HLTH 1037: Mental Health OSCA Assessment 2 - ISBAR and MSE Handover

This assignment presents a comprehensive ISBAR (Identify, Situation, Background, Assessment, Recommendation) clinical handover, simulating a registered nurse's communication to the next shift regarding a 45-year-old male patient, Mr. John, experiencing symptoms of depression. The handover details Mr. John's presentation, including lack of sleep, motivation, and concentration, along with negative and aggressive thoughts, potentially linked to separation from his wife and alcohol consumption. The background includes his admission to the hospital, relevant medical history (hypertension), and current medications. The assessment section outlines clinical manifestations aligning with major depressive disorder, potential risks (suicidal ideation, aggression), and the need for further assessments like a mini-mental state exam and monitoring vital signs. Recommendations encompass both short-term (antidepressants, relaxation) and long-term (dialectical therapy, cognitive-behavioral therapy, dietary improvements) plans, alongside multidisciplinary team involvement (counselor, dietitian, social worker). A mental state examination is also included, detailing the patient's appearance, behavior, conversation, affect, perceptions, cognition, and insight, as well as identified risk issues, such as violence and suicide. The timeframe for care is set at 6 months, with emphasis on patient and family involvement in the treatment process.

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:
I am Adelaide, a registered nurse who will handle a patient of 45 years, Mr. John. He was experiencing the
symptoms of depression for the last three months. He was living overseas on his own. He was involved in
therapeutic communication to identify symptoms and concerns
Situation:
 He was admitted to hospital due to the exhibition of certain symptoms such as lack of sleep, lack of
motivation which further indicated the presence of depression.
 He mentioned that agitated, recently feeling worthless while lying in bed. His statement indicated he
has poor concentration while he is watching TV. He tends to eat at night.
 He stated that to experience negative thoughts and become abusive during driving, indicating violent
and aggressive thoughts.
 He mentioned that he was experiencing a lack of motivation in the workplace, spent mostly sitting
around.
 The duration of these clinical manifestations is the last three months.
 Separation from wife after being married for 3 years might be the potential stressor behind the
development of the major depressive disorder.
 Significant stressor for depression in this case include separation from wife, social withdrawal and
consumption alcohol.
 Considering the mental health act 2017, he is suffering from mental illness and he would be provided
with standard care and voluntary admission (UN principle 15).
Background:
 The patient was admitted to the hospital due to an exhibition of symptoms of the depression which is
worsening in the previous three months.
 He was separated from his wife with whom he had two daughters. Currently, he has a significant

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relationship with his mother.
 He had an unhealthy habit of consuming alcohol after work. Moreover, he had irregular habit of
eating and eating junk food at night.
 No history of delusions and auditory hallucination was observed. He was lonely and exhibited social
withdrawal.
He had a history of blood pressure and currently on medication to manage hypertension
 The primary carer is his mother.
Assessment:
The patient showed agitation, lack of sleep, negative thoughts of violence and aggression, poor
concentration, lack of motivation and social withdrawal. The clinical manifestation suggested that he was
experiencing major depressive disorder according to DSM V. Separation from wife, social withdrawal,
loneliness and alcohol consumption are the reason behind development of the symptoms.
· He had no tendency of self-harm but his stated he said he had negative thoughts such as become
abusive in the supermarket while driving indicates the violence and aggression in him. It may pose a threat
to others.
· He said he feels worthless for living a life, indicating suicidal ideation. Suicidal ideation is required to
assess.
· Vital signs are required to assess and monitoring of the blood pressure is required to conduct. His
medication
Adherence is required to assess.
· The alcohol consumption and frequency of eating junk food is required to assess.
Recommendations:
· Taking into consideration of his health condition, assessment through mini-mental state is required to
conduct for gathering the knowledge of thought process, coping skills and cognitive abilities.
· The short term plan is to improve symptoms such as mood through antidepressant and facilitate sleeping
pattern through relaxation technique and improvement of sleep hygiene within the next 5 days.
· The long term plan is to reduce suicidal ideation with the help of dialectical therapy. On the other

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hand, negative thoughts can be reduced with the help of cognitive-behavioral therapy and psycho-education
within next 5 months · Improved diet with fruits, vegetable and properly cooked food can be provided to him
for reducing unhealthy food habits.
To improve his mood, he can be involved in physical activity. For alcohol cessation he can be referred to
rehabilation where he will get support to overcome unhealthy coping mechanism.
· The special consideration of multidisciplinary team include involvement of counselor for therapies and
physical trainer for physical activity. Dietitian can be recruited who will monitor his food habit and improve
his daily diet. To support him for overcoming loneliness and social withdrawal, he can be referred to the local
social welfare where social workers can be provide him emotional support.
· The recommendation is to monitor blood pressure for the stability of the blood pressure (Cardona-Morrell et
al. 2016)
. He would require to involve in the communication daily. His mother is required to involve in the treatment
process.
· The time frame of the care is 6 months.
Mental State Examination
Appearance:
 The apparent age is 45 male.
 General appearance with no peculiarities observed in the dressing sense.
 He was wearing a t-shirt and pant along with watch in the hand.
 Failed to do eye contact while communicating
 He was tidy and no signs of tattoo or marks was observed.
 Slightly overweight or healthy
Behaviour:
 Posture was kyphotic. No tremor was observed but continuous fidgeting of finger was constant
 Physical behaviour was underactive and disorganized. He was scratching his forehead frequently.
 Made furtive eye contact (indirect) and had a grimace expression.
 He had tensed, worried and tensed expression
 Based on his negative thoughts, He might have bad temper.

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Conversation/Communication/Speech:
 He was soft spoken with frequent shuttering and hesitation.
 No signs of pressure while communicating was observed in patient.
 Uneven flow of conversation with frequent pause in between.
 A clear sign of echolalia was observed from his repeating sentences or word. There was a gap in
response during communication.
 Reference of negative thoughts such as feeling of worthlessness and violence along with aggression
was evident.

Affect/Mood:
 Mood was dysphoric such as exhibition of low mood, anxiety and depression, indicating depression.
 He was agitated and restricted.
 Communicated in monotonous voice and reduced display of emotion or affect expect pain and
hopelessness.
 Mostly had dull expression and labiality in affect.

Perceptions:
 No auditory or visual hallucination and delusion was observed. However, separation from wife might
facilitate feeling of worthlessness and hopelessness.
 He had unhealthy coping mechanism, his habit of drinking alcohol indicated that.
 His feeling worthlessness in life facilitate suicide ideation followed by committing suicide.

Cognition (Including thoughts, memory and orientation):
 No memory disturbance was observes as he was able recall that he is hospital, his marriage with his

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wife and how long he is experiencing these symptoms.
 Flight of thoughts and insertion of thought, indicated disturbed thought content such as suicidal
thoughts.
Insight & Judgement:
 He was unaware of the fact that he was experiencing mental illness, indicating lack of adequate
literacy and self-care deficit. He was able to state what he was feeling but unaware of reason behind
it.
 He was unaware of the impact of the disorder he will experience.
 He appreciated treatment after elaboration.
 No financial management difficulties was observed.
Rapport:
The registered nurses was able to establish therapeutic relationship with patient. The patient was involved
in the face to face communication in a room and full attention was given to him which further empowered
patient and provided the feeling of safety. However registered nurse failed to introduce him to the patient
which further impacted his nursing practice. Introducing to him or herself is essential part of therapeutic
practice (Cashin et al. 2016)
Risk Issues (if identified):
 Violence and aggression while driving which pose harm to others
 Risk of committing suicide.

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