. When asked whether she believes in God has
changed, she claims it has not but she believes that God has neglected her and the family since
they have experienced numerous challenges since childhood.
xi. GENERAL PRESENTATION
The consumer is known for being tidy and concerned about how she looks. She was cautious
about how she dressed; however, there was a significant change that depicted that she was going
through life issues. She was no longer that presentable employee at the workplace and it never
bothered her anymore like it used to be a few months ago and previously.
xii. ORIENTATION
The consumer presented a disintegrated orientation. At times she was aware of events based on
time, place, and how they influenced her wellbeing. On some moments, she did not understand

COMPREHENSIVE CONSUMER ASSESSMENT 8
the conversation going on during the assessment, which forced the psychiatrist to constantly call
her to attention. This was the reason why some of her colleagues thought she must have been
under the influence of something.
10. THOUGHT
i. Content
The consumer was aware of the events that took place but could not account for her aggressive
reaction. She was aware of her previous life history and recent events including the
circumstances that led to her admission to a mental health department. She was able to
understand the questions asked based on the responses she made.
ii. Stream
When he psychiatrist kept on insisting on the need for her to pay attention, she was able to create
a link between the events and her perceptions or attitudes. However, from time to time, she was
unable to have a clear thought about the things she was experiencing. She dwelt so much on the
negative side of the entire scenario.
11. MOOD & AFFECT
The mood and affect of the consumer were dysphoric. She was depressed, anxious and
melancholic. She depicted a withdrawn tendency and could sometime burst into tears and
sobbing. She at times expressed her anger towards life and what has happened in her life since
childhood. However, when she remembers her children she felt sad and in extreme despair. At
some point she exhibited the fear of the unknown of someone who was scared of what could
happen next.
12. PERCEPTUAL ABNORMALITIES
The consumer showed signs of perceptual anomalies. She expressed how she usually sees herself
attending her burial ceremony. She could at times her noises of her children lamenting about
their desperation. At some point, she was unable to pay attention to a work meeting because of

COMPREHENSIVE CONSUMER ASSESSMENT 9
hallucinations and daydreaming.
13. ATTENTION / CONCENTRATION
The consumer was unable to focus and pay attention during the assessment. She was unable to
listen constructively; however, this changes when she becomes angry since she takes each
statement personal and offensive. The problem of attention or concentration stemmed from her
inability to disintegrate the link between questions meant for assessment purposes and those
meant to judge her behavior.
14. MEMORY
The consumer had good memory however she could forget a conversation that just ended, which
implied that she was unable to construct meaningful insights from short-term memory unless
repeated or emphasized. Her colleagues expressed how her output at work was deteriorating
because of her disintegrating ability to recall pending or assigned tasks.
15. INSIGHT
Although the consumer was aware of how she felt and the symptoms she experienced, she did
not comprehend what was happening. There was limited self-understanding especially when it
comes to behavior and attributions. At the same time she did not comprehend why she needed a
treatment, which stemmed from relabeling of the symptoms experienced as normal and not
extreme. The consumer was not aware of the underpinning psychotic experiences.
16. JUDGMENT
When assessing the consumer’s judgment, it was clear that she was not conscious of the
consequences of her action. She believed that they were justified. At the same time she though
committing suicide was an end to the suffering but did not consider the impact of such an action
on her children, which she claimed she loves them so much.

COMPREHENSIVE CONSUMER ASSESSMENT 10
17. RISK ASSESSMENT
The consumer is capable of doing or engaging in some behavior that could endanger her life and
the lives of people around her. The consumer is suicidal having repeated thoughts of committing
suicide or ending her life. This puts herself in danger and the children at risk.
18. SUMMARY
In summary, the consumer has a depressive mood, which is mixture of sadness, anxiety, and
outburst of anger. She has a declining interest in major life issues and at work. She has lost
weight and repeatedly unable to get sleep. She is restless and cannot constantly concentrate on
long conversations. At the same time she depicted extreme fatigue and loss of energy that
seemed to have been extensive and persistent. During the day and night she feels worthless,
indecisiveness, and ruminates over the past experiences. Moreover, she has recurrent thoughts of
death and repeated suicidal ideas. All these factors have been cumulatively been triggered by her
past childhood experiences which emerged after the death of her husband and the inability of her
current financial position to meet her material needs.
19. FORMULATION (Diagnostic)
Based on the assessment outcomes, it confirms that the consumer has Depressive Symptoms
(Major Depressive Disorder)
20. PROBLEM DEFINITION & INITIAL MANAGEMENT PLAN
The first issue to be addressed in the management plan and intervention decisions are how to
prevent the recurrent thoughts of death and suicide. The second issue is how the consumer needs
to understand her mental status and strive to comprehend the need for medical and therapeutic
interventions. The third aspect to be considered is how to regain her psychological ability to
work and fend for her family while linking her to available social help or service.

COMPREHENSIVE CONSUMER ASSESSMENT 11
Reflection on the Assessment
Mental health is a critical problem in society that requires a multidimensional and
collaborative approach to prevention, diagnosis, treatment, and prognosis care (Liu, Daumit, &
Dua, 2017; Pincus et al., 2016). Healthcare practitioners require a comprehensive understanding
of mental health implications to be able to assist the affected patients (Quinlivan et al., 2016).
One of the major roles played by practitioners that directly influence the outcomes of mental
health interventions is the assessment of the patient (Vigo, Thornicroft, & Atun, 2017). In the
above case example, I expected the assessment process to be a straightforward issue where it will
be easy to identify the specific challenges facing the patient and come up with the treatment plan.
However, it was not so since at times I found out that my emotional inclination could impair my
judgment about the case about the patient.
During the assessment of the case, contextual factors also came into the picture. Mild to
chronic depression is a common occurrence in Australia; however, there is little knowledge
regarding the social factors that fuel the reported escalations among middle-aged adults. At the
same time, a significant number of mental health patients do not entirely believe in the efficacy
of clinical interventions when it comes to mental health (Walker, McGee, & Druss, 2015). For
example, in this case, this was a contextual factor that influenced the consumer’s perception and
attitude. Nevertheless, I believe it is the role of mental health practitioners to neutralize prejudice
harbored by the client to ensure that it does not become an impeding factor to effective treatment
outcomes after a diagnosis has been made.
During the assessment, I noticed that there are some elements associated with mental
health that could only be identified when during the assessment as opposed to the initial
observation made and the narration of experiences. I thought about how the outcome of the

COMPREHENSIVE CONSUMER ASSESSMENT 12
assessment could be improved. Therefore, I resorted to engaging with the patient through
therapeutic communication and interaction. I realized that when a patient develops trust and a
feeling of safety when interacting with the psychiatrist it enhances the assessment process and
outcomes (Carter et al., 2017). Nevertheless, it is the responsibility of the practitioner to use their
professional experience to establish the links between experiences and outcomes for
comprehensive mental health diagnosis.
Furthermore, the attitude, experience, and perceptions of the psychiatrist during an
assessment process could impact the outcomes of mental health diagnosis (Whiteford,
Degenhardt, & Rehm, 2013). Such occurrences should be avoided since they negatively impact
the judgment of the practitioner (Carter et al., 2017; Cook, Zuvekas, & Carson, 2014). In this
case scenario, I at first felt anxious when starting the assessment owing to the manner in which
the patient reacted when brought to the facility. However, with time she managed to come down
and started to positively respond to the questions asked. I was able to empathize with the
consumer, which created a mutual platform that was comfortable for a broader conversation.
Finally, I felt I understood the experiences of Prudence and professionally related to her
feelings about what she was going through. It is important for mental health practitioners to
strive to relate and get the real sense of the consumer’s world or experiences (Harris, Gupta, &
Bowe, 2015; Harris, Hobbs, & Burgess, 2015). However, based on this assessment I will
consider a number of issues in case I face a similar scenario. First, I will remain composed to
ensure that the entire process is not affected by my inability to control my anxiety. Moreover, I
will ensure that I give the consumer enough time to reflect or relax within the assessment period
to improve the outcome of the process.