NUR2200 - Mental Health: Mental State Examination of Harry Report

This report presents a mental state examination (MSE) of an 18-year-old patient named Harry, who was brought to the emergency department following erratic behavior. The assessment covers various aspects, including general appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, judgment, and insight. The report identifies Harry's symptoms, such as hallucinations, anxiety, and depression, and proposes interventions like counseling, medication, and cognitive behavior therapy. A nursing report summarizes the findings, highlighting Harry's memory loss, incongruous speech, and potential risk factors, including thoughts of violence. Risk screening tools are also discussed to assess Harry's overall risk, considering factors like advanced health directives, violence, vulnerability, and parental status. This comprehensive assessment aims to provide a holistic understanding of Harry's mental state and guide appropriate interventions.

Student Name: Student Number:
Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family name:
Given names:
Date of birth:
Sex:
MENTAL STATE EXAMINATION
General
appearance
Through evaluating the whole interview of Harry, it is clear to know the
exact details and detect the parameters of the mental patients like Harry.
As far as the interview is concerned, Harry is suffering from the
hallucination, anxiety, and the depression. It is more complicated for the
clinicians to discuss the problem from different parameters such as the
behavior and the appearance, perception, thought process, cognition,
insight, speech mood and effect. The MSE (the mental status examination )
is the systematic process of the behavior, appearance
The appearance of Harry provides everything off his mind, when Harry is
found in the street as semi-naked. So through the appearance, it is
understood that the patient somehow is suffering from the hallucination
and depression. Through the interview process, it is clear that when the
patient does deliver the answer, he does not maintain the proper eye
contact with the interviewer. During the interview process, he looks shy
when he delivering the answer (Engdahl, 2010).
Behaviour Behaviors: While conducting the interview, it is very important to
look at the patient's behaviors. The behavior is often considered as
the non-verbal communication. The facial expression of Harry
expresses much about his imagined world where he now lives. But
on the other hand, it is interesting to find in Harry that he maintains
the common rapport with his family member. He also gives the
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exact reply on the question during the interview.
Speech
The speech given by Harry was not based on reality. The speech was
irrelevant and absurd. It did not have any practical relevance. As he stated
that he has the superpower to become invisible.
Mood and
Affect Mood: During the interview process, Harry's mood is not rude. He looks
calm and quiet. It is seen in most of the cases that the patients of the mental
look depressed. But it is the exceptional case for Harry that he happily
gives the exact reply on the question of the interviewer. But the reason for
his mental problem is somehow his hallucination and depression.
Affect: While conducting the interview, it is seen that he has the
appropriateness while giving the answer. But when asking some of the
tough questions, he gives the answer in a roundabout way.
Thought process Process: During the interview process, he has given the answer which is
full of irrelevancy. While giving the answer, he ( Harry) halt his speech. It
is seen that he has the memory loss. While conducting the interview, Harry
expresses his thought which is full of circumstantial thinking. His
irrelevant comments display everything about his mental state.
Thought content
Based on the patient's thinking it is understood the exact thought of the
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patients. But during the interview process, his ideas seem too
unreasonable. His thinking of himself is overweight. But there is no
thought of self-killing. During the interview process, it is known from him
that he has the plan of killing his brother in near future (Quigley, 2007).
Perception
He was not able to perceive the situation. His perception was totally based
on a make belief world. He was hallucinating and showing symptoms of
hallucination
Cognition
Harry showed cognitive impairment. His mental state was not right. He
showed signs of memory loss.
Judgment This process of the medical status examination refers to the proper
guidance whether the patient has the ability to solve the daily problem or
not. But in this case, the patient like Harry does not possess this quality.
Through this process, the practitioner can have the way to lead the
treatment.
Insight
Through this process, it becomes easier to detect the possible problem of
the mental health problem. Through this process, it is important to know
the possibilities of the hallucinations and the impulses of the suicide of the
patient. It also gives the best possible solution to the mental health
problem.
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SYMPTOM INTERVENTION
According to the
case study, it is
clear that Harry is
suffering from the
clear problem of
hallucination. He is
hallucinating and
showing a
schizophrenic
tendency. As he is
thinking that he is
invisible. He shows
mainly
hypnopompic
hallucination which
occurs in the
general population
during waking up.
The nursing should
be done properly to
maintain the patient
who is suffering
from hallucination.
Proper counselling- The nurse has to develop a relationship with Harry based
on trust and empathy. Besides that, it is important to win his trust through
proper communication. If it is not done then Harry will not follow or listen to
the instruction of the nurse. The nurse has to comprehend and document the
time when Harry is showing a hallucinating tendency. Proper counseling and
medication should be given by the nurse.
Appropriate routine management and medication: Psychological strategies
suggest the use of antipsychotic drugs according to the need of Harry. The
medical background of Harry should be assessed before using the antipsychotic
drug. Harry daily routine should be properly managed which is one of the
essential parameters of intervention. A healthy routine of proper sleep and good
dietary intake will help Harry get over this situation. The family members
should also be empathetic to the situation (Hunnicutt, 2010).
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During the
conversation, Harry
is not looking
directly at the
interviewer that
shows that Harry is
going through
depression and his
confidence is very
low. From the
background
information, it is
also clear that
Harry has stopped
talking to his
friends recently. It
is clear that he is
suffering from
clinical depression.
The nursing care
and intervention
for the patients
with clinical
depression are as
below.
Cognitive Behaviour therapy: Concealing will help the patient in fighting the
problem. Harry is going through a phase of clinical depression. Regular
counselling and empathetic and supportive behaviour by the nurse will help the
Harry get over this situation. One of the most important interventions is the
cognitive behaviour therapy. The cognitive behaviour of the Harry is analysed
and particular management is done on that to reduce the level of depression.
Interpersonal therapy which is counselling can also be done by the by the nurse
for a cure.
Medication: Intervention through proper medication will inhibit the
depression. Proper serotonin uptake inhibitors like sertraline medicine can be
given along with proper diet by the nurse. Antidepressant drugs can be used to
treat clinical depression of Harry. Drugs like nefazodone can be used but before
this intervention, proper medical background assessment of Harry should be
done.
The case study and
Interview it is clear
that Harry ha
severe level of
anxiety. Proper
nursing care should
be done to treat this
Stress management techniques: Through proper communication and
counseling through empathetic discussion the stress management can be done.
Through medication and proper routine, it can be achieved.
Motivation and medication: Through proper motivation is and medication it
is possible to decrease the anxiety level in harry. It will also help in increasing
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anxiety.
The nursing care
intervention for
anxiety is as below.
the confidence level of Harry.
NURSING REPORT
To solve the whole matter, Harry is needed to take care of the clinicians in this case. Through
the interview, it can be understood that the patient has a various problem due to the anxiety
and depression. To sort out the entire problem, the clinicians need to take the extra attention
to Harry. It is seen in the interview process that Harry loses his memory, and his thinking is
about the outside of this universe. While he is talking with the interviewer, his speech seems
to have incongruousness. Though there is not any proof of self-killing in the interview, he
gave his future plan of killing his brother.
The risk screening tools which should be used in this nursing report are as below.
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Risk screening tool
The risk screening tool plays a pivotal role in the assessment of the overall risk that is
possessed by Harry. The risk screening tool comprises of the different parameter those areas
below.
Advanced health directive: Here the main condition of Harry will be assessed, if he has
grown any suicidal tendency in the recent time. The stressful events will be noted in this tool.
According to the case study, Harry is hallucinating and thinking his brother as his own
enemy.
The violence of aggressive factors: These factors should be assessed properly because it
plays a very important factor. In the case of Harry, he is showing a sign of violence and he
has a thought of murdering his own brother. This is one of the huge risks which are assessed
by communicating with the patient. The entire background of Harry is also assessed to
analyze any factors which will explain these events of violence (Miller, 2011).
Vulnerability assessment: This is one of the essential assessments done to find out any
events of trauma that occurred in the in the Past. Harry hallucinating tendency might be any
reason of traumatically events from the past.
Absconding factors are assessed- It is noted that if the patient has any absconding events or
not.
Parental Status and responsibility- During the assessment the status of the parents are
also considered because it has a huge effect on the victims. In the case of Harry, it is
important to know the family background to do the final holistic assessment in a proper way.
The holistic risk assessment should be performed in Harry for the mitigation of the possible
risk that will develop from the symptoms like a hallucination, rage, and depression shown by
Harry.
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References
Engdahl, S. (2010). Mental health. Farmington Hills, MI: Greenhaven Press/Gale Cengage
Learning.
Hunnicutt, S. (2010). Universal health care. Detroit: Greenhaven Press.
Miller, D. (2011). Health care. Detroit, Mich.: Lucent Books.
Quigley, A. (2007). Mental health.Detroit: Greenhaven Press.
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