NURS 20157 Assignment: Mental Health Nursing Assessment and Formulation

Building and maintaining rapport in investigative interviews.

Impact on perceptions of listener helpfulness, sensitivity, and supportiveness and discloser emotional improvement.

What is the work of recovery oriented practice?

Does enhanced rapport-building alter the dynamics of investigative interviews with suspected victims of intra-familial abuse?

Examine the use of a comprehensive mental state examination within the therapeutic relationship.

Appraise aspects of consumer and nurse safety and determine ways of reducing risk across different mental health settings.

Does enhanced rapport-building alter the dynamics of investigative interviews with suspected victims of intra-familial abuse?

In the field of mental health and psychiatry, mental status examination is an important component of patient interview as it helps to classify and interpret type and severity of mental disorders in patient. Apart from the use of clinical skills to complete the mental status examination, skills related to establishing rapport with client during the assessment and use of appropriate questions enhance the quality of therapeutic relationship. The report provides an overview about a mental status assessment done for a client with mental issues and critically evaluates the approach used to develop rapport with client during the mental status examination and risk assessment. This would help to develop understanding regarding multifaceted elements that influence therapeutic relationship in mental health nursing.

Pre-disposing factors:

Ms. Ketty (hypothetical client) is a 35 year old lady who came to the mental health clinic presenting with symptoms of poor mood, irritation and suicide ideation. The review of patient information revealed Ms. Ketty used to work as bank employee and she left the job two months back. She lives alone in her apartment and her elder sister lives nearby. Her mother died because of cancer two years back and her father died when she was 10 years old. After her mother’s death, she was in depression for five-six months and has to take anti-depressant to cope with her mother’s death. She was in stable mental status after getting job in a bank. However, since two months, her mental state worsened and she left her job too.

Precipitating factors:

The current issue for Ms. Ketty is that her symptoms of poor mood and irritation have continued since the past one month. She restricts herself in one room throughout the day and does not interact with anyone. She also tried to attempt suicide on two occasions. Because of her worsening mental state, her sister has come to be with her and support her. One of the major issue is the development of suicide ideation which was never seen before even while reviewing past history of depression. Hence, to prevent risk of suicide and harm to Ketty in the future, contacting mental health clinic was important.

Perpetuating factors:

Since the death of Ketty’s mother, she has become very isolated. Getting no emotional support and attachment from family members and living alone is one of the perpetuating factors has deteriorated client’s level of mental health and well-being. She is 35 years old and poor relationship experiences in the past is also a reason for her dissatisfaction with life.

Protective factors:

Being employed and economically independent after getting a job was a source of strength for her as her job helped her to positively cope with her mother’s death. However, relationship issues with boyfriends disturbed her so much that her feelings of low mood and irritation affected her job performance. She was finally fired from her job. This event worsened her mental state. Her elder sister is only her source of support and strength now. However, since she is married with two children, her elder sister finds less time to visit Ketty. Her elderly sister is now staying with her because of her two suicide attempts and poor mental condition.

Mental status examination:

Mental status examination for Ms. Ketty was done as part of clinical assessment process to analyse different domains of behavioural issues for client and diagnose type of mental health disorder for Ms. Ketty. The following are the details for mental state examination done for Ms. Ketty:

Appearance and general behaviour: Assessment of appearance and general behaviour was done by observing client and asking self-reflecting questions like ‘Is the client well-dressed or is the clothing appropriate for the occasion?’.  Ms. Ketty was found wearing dull clothes and her hair looked tangled too. Her clothes were tidy, however her nails were very dirty. She was very restless and anxious. NURS 20157 Assignment: Mental Health Nursing Assessment and Formulation

Motor activity:

Speech: Speech pattern of client was assessed by means of observation methods. During the interaction, Ms. Ketty was found to have monotonous speech and low volume of speech.

Mood and affect: Mood and affect was assessed by asking questions like ‘How are you feeling now?’.  Ms. Ketty was found to be irritated, depressed, anxious and hopeless. She faced difficulty in initiating a conversation.

Thought processes: Thought process was inquired by asking general questions like ‘Do you know what is affecting you right now’. The response of patients was irrelevant and she had vague idea about her future life.

Thought content: Thought content was evaluated by inquiring about ideas and beliefs of client related to her current mental problem. For example questions like ‘Why do you detach yourself from social gathering?’ and ‘Do you have any unshared beliefs?’ were used to conduct mental status assessment. No delusion was found, however suicide ideation was present.

Perceptual disturbances: Perceptual disturbances were judged by analysing whether client has experiences any hallucinations and illusions or not. No disturbance related to hallucination was found. However, extreme feelings of detachment from the surrounding people or environment existed.

Sensorium and cognition: This was done by assessment throughout the interview regarding orientation and concentration of client. Ms. Ketty had good abstract reasoning, however her concentration was poor.

Insight: Insight of Ms. Ketty was determined by asking questions that defined client’s awareness and understanding about illness. She was regarding her mental state; however she had poor insight regarding the way to manage her illness.

Judgment: Client’s judgment level was inferred throughout the interview by critically evaluating Ms. Ketty’s understanding about ways to manage his or her behaviour. Judgment level of Ketty is poor and she has negative coping styles to deal with her life issues and stressors.

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Risk assessment:

Risk assessment for patients with depression is important to identify the likelihood of harm to self and others. Major depression is one of the significant risk factor for suicide and risk assessment process provided health care professionals the opportunity to identify at risk individual and intervene at the right to prevent future events of suicide or harm. For the risk assessment of Ms. Ketty, the square risk assessment tool and the brief risk assessment form has been used. The main advantage of using a risk assessment tool is that it helps in checking for known risk factors of suicide, eliciting suicide ideation and also identifying whether patients is at imminent risk of suicide or not (Singhal et al., 2014). In the context of risk assessment for Ms. Ketty, the square risk assessment tool helped to obtain data related to severity of harm to self and others.

As Ms. Ketty was found to suffer from extreme depression, comprehensive risk assessment for the client was important to determine whether her condition can cause harm to her or others. The square risk assessment tool was to conduct risk assessment. The square risk assessment tool identifies risk in mentally ill patient by parameters like risk of harm to, level of problem with functioning, level of support available, history of response to treatment and attitude and engagement to treatment. The outcome for each of the parameters was as follows:

Risk of harm to: Significant level of harm to self was identified based on current thoughts/past impulsive actions and harm to others.

Level of problem with functioning: Serious impairment was found in the area of social and occupational functioning. This can be said because severe impairment affected both her occupational performance and social engagement.

Level of support available: Her level of support available was found to be minimal as only her sister was involved to provide support and Ms. Ketty had no contact with family members.

History of response to treatment: During her past episodes of depression, she received moderate response to treatment. NURS 20157 Assignment: Mental Health Nursing Assessment and Formulation

Attitude and engagement to treatment: Moderate response to treatment found in the past.

From the risk assessment using the square risk assessment tool, moderate risk of harm to self has been identified. This is evident from the fact the fact Ms. Ketty was involved in past suicide attempts. Her recurrent episodes of depression and feelings of hopelessness are also significant markers for suicide risk. Ng, How and Ng (2017) argues that pervasive thoughts of hopelessness and additional psychiatric co-morbidities like substance abuse, poor physical health, social isolation and having stressful life event are also risk factors of suicide. Few of the psychiatric co-morbidities were also found for Ms. Ketty as she expressed stressful life events, social isolation in the past.

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