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CONCEPT MAP - UNDERTAKING A MENTAL STATE EXAMINATION WITH A PATIENT IN THE…
CONCEPT MAP - UNDERTAKING A MENTAL STATE EXAMINATION WITH A PATIENT IN THE MENTAL HEALTH WARD
The patient is a 58 year-old European male admitted to the Mental Health Ward due to suicidal ideation and behaviours of concern
Has a long history of mental health issues
The patient is under the Mental Health Act section 29.3 - Compulsory Community order
Was a patient at Lake Alice
Suffered trauma in childhood and adolesence
Has a diagnosis of paranoia schizophrenia
Relapse indicators present delusional content, suicidal thoughts, aggression, grandiose thoughts and paranoia
Tried to overdose on his medications
Has a key worker and medication support while at home
Poor family support
Has arthritis and asthma
Damaged his rental property, smashed windows and the inside of the house
Poor sleep hygiene
Has auditory hallucinations which keep him awake
Experiences delusions
Is a heavy smoker
Has a history of violence
History of aggression towards staff over the years
Nil current aggression
Introductions, gain consent to undertake vital signs, provide privacy, cultural considerations
Blood pressure 12/76, Respiratory rate 18, SP02 98%, Temp 36.1, Heart rate 68, EWS=0
Reported bowels not open for two days
Encouraged to increase fluids
Lactulose offered as this is prescribed for him as PRN
Encouraged to increase his fibre (fruit and veges)
Reported pain in ankle 3/10 while mobilising
The preceptor is informed. Analgesia is offered.
Encouraged to inform staff when pain relief is required
Develop rapport by initiating a conversation to make a connection with the patient
Interact in a calm and friendly manner
Actively listen to the patient and paraphrase to show understanding of their feelings
Be empathetic and acknowledge how the person is feeling
Use open and closed questions to gain information
Ask specific questions about the person's thoughts, feelings and perceptual experiences
Non-judgemental attitude
Appearance is dishevelled
Maintained a quiet profile and utilises 30 unescorted leave
Minimal eye contact
Reported having auditory hallucinations but were manageable
Nil delusional content voiced
Nil reports of suicidal ideation
Clothes appear worn out and slightly unclean
Low to euthymic mood, affect congruent
Speech was normal tone and volume
Poor personal hygiene
Review patient's medical files, progress notes and handover
Maintain confidentiality of patient information only discussing with staff in direct care with the patient
Minimal engagement with co-clients
Makes his needs known to staff
Cooperative and polite during interaction
The student worked within her scope of practice
Encouraged patient to clean his room, assistance given
The patient vacuumed his room and assisted to use the washing machine
Provide empowerment and encourage self-determination