NURS1087 Comprehensive Assessment Task: Assessment Section Checklist No. Consumer Assessment checklist Included Not Included Demographic Data: · Name of Mental Health Nurse Assessing Consumer · Date...

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Hello this is a mental health nursing assignment. There are two parts to this one part is A mental health examination about a patient I have attached. And the other is a reflection about interviewing this patient. Please use intext citation APA for both parts.


NURS1087 Comprehensive Assessment Task: Assessment Section Checklist No. Consumer Assessment checklist Included Not Included Demographic Data: · Name of Mental Health Nurse Assessing Consumer · Date of Assessment · Consumers full name (pseudonym) · Consumers date of Birth (pseudonym) · Consumers gender (pseudonym) · Martial status · Consumers Address (pseudonym) · Consumers telephone number(s) · UR Number · Next of Kin / Contact person · Name address and contact phone numbers · Name of Referral Source · Name of any other worker or agencies involved Presenting Complaint: · Why has the Consumer presented at this time? · What are the Consumers’ main concerns? · Are there any identifiable precipitating factors? Past Psychiatric Treatment: · Admission · Year and type (voluntary Involuntary) · Diagnosis (if known) · Treatment employed (ie. ECT, Medication, Therapy, etc). · Treating agencies (ie. Community Assessment Teams, Hospitals, Clinics, Private Psychiatric) Current Psychiatric Treatment: · Psychoactive medication · Therapies · Rehabilitation Recovery Model Factors: · Strengths, abilities, capacity, resources? · Key relationships, community engagement. Accommodation: · Type · Length of Stay · Problem associated with? No. Consumers Assessment checklist Included Not Included Financial Arrangements: · Source of Income · Debts · Any Administration Orders? History As Reported By Others: · Name of source · Relationship to Consumer Family History: · GENOGRAM · Other family members psychiatric history · Dates and causes of death · Relationship descriptions between family members (How does the Consumer and others view the family)? Personal History: EARLY CHILDHOOD DEVELOPMENT · Problems encountered during the pregnancy by mother · Birth (ie. prolonged labour, forceps delivery, caesarean) · Developmental Milestones · Childhood social relations · Significant early life events SCHOOL PROGRESSION · Progress · Levels of achievement v/s perceived level of potential · Problems encountered (ie. truancy, bullying, etc) OCCUPATIONAL HISTORY · First job · Number and type of jobs · Reasons for changing jobs · Unemployment (Length of time and effects on Consumer and family) RELATIONSHIPS / MARTIAL HISTORY · Psychosexual development · Current relationship with partner · Name and ages of children · Feelings towards children No. Consumers Assessment checklist Included Not Included DRUG AND ALCOHOL USE · As reported by self and others FORENSIC HISTORY /LEGAL MATTERS · Does the person have any legal proceedings underway or pending? · Are there any legal restrictions or orders applying to this person? · Does the person have a criminal record? MEDICAL HISTORY PERSONALITY · Self perception · Families perceptions of consumer · Changes CULTURAL / SPIRITUAL ISSUES Mental Status Examination: · GENERAL PRESENTATION · ORIENTATION · THOUGHT · Current · Stream · MOOD & AFFECT · PERCEPTUAL ABNORMALITIES · ATTENTION / CONCENTRATION · MEMORY · INSIGHT · JUDGEMENT · NEUROLOGICAL EXAMINATION Risk Assessment: · Summary /overview of the consumers major risk issues Summary: · Summary /overview of the consumer identifying major issues Formulation: (Diagnostic) · According to DSM-5 Problem Definition: · Statement of problems to be addressed in management plan Reflective Journal: Mandatory · A descriptive exploration of your experience of conducting the assessment. Mandatory Appendix: · Use of additional assessment tools to support diagnosis Appendix: · Assessment Analysis in Mental Health Service Delivery1 Assessment Task Number Two: A Comprehensive Consumer Assessment Assessment Task Two Example Format (Word Document): Psychiatric Nurse Assessing: Date: Consumer Name (in full): Date of Birth: Sex: Male Female Address: Telephone Home: Telephone Work: UR Number _ _ _ _ _ _ Next of Kin Contact Person: Name: Relationship to the Consumer: Address: Contact Telephone Number Home: Contact Telephone Number Work: REFERRAL SOURCE: OTHER WORKERS / AGENCIES INVOLVED Assessment Task Two Example Format (Cont…) PRESENTING ISSUE: PAST PSYCHIATRIC TREATMENT: CURRENT PSYCHIATRIC TREATMENT: ACCOMMODATION: FINANCIAL ARRANGEMENTS: HISTORY AS REPORTED BY OTHERS: FAMILY HISTORY: GENOGRAM RECOVERY ENGAGEMENT / RESOURCES / RELATIONSHIPS: Assessment Task Two Example Format (Cont…) PERSONAL HISTORY: EARLY CHILDHOOD DEVELOPMENT SCHOOL PROGRESSION: OCCUPATIONAL HISTORY: RELATIONSHIP / MARTIAL HISTORY: DRUG AND ALCOHOL USE: FORENSIC HISTORY / LEGAL MATTERS: MEDICAL HISTORY: PERSONALITY: Assessment Task Two Example Format (Cont…) CULTURAL BACKGROUND: SPIRITUAL CONSIDERATIONS: GENERAL PRESENTATION: ORIENTATION: THOUGHT Content: Stream: MOOD & AFFECT: PERCEPTUAL ABNORMALITIES: ATTENTION / CONCENTRATION: Assessment Task Two Example Format (Cont…) MEMORY: INSIGHT: JUDGEMENT: RISK ASSESSMENT: SUMMARY: FORMULATION (Diagnostic): PROBLEM DEFINITION & INITIAL MANAGEMENT PLAN Assessment Analysis in Mental Health Service Delivery13 Microsoft Word - NURS1087 2020 Assessment 2 Comprehensive Consumer Assessment V2 20-07-20 Assessment Analysis in Mental Health Service Delivery 1 Assessment Task Number Two: A Comprehensive Consumer Assessment DUE: Due at the end of week 12 (Sunday 18th October, 2020) by 23:59. Title: 2500 Word Consumer Assessment 50 % Assessment Task Number Two: 50% You are required to complete the following Comprehensive Consumer Assessment Task. This assessment task needs to be submitted by the end of Week 12 [October 18th]; submission deadline is 23:59 AEST (Australian Eastern Standard Time). Please post any questions you have about the assignment in general on the relevant course Discussion Board. If you have any questions specific to your personal situation and the assignment please email the course coordinator as required. The Assignment should include a brief introduction that will provide an outline of the assignment to follow. Any additional information deemed relevant by the author should be included as an Appendix. The assignment should be submitted through Turnitin available via the course webpage from the beginning of Week 10 of semester 2 onwards. Please post any questions you have about the assignment in general on the Assessment Task 2 Discussion Board. If you have any questions specific to your personal situation and the assignment please email the course coordinator as required. Instructions on the Consumer Assessment Task: You are required to complete the following consumer assessment task. 1. For the consumer assessment you are required to choose a consumer from within your practice in the field of mental health nursing for your assessment. 2. You should seek to choose a consumer with whom you will be able to do more than one interview (or will have regular contact). 3. You are required to choose a consumer with whom you would already have had regular contact in the course of undertaking your work as a mental health nurse, and base your assessment upon any interactions that you would normally have had with that consumer. 4. You are required to maintain the consumer’s confidentiality and anonymity at all times (I’d suggest you create a pseudonym for this). Assessment Analysis in Mental Health Service Delivery 2 5. You are required to complete the consumer assessment by utilising:  Consumer Interviews  Case Notes  Other appropriate information sources Please note, that information sourced must be noted / referenced within your consumer assessment. 6. You will also be required to incorporate into your assignment any appropriate consumer assessment tools such as the Suicide Rating Scale and HoNOS that you have used. These tool(s) should be attached as an Appendix. 7. You are also required to undertake and journal your reflections on the process of completing the assessment as you go along. You will then include this as the final (separate) section of the assignment as a personal reflection. This section is expected to be approximately 500 words in size. 8. A Checklist and Example Format is included below for your use though you can utilise a different structure for your assignment if would like to do so. A Marking Guide is also included. If you decide to use a different structure for your assignment please make sure that you have met all the requirements of the marking guide. 9. As with the first Assessment Task you must support your writing with appropriate intext references from the literature to support your work. Areas that will lend themselves well to support from the literature include: 1. Key clinical concepts and ideas. 2. Specific Assessment skills utilised/ applied. 3. Theoretical constructs or models utilised. 4. Symptoms and diagnoses. 5. Specific Communication strategies / observations used / applied. 6. Specific Reflective techniques utilised in undertaking the Assessment. 7. Any other situations where your writing is based upon prior knowledge / literature. An Alternative Assessment Focus Students that do not have access to mental health consumer are able to undertake this consumer assessment assignment by developing a case study. This can be based upon their [a] previous clinical experience, [b] personal life or [c] a combination of the above. If you wish to use this option please contact the Course Coordinator to discuss the details. Assessment Analysis in Mental Health Service Delivery 3 Assessment Task Two Assessment Section Checklist This is a Guide only to get you started: you should focus on the
Answered Same DayOct 02, 2021NURS1087

Answer To: NURS1087 Comprehensive Assessment Task: Assessment Section Checklist No. Consumer Assessment...

Malvika answered on Oct 17 2021
122 Votes
2
Mental Health Assessment
Assessment Task Two - Assessment Analysis in Mental Health Service Delivery
    Psychiatric Nurse Assessing:
    
    Date:
    
    Consumer Name (in full):
    Craig Hill
    Date of Birth:
    01/Sep/1969
    Sex:
    Male
    Female
    Address:
    Glenlyn Aged Care Facility
34 Finchley Ave
GLENROY VIC 3046
    Telephone Home:
    
    Telephone Work:
    
    UR Number
    _ _ _ _ _ _
    Next of Kin Contact Person:
    
    Name:
    
    Relationship to the Consumer:
    
    Address:
    
    Contact Telephone Number Home:
    
    Contact Telephone Number Work:
    
    REFERRAL SOURCE:
    
From a friend
    OTHER WORKERS / AGENCIES INVOLVED
    PRESENTING ISSUE:
    The current diagnosis for Craig is that he has Schizoaffective disorder. The work by Madre et al. (2016) suggests that the grey matter volume loss is more in schizoaffective disorder than in schizophrenia. Schizoaffective disorder is a mental health illness wherein a combination of symptoms of schizophrenia and mood disorder are visible. The differential diagnosis identified is bipolar affective disorder wherein severe mood swings are observed. Goghari & Harrow (2016) have suggested in their work that the schizoaffective patients have a higher rate of auditory and also visual hallucinations as compared to the bipolar ones. In order to differentiate between patients that have schizoaffective and bipolar disorder it becomes essential to evaluate the initial years of the mental health illness issues.
    PAST PSYCHIATRIC TREATMENT:
    Craig has shown alcohol-related cognitive impairment due to alcohol dependence. He was first diagnosed with BPAD in the year 1994. From 1994 until 2019, Craig has been admitted 11 times for psychiatric treatment. Under the effect of toxication, Craig has behaved loudly and irritably. In the year 2016, he was admitted in the ICU, as he had lithium toxicity. He stayed at Broadmeadows health service for a week in 2019, as complications from alcohol withdrawal surfaced. The initial diagnosis for Craig was schizophrenia and later is was changed to schizoaffective disorder or bipolar affective disorder.
    CURRENT PSYCHIATRIC TREATMENT:
    Craig is diagnosed to be having a possible non-compliance with medicines and alcohol overuse during his stay with the family. A manic relapse is identified, as the financial autonomy has been taken over by the state trustees. He is being given medications for psychosis, mood stabilisers, agitation control medication is given every four hours, medication for hypertension, and also for bilateral dependent pitting oedema.
    LIVING, FINANCIAL AND OCCUPATIONAL STATUS:
    The current facility where Craig resides has individuals from older age group. The facility is also at a greater distance from home and Craig’s family wants him to stay at a facility that is closer.
The financial control is overtaken by state trustees and he has lost any direct access to his finances.
He does not seem to be working anywhere at the moment as he has been on and off to the care facilities.
    FAMILY HISTORY: GENOGRAM
    
    RECOVERY ENGAGEMENT / RESOURCES / RELATIONSHIPS:
    Craig has extremely supportive parents. The engagement in recovery process is based on the support that he is getting from his parents, as he is happy with their involvement.
    PERSONAL HISTORY:
    EARLY CHILDHOOD DEVELOPMENT
    Craig has had a happy childhood with the family that was overprotective. He mentions that he has had a good relationship with his mother. At present he has a constrained relationship with his family. A defined strained relationship with half-brother but a good relationship with sister is also observed.
    SCHOOL PROGRESSION:
    Craig completed year 12 and pursued 3 years of Osteopathy course before he dropped out of it.
    OCCUPATIONAL HISTORY:
    No evidence.
    RELATIONSHIP / MARTIAL HISTORY:
    Craig has supportive parents and they visit him every weekend.
    DRUG AND ALCOHOL USE:
    A history of alcohol-related cognitive impairment has been recorded. The alcohol dependence is attributed to the use of alcohol since the age of 16 wherein he was recorded to have at least 6 standard drinks a day. The behavioural problems associated with alcohol are also present. The discussion presented by Jakubczyk et al. (2018) highlights that the alcohol use disorder is associated with emotional disbalance and turmoil. It is established that since after brain haemorrhage, Craig has avoided drinking. However, recently Craig left the facility without imitation and was found by the police in an intoxicated state.
    FORENSIC HISTORY / LEGAL MATTERS:
    Craig is found to be on administration order of the state trustees and also guardianship orders i.e. OPS apply on him. The outstanding charges are however nil.
    MEDICAL HISTORY:
    Craig has a medical history of hypertension. Additionally, alcohol-related cognitive impairment has been found in the recorded medical issues. He also used to smoke marijuana but does not admit to using any drugs currently.
    PERSONALITY:
    Craig seems to have an engaging personality with several hobbies like reading, drawing, meditation, and also reading poetry. Eastern philosophies and religions interest him making him a well-read individual.
    
CULTURAL BACKGROUND:
    Australian individual with an English-speaking family.
    SPIRITUAL CONSIDERATIONS:
    Shows an inclination towards Buddhism.
    GENERAL PRESENTATION:
    General presentation places Craig at the centre of severe mood swings, which are based on his bipolar disorder. Craig also shows signs of no understanding of his outbursts and their impacts.
    ORIENTATION:
    A formal medication plan is required by Craig to keep him from succumbing to the effects of bipolar disorder. The right dosage of medication and proper attention with...
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