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NUR2200 Mental Health Across the Lifespan

Assessment 2 – Mental State Examination

Mental State Examination  Assessment

Task Description

It is expected that as a student you will develop an ability to observe consumer behaviour and accurately document those observations as findings on the Mental Status Examination (MSE) and risk screening tool in the correct assessment categories using the correct terminology. You will also develop patient-focused documentation skills in reporting the identified MSE and risk assessment findings concisely and accurately within the nursing report. From your findings, it is also expected that you will be able to identify symptoms about the client and consequently be able to develop mental health nursing-specific interventions to assist the client.

NOTE: This is an individual student assessment and not a group assessment. Therefore, students must submit original work. Students are required to adhere to USQ policies in the gathering and completion of this assessment.

Rationale for the Assessment Task

Assessment is one of the most important and fundamental skills of the mental health nurse. Through assessment, the mental health nurse develops an understanding of the consumer, formulates a plan of care and contributes to the decision making of the multidisciplinary teams.  Additionally, undertaking assessments is an important means of connecting with the consumer to commence the process of developing a therapeutic relationship.

Assessments performed in the mental health care setting, which can be consumer or health care centred, is the first step of the nursing process and is ongoing over the time that the consumer is engaged with mental health care(Evans et al., 2017,p. 519).  This process is systematic and organized, to ensure that the mental health nurse critically thinks and documents data, to implement and evaluate the individualized healthcare need of the consumer in their care.

Continuity of patient care is achieved by the clear and concise transfer of patient clinical information from one health care provider to another during handover. Effective communication is a vital factor in providing safe patient care.

Standardised assessment tools used can be formal or semi-formal, and include the mental state examination (MSE) and clinical risk assessment, however, there are numerous other tools incorporated to collect data in the clinical setting.

Length

• There is a 7 page limit to this assessment.
• Two pages for the MSE
• Two page completed Risk Assessment Tool
• Maximum of one page each for the Mental Health Nursing Interventions; Nursing report and Reference list. This will complete a seven -page assessment and must be uploaded in that order.

Weighting: 40%

Aligns to the Course Objectives 3, 4 & 5.

• LO 3- Legal and ethical issues in caring for people with a mental illness. Mental health act legislation.
•  LO 4- Diagnostic related groups and contemporary mental health nursing practices.
•  LO-5 Treatment Modalities and Medication Safety.

Task Detail:

Please include the following consumer details on the appropriate documentation for this assignment.

Download and read the history related to Peter Goldblum.

• Access and download the MSE form and risk screening tool from the study desk. “MSE Form & Risk Screening Tool.” The MSE is a word document, and you are required to type directly into the formatted document provided.
• From the information obtained from Peter and documented on the MSE, a risk assessment is also to be completed using a Risk Screening Tool (separate from the MSE that you will complete). The risk screening tool is available via the study desk. Print both sides of the risk screening tool form and complete the assessment in your own hand writing. As this form must be handwritten, writing must be legible for marking and no other risk assessment form will be accepted.
• Watch the video about Peter that is located on the study desk. Record your observations from the interview/assessment between Peter and the mental health consultant, on the MSE form. Refer to your text and lectures throughout the semester on the study desk for assistance, ensuring that you use the appropriate mental health terminology to communicate your findings.
• You may record findings in dot point or in a short paragraph, however, you must support and specify the evidence that substantiates your observation,
• e.g. paranoia  Peter believed that he was being followed as evidenced by…..
• The MSE report is to be typed as a word document, be succinct and relevant to your findings that were included in the interview content.
• From the findings and documentation in the MSE or Risk Assessment screening for Peter, identify THREE (3) relevant symptoms or issues that Peter displayed during the interview, or is recorded on the Risk Assessment.
• Research TWO (2) evidenced-based nursing mental health interventions per finding / symptom to assist you in completing the management plan for Peter.
• Complete the symptoms / findings and intervention page. There should be THREE (3) symptoms / findings in total identified, and TWO (2) evidenced mental health nursing based interventions per symptom (total of six interventions) and one reference per intervention to a total of six individual references.
• The symptoms / findings that you record on your intervention page, must be from documented evidence within your MSE and or risk assessment report.
• Nursing Report: Together with your findings from the MSE and the risk screening assessment, you are required to write a one-page nursing report ( between 400-500 words) , as if you were documenting your findings into a patient chart, by using the SHARED tool that is commonly the preferred communication tool in QLD mental health.– situation, history, assessment, risk , expectation and documentation.  Refer to the link: https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/communication-clinical-handover/action-67
• This will require you to gather the relevant and pertinent details and combine this into your nursing report. This is not a narration of your findings; this is to be succinct, pertinent and relevant information that would be important and critical to document in a patients chart. As this is report style writing, references are not required for the nursing report as you have gathered the details from your findings.

Writing Style: This assessment piece will be written in the form of a Mental Health Assessment providing links to relevant peer reviewed articles.