Mental Health OSCA Assessment 2 (HLTH 1037) - Clinical Handover Report

This report presents a mental health assessment of a 45-year-old male patient experiencing depression, anxiety, and related physical health issues, including weight gain, sleep disturbances, and alcohol dependence. The assessment follows the ISBAR (Identify, Situation, Background, Assessment, Recommendation) framework, detailing the patient's history, presenting symptoms, and mental state examination findings. The patient's history includes a recent diagnosis of depression, medication for hypertension, and social isolation. The assessment reveals moderate to severe depression, negative thoughts, and suicidal ideation. The report includes a detailed mental state examination, noting the patient's appearance, behavior, speech, affect, and perceptions. Recommendations emphasize cognitive behavioral therapy, improved communication, healthy lifestyle changes (diet, sleep, exercise), and motivational therapies to address the patient's depression and improve his overall well-being. This report, contributed by a student, is available on Desklib, a platform providing AI-powered study tools.

HLTH 1037 – Mental Health OSCA Assessment 2
Name of the Student
Name of the University
Author note

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:
My name is (add your name) and I work as a registered nurse in the XXX helathcare facility. While working in the mental health ward I
was assigned to take a mental health assessment of Mr. Johannes (approximately 45 year old) (MRN number XXXXX) living alone in
Australia. He was admitted to the mental health ward by her mother as she noticed signs of depression and deteriorated health conditions.
Situation:
As stated by the patient in the mental health assessment, depression is the primary problem of the patient in current situation. There are
secondary health issues, due to which physical health of the patient is also deteriorating such as increased body weight, unusual sleep
pattern, hyper pressure, anxiety, agitation, lack of concentration and high drinking pattern that affects his physical health by decreasing
his strength and immunity. His increased addiction for alcohol, negative thoughts about his self-worth and affected personal as well as
professional life (Anderson et al. 2015).
While describing his symptoms, his body language and his statements about his health conditions should be stated. In the entire mental
health assessment related conversation, patient did not make direct eye contact with me and was constantly moving his hands, eyes and
face. He was not stable to his thoughts and statements and for several responses changed his response within fraction of seconds. For
example while replying to the question about his personal life related problems affected his professional life, he changed his response
from yes to no within seconds and stated that personal problems are concern for every individual and it does not affect someone’s
professional life. Further as per the statement of the patient, he was on medication for hyper pressure and was suffering from anxiety and
agitation. he was unable to sleep properly from last three months and was suffering from binge drinking and eating due to which his body
weight increased (Dawson, King and Grantham 2013).
The client was currently living in his house where no one came to visit him except his mother as he did not wanted to disclose his health
condition to others.
As per the mental health act for determination of severity of mental health of the patient, assessor should rate several points while
conducting the mental health assessment with patient. These are level of consciousness, thought perception, attitude and insight, speech
and activity of motor sense, and cognitive abilities. In this assessment with Mr. Johannes, he was having low mood, less self-confidence,
negative thoughts, dull appearance and lack of consciousness and hence, his level of depression could be rated as moderate to severe as
the episodes lasted for three months.
Background:
As stated by the patient, he was diagnosed with depression when he was admitted to the hospital. However he was given with medication
for hyper pressure. Further, he also mentioned that due to his deteriorated physical and mental health condition, he was admitted to the
hospital by his mother.
He did not had any past medical history and this depression episodes are the only health concern he is suffering from in the current
situation. Currently he consumes medication for hyper pressure once every morning and did not mentioned any signs and episodes of
allergies. His mother is his primary carer and without her no one comes to take a visit to his home as he has isolated himself from the
entre society. Therefore, his house is his only accommodation where he performs all his activities of daily life alone. This was the health
background which was collected from the mental health assessment of the patient (Bost et al. 2012).
Assessment:
In the current situation, the patient was suffering from the severe depression due to his grievous experiences of life. He stated that he
never experienced depression before. However, due to his thought of being worthlessness, he gradually developed the symptoms of
depression. He was exhibiting different clinical signs related to the depression. He stated that he had the abnormal sleep pattern.
Previously he used to wake up at 6’o clock for work but due to negative thoughts, he had the unusual sleeping pattern. Besides, he stated
that he had anxiety and he was feeling agitated at the same time. He had a lack of concentration in the last three months. After having the
conversation, he reported that he usually had negative thoughts and he kept questioning his self-worth. He gained significant body weight
due to the negative thoughts and alcohol consumption habit. He did not have any ideas of attempting suicide but the negative thought
process of him may leads to the attempt of suicide. He was consuming the medicines of hypertension every morning on a daily basis. No
diagnosis has been planned for him and he never went through any diagnosis process. However, he suggested that communication may
help him to overcome the obstacles of life by releasing the negative thoughts. Medical experts also suggested that effective verbal
communication with any individual would help him to overcome the depression he was experiencing for the more extended period
(Eccleston et al. 2016). The thought processes of him affected his lifestyle since he was an alcoholic and eat unhealthy foods which
influence his daily activities and health. He was willing to involve himself in the treatment plan so that he can get over the negative
experience and ability to lead the quality life.
Recommendations:
In such a situation, when patients are experiencing depression, few therapies can help the patient to overcome the situation. A systemic
review and empirical studies of depression suggested that cognitive behavioural therapy is the best therapy for coping up with severe
depression. Depression usually makes people helpless about their self and subsequently affects the daily routine and lifestyle of the
patient. Effective communication with a patient in the 30 to 60 session of cognitive therapy may help the patient to boost the self-esteem
and gain the self-worth. In a majority of the cases, patients have low self-esteem due to the series of adverse events they are
experiencing. Communication with empathy and compassion would help him to gain the self-worth and confidence in coping up with
negative experiences.Moreover, he would have a sense of security, and he would be able to talk about his area of concern to the
caregiver. Moreover, the exercise daily will boost the endorphins which would give the long-term benefit to cope up with depression
(Eccleston et al. 2016). Since he had unhealthy eating habits and alcohol consumption, eating healthy would help him to get over his
problem. Incorporation of fruits, more vitamins and vegetables is the crucial part of food diet to live the standard life. Since he had the
abnormal sleeping pattern, getting enough sleep and fixed sleeping time would help him to enhance the quality of life (Anderson et al.
2015). Engaging himself with motivational therapies, motivational speech about leading life would help him to overcoming the phase of
negative experiences (Pennant et al. 2015). Taking responsibility for his own, encouraging him to live a quality life would help him to
ease the negative thoughts. Three months of communication therapy along with other change of habits would help him to manage
depression completely.

Mental State Examination
Appearance:
The patient was a middle aged Caucasian male. He is suffering from severe depression. While talking to the emotional advisor the patient
appeared to be quite disturbed and depressed. He did not want to express much about himself unless asked about. He was constantly
fidgeting which showed that he was not entirely comfortable with the conversation. It was seen that he kept on twitching his mouth to the
right side of his face every time he started to talk. He seldom looked up to the doctor and answered his questions, throughout the
conversation (Brownlie et al., 2014). He was wearing very simple clothes, such as a grey t-shirt, track-pants and had a watch on his left
hand. He did not have any distinguishing marks or tattoos that were visibly exposed.
Behaviour:
All through the conversation, the patient stayed in the same posture. He sat on a chair with his head bowed down. He rarely put his head
up and looked to the doctor while answering his queries. It appeared that the patient had an issue with his hands and that he had a
shuffling gait problem, even though he was sitting the entire time. From the way he was speaking it was evident that he had apraxia of
speech which is motor disability that makes the individual unable to converse in a usual manner. The patient was following the question
word-by-word to answer them and he was clearly having difficulty connecting the questions to his own experiences and was taking a bit
more time to answer them. His facial expression showed that he was in pain and deeply troubled. He did not laugh or spoke in a friendly
manner, he was completely indifferent even though the doctor was trying to make him comfortable all the while. While talking about his
family or even his own issues he seemed to be quite embarrassed (Brink, 2014). He was constantly placing his hand on his head while
talking and kept on fidgeting with his fingers the entire time. He was grimacing occasionally. Even though he did not show any signs of
tremors, his appearance seemed to be quite disorganised.
Conversation/Communication/Speech:
While talking to the RN the patient seemed to be extremely hesitant. He had a trouble with his speech. He was stuttering all the time he
was asked a question. It seemed that the patient had an issue of echolalia which is a psychiatric disorder where the individual repeats the
words of others while speaking. Every time the RN asked him a question, the patient followed and repeated his words to answer him
(Rayner et al., 2014). The conversation was almost forced. Since the patient did not talk unless he was asked a question. It was the RN
who kept the conversation ongoing and maintained the flow. The client expressed that he was lacking concentration and motivation at
work. The patient admitted that he was having negative thoughts and even developed suicidal tendency recently. Although it did not
seem that he was having any kind of thought blockage, but then it could not be clearly distinguished since he was so hesitant to talk
about all the things that were troubling him.
Affect/Mood:
While assessing his mental state from the entire conversation it was found that the patient was very depressed and lost all motivations in
life. He did not seem to care much about anything in his life anymore and nothing seemed to influence him at work either (Paniagua &
Yamada, 2013). He felt agitated the whole time. The patient even became abusive to people while he drives to supermarket and this has
worsened in last 3 months. People have been reacting to his behaviour as well, although no one has physically hurt him till then. It was
indicated that he was having dissociation and suicidal thoughts as he said that he felt like “not worth living sometimes”. He had issues
with drinking. Occasionally he got drunk, although he confessed that his drinking issue did not affect his work and he was not concerned
about it.
Perceptions:
The patient has got the perception that the medications for depression does not work for him. Therefore in spite of the fact that the doctor
had prescribed medications for his condition, he did not take such medications.
The patient did not have any hallucinations or any such visual disturbances. The patient also did not undergo any unusual experiences.
However most of the time the patient remains distracted. There is often lack of concentration. Even while watching television, he just
flickers through the channels and does not pay much attention to the content of the show that is going on.
Cognition (Including thoughts, memory and orientation):
Due to the prevalence of depression, the patient was occasionally having negative thoughts. He also feels a sense of worthlessness.
However this not does not occur regularly but only on some occasions when he level of stress is more. There are some blocking ideas
presented by the patient.
The patient was recalling the incident when his wife left him due to certain problems that had developed between them. This is memory
is hurtful for him. He also has no contact with his daughters although he recalls their memory.
The orientation of the patient is normal. He is aware of where he is present currently. He can also recall the hospital where he was taken
to for his check-up. He is also aware of the orientation of himself and also of others (Cumming et al. 2013).
Insight & Judgement:
The patient fails to realise the significance of his symptoms and his current situation. This is mostly because no one around him points
this out to him. At work no one notices the differences in his behaviour. While he gets drunk occasionally, about twice a week, Mr.
Johannes is not concerned about it. He feels it is quite alright getting drunk after work, as it is not affecting his work and he has got no

complaints regarding such matter form his boss.
Therefore there is lack of proper judgement of his present condition. However he does go to work properly and is able to manage his own
finances. He does lack motivation to work like before, but continues to work on the activities that are required on a daily basis.
Rapport:
The therapeutic relationship that has been established is not yet a very strong one. The patient lacks the openness while communication
with the counsellor. He is also hesitant about sharing his intimate details. He is not able to make direct eye contact while communication
which proves that the therapeutic relationship is not strongly established (Cameron et al. 2013).
Risk Issues (if identified):
The risk issues that were identified included his negative thoughts which at one point might and up into suicidal thoughts since the
patient was suffering from episodes of major depression (Arevalo‐Rodriguez et al. 2015). The patent also had thoughts of worthlessness,
lacking any motivation in life. The patient Mr. Johannes has been agitated and abusive towards the other people while driving or while
sopping in the supermarket. Therefore this increases the risk of getting hurt or being hurt by other people. However now up till now there
have not been such incidences.

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