Mental Health Assessment Case Study Using Clinical Reasoning Cycle

This paper intends to provide a reflection upon a case study of ‘Alison’, who is a 38-year-old single mother of two. It uses the clinical reasoning cycle as a framework to explicitly discuss the situation and learnings from the mental health assessment (MSE) of Alison by utilizing the clinical reasoning cycle (CRC) and referencing to the components of MSE upon watching the video. Levett-Jones (2018) describes CRC is as a process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and learn from the process. It can be used to assist us to learn about critical thinking and decision-making. Alison works in a local supermarket. She went to see her general partitioner due to low mood and was currently diagnose of Clinical Depression. In consideration of her current situation financially, it causes her low mood and anxiety to occur again after being divorced with her husband. Financial stress has an enormous impact especially on a single parent which contributed to being a significant stressor of Alison. On the other hand, there are some protective factors that can alleviate the situation Alison such as having loving children and supportive sister as well as good friends.

In mental health, there are various components and factors that influence mental illnesses. According to Stallman & Wilson (2019), biopsychosocial approach plays an important role in examining the cause of these mental illnesses to enable clinicians to evaluate the corresponding intervention to have a positive outcome. MSE is one of the assessment tools that can be used to identify the patient’s current mental state. In Alison’s case, this was undertaken by her general partitioner. Alison presented to be neat and tidy in her pink blouse. During her interview, Alison is very depressed and tearful, poorly eye-contact and sitting at a slumped posture with fidgeting her hands at times. Her speech was soft, slow and mumbling at times. Thought form was relevant and logical. But she displayed a depressed, restricted and congruent affect. No perceptual hallucination was observed with Alison. There was no delusion and paranoia observed, however, there was self-harm reported. Regarding perception and cognition, Alison was alert and orientated with a good memory. However, she had poor concentration and she also stated that she felt exhausted and not interest in having social activities with her friend. She aware of her illness and seek for mental health professional help. Therefore, her level of insight was good, and her judgment was unimpaired.

By analysing the data gathered after the MSE assessment, Alison was diagnosed with depression. American Psychiatric Association (2013) explains that depression is the presence of sadness and feeling empty that coexist with somatic and cognitive changes that considerably affect one’s capacity to function. Major depressive disorder criterion symptoms of Alison include depressed mood or anhedonia, sleep disturbances, change in appetites or weight, poor concentration, and feelings of worthlessness or guilt. In a review of the risk assessment of Alison, she has a suicidal history record in the past. Hence, it is important to clarify the risk factor of Alison to harm self and prevent her from relapsing into that situation.

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The current financial status and the mental state of Alison has a significant impact on her ability to function as a single mother of two children, who are 11 years old and 9 years old. She feels that she is useless in taking care of her children. Moreover, the relationship between Alison and her boyfriend is complicated. Dave is upset with Alison that he does not want to communicate with her.

For Alison, her nursing care plan is to let her ability to cope with her life and her stress. In order to establish a treatment plan, Evans, Nizette & O’ Brien (2017) explain that the health-promoting behaviours could contribute to the good relationship by building effective communication. The health professionals should assist patients in identifying their goals and aims for the future. According to The Department of Health (2013), recovery-oriented approach is a way to support patients to recognise and embrace the possibilities for recovery and wellbeing created by the inherent strength and capacity of their mental health issues, to maximise self-determination and self-management of their own mental health and wellbeing, and assist their families to understand the challenges and opportunities arising from their family member’s experiences.

When an individual under treatment presents with symptoms of depression, with compounding financial and personal issues, as a nurse, I would consider building a therapeutic relationship and goals for my patient. For example, active listening can establish a rapport and trust to Alison to allow us to achieve some goals together. Moreover, motivational interviewing can assist Alison in constructing back her self-esteem will enable her to contribute to her distress and resolve her emotional difficulties (Evans et al., 2017). Furthermore, collaborating with multidisciplinary teams such as social worker and the mental health professional might help to meet patients’ needs more effectively (Evans et al., 2017). Multidisciplinary teams convey many benefits to both the patients and the health professionals working on the team. These include improved health outcomes and enhanced satisfaction for patients, and the more efficient use of resources and enhanced job satisfaction for team members.

In order to evaluate clinical outcomes, I might need to discuss at a later date with the individual the mutual set goals. Other means of evaluation could be the complaint on her depression and prescribed medications and the relationship between Alison with her children and her boyfriend.

Through the case study and assessment of Alison, I have learned that MSE can provide information and psychiatric history about the client’s mental state, which includes educational, cultural and social factors. It also involves establishing a therapeutic relationship and using that relationship to collect a range of information about the client and to formulate a collaborative plan of care. Moreover, I realised that depression is a serious condition that affects your physical and mental health. It might impact the performance at work and the levels of concentration; hence it could negatively affect productivity. As a student nurse, I believe that in my future practice, the mental health assessment will enhance me to understand the client’s mental status. It also assists me to deliver high quality of care to my client.

This paper embedded steps of the CRC (Levett-Jones, 2018) for the purposes of reflecting upon the scope, nature and rationale for assessment of Alison in this case study.

References

• American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5. Washington, DC: APA
• Evans, K., Nizette, D. & O’Brien, A. (2017). Psychiatric and Mental Health Nursing. (4th ed.). China: Elsevier.
• Levett-Jones, T. (Ed.) (2018) Clinical Reasoning: Learning to think like a nurse. (2nd ed.) Frenchs Forest, N.S.W.: Pearson.
• Stallman, H., & Wilson, C. (2019). Attending to the biopsychosocial approach in Australia’s mental health agenda. Australian & New Zealand Journal of Psychiatry,53(2), 173. doi:10.1177/0004867418783569