Nursing Process - MSE Form and Risk Screening - History Related to Leroy - Mental Health Nursing - Health Assessment Answer

Assessment Task:

Nursing Process Mental Health Nursing  Assessment Answer

Rationale:
A nursing process is a tool that ensures nurses critically think and document the assessment, diagnosis, planning, implementation, and evaluation of competent care provided to a person under the registered nurses care (Lemone et al., 2014, p.7). Nursing assessments performed in the mental health setting include the mental status examination as well as several risk assessments, which may be client-centred or health service centred (Edward et al. 2014, p.341). It is essential that the nurse includes a lifestyle assessment and an assessment of the client’s physical health. Some lifestyle choices, such as substance use or inadequate dietary intake, can produce a disease that may manifest as disorders of mental status. This origin of the disease needs to be exposed through questioning so that other causes and influencing factors of mental health can be investigated and eliminated.

Learning outcomes:
It is expected that a student will develop an ability to observe client 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. Students 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 students will be able to identify symptoms about the client and consequently be able to develop mental health nursing-specific interventions to assist the client. 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
the gathering and completion of this assessment.

Instructions:
Please include the following client details on the appropriate documentation.
URN: 8675309
Leroy James Smith
11 Salisbury Lane, Ipswich, QLD, 4306
DOB: 25th December 1983
1. Access the MSE form and risk screening tool from the study desk. “MSE Form & Risk Screening Tool.” The MSE is a word document, and students will be able to type directly into the formatting document provided (this must be submitted as a word document). The risk screening tool requires printing, completed by hand and then submit as a PDF file with your other assessment requirements. Please ensure that you insert your name and student number on the top of all the forms and word documents.

2. Download and read the history related to Leroy.

3. Watch the video about Leroy that is located on the study desk. Record your observations from the interview/assessment between Leroy and the mental health clinician,
on the MSE form. You can minimise the MSE form while watching the clip and pause the clip while documenting.

4. Once the MSE is completed, identify and record three relevant symptoms that Leroy displayed during the interview and within the background/collateral history, locate two evidenced-based nursing mental health interventions persymptomto assist you in completing the management plan for Leroy.

5. Complete the symptoms and intervention page. There will be three symptoms in total identified and two interventions per symptom (six interventions) and one reference per intervention to a total of six individual references.

6. The symptoms that you identify with your correlated interventions must be found from documented evidence within your MSE report.

7. Support your two interventions per symptom with current evidenced-based nursing literature/journal articles and textbooks references (Six individual references required do not repeat the same reference) – Use a minimum of four up to six current scholarly journals references or a maximum of two textbooks and four scholarly journals within the past five years. No links, Blogs or websites will be accepted.

8. 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.

9. Students may record findings in dot point or paragraph form. However, you must support and specify the evidence that substantiates your observation, e.g., paranoia – Leroy 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.

10. Separate from the MSE requirement, a risk screening tool is to be completed from the information obtained on Leroy. The risk screening tool is available via the study desk and must be used to complete this requirement. Print both sides of the form. This form must be handwritten onto. However, writing must be legible for marking. No other assessment form will be accepted. Upload as a PDF document with your MSE, mental health nursing interventions and nursing report.

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