Child and Youth Mental Health Services
60960762000
Child and Youth Mental Health Services
CONSUMER ASSESSMENT
Date: 13/07/2020 Time: 1200 URN: USQ 112233
Family Name:SmithGiven Name(s):Kate Ebony
Address: 321 Jones Road,
Date of Birth: 12/07/2006
Mental state examination
General appearance
Kate is a 14-year-old Caucasian female appearing younger than her stated age.
She is wearing a winter tracksuit with an additional coat. Her stature is short, and build is extremely thin, with an overall cachexic appearance. Her current weight is 40kg and height at 164cm = BMI of 14.9. Hair is blond, shoulder length lacks lustre and thinning. Complexion is pale, skin is dry, with evidence of lanugo.
Behaviour
Kate is not engaging in conversation and rapport if difficult to establish. Minimal eye contact. She is resitive to being assessed as she is declining the need for an admission. She is at times displaying verbal aggression towards the assessor and her parents due to her not wanting to be admitted.
Speech
Her speech was slow, with a soft volume for the majority of the time, however periods of raised volume when distressed about being admitted. She was articulate, but content limited.
Mood and
Affect
Voiced having a low mood for the past few months especially when at home but can feel happier when at school with her friends.
Affect anxious. Mood and affect congruent.
Thought process
No formal thought disorder evident. Logical flow of thought.
Thought content
Belief that she is overweight with too much fat on her stomach and thighs and has a lower self-esteem with her belief that she perceives herself to be fat.
Perceives that by being hospitalised she will not be able to lose more weight to achieve her goal weight of 38kg.
Denied any past thoughts of self-harm, suicide or homicidal ideation, but indicated that if she was to be forced fed that she would most likely self-harm as she does not want to gain weight.
Perception
Disturbed body image. Nil evidence of other perceptual disturbance.
Cognition
Orientated to time place and person.
Recent and remote memory appears intact.
Concentration decline.
IQ is average to above average obtaining A grades at school.
Insight
Impaired insight - Kate does not acknowledge that her current physical condition is life threatening and requires the need for hospitalisation.
Judgment
Impaired Judgement - Restricting her oral intake to achieve a weight of 38kg which is impacting her physical and mental state.
SYMPTOM INTERVENTIONS
Impaired nutritional intake
A behavioural modification approach in collaboration with Kate to encourage an amount of food to be eaten each day to result in a desired weekly weight gain of 500gms. Positive reinforcement will be set if weight is gained and negative reinforcements if not achieved (Kieling et al., 2015).
Provide supportive meal supervision with constant observations, designed to achieve nutritional rehabilitation, normalising eating to ensure a reduction in compensatory behaviours (Evans, Elder & Nizette, 2015).
Disturbed body image
Kates disturbed body image will incorporate the staff to discuss with her aspects of her physical appearance around which she feels positive. This will assist to her separate physical appearance from personal worth (Townsend & Morgan, 2017).
Acknowledge Kates anxiety and fear of weight gain, be non-judgemental and reassure that her fears are expected and not unique (Sadock et al., 2015).
Physical compromise due to greater than 10% of ideal body weight Monitor daily fluid and oral intake and output, an ECG, Blood Sugar Level, and undertake physical observations 4/24 whilst medically compromised as this provide accurate records that can be acted upon if there are changes (OKane & Henderson, 2017).
Monitor and record any evidence of oedema, increased respirations, and pulse, rapid weight gain or abdominal distention after re-feeding commencing as this could be significant of re-feeding syndrome. Notify medical officer immediately. (Scott-ricahrds et al., 2017).
Mental Health Alcohol and Other Drugs Services
Risk Screen
Facility: Child and Youth Mental Health Services URN: USQ 112233
Family Name: Smith
Given Name(s): Kate Ebony
Address: 321 Jones Road,
Date of Birth: 12/07/2006
Sex: M F Other
Instruction: this Risk Screening Tool must include consideration of collateral information
Treatment status Mental Health Act (MHA) 2016 status:
None Person AWA (interstate) Recommendation for assessment
Forensic order (mental health) Classified (involuntary) Treatment authority Treatment support order Examination/judicial order Classified (voluntary)
Transfer recommendation Forensic order (disability)
Examination authority Forensic order (criminal code)
Conditions of MHA order:
Other status:
Substitute Decision-Maker Details
Substitute decision-maker: Yes No
Advance Health Directive Enduring Power of Attorney Guardian Administrator Y = yes N = no UK = unknown
Suicide
Static factors Y N UK
Previous attempt:
Previous self-harm:
Exposure to suicide
Stressful life events (mental disorder,
physical illness/pain, unemployment,
history of trauma, homelessness) Dynamic factors Y N UK
Suicidal thoughts:
Plan: (consider detail of plan and
access to means)
Loss of hope:
Lack of social support:
Future factors Y N UK
Foreseeable stress/destabilising situations:
Comments
Currently expressing suicidal ideation. No plan reported. Unknown access to means.
Pending admission to acute mental health unit for medical stabilisation of weight loss likely to increase risk above baseline.
Mental Health Alcohol and Other Drugs Services
Risk Screen
Facility: Child and Youth Mental Health Services URN: USQ 112233
Family Name: Smith
Given Name(s): Kate Ebony
Address: 321 Jones Road,
Date of Birth: 12/07/2006
Sex: M F Other
Instruction: this Risk Screening Tool must include consideration of collateral information
Violence/aggression
Static factors - history of: Y N UK
Violent/aggressive behaviour:
Sexually inappropriate behaviour:
Criminal charges:
Problematic substance use:
Personality disorder/s:
Problematic treatment adherence:
Violent ideation:
Pro-violence attitudes:
Symptoms of psychosis:
Domestic/family violence:
Other mental disorder/s:
Other problematic behaviour:
(e.g. fire setting, stalking, threats) Dynamic factors Y N UK
Anger:
Impulsivity:
Problematic substance use:
Problematic treatment adherence:
Violent ideation:
Pro-violence attitudes:
Symptoms of psychosis:
Carries weapon/access to firearm*:
Exhibits bullying behaviour:
*Consider the need to notify the Weapons Licensing Branch
Future factors Y N UK
Foreseeable stress/destabilising situations:
Comments:
Kate presents with no history of aggression or violence. However, pending admission to acute mental health unit for medical stabilisation of weight loss may minimally increase risk above baseline.
Vulnerability
Static factors (history of) Y N UK
Trauma/abuse:
Domestic/family violence:
Financial vulnerability:
Cognitive impairment/disability:
Lack of family support:
Blood borne virus: Dynamic factors Y N UK
Impaired decision making:
Sexually disinhibited:
Self neglect:
At risk of victimisation (incl. sexual):
Impaired interpersonal boundaries:
Pregnant:
Recently incarcerated:
Future factors Y N UK
Foreseeable stress/destabilising situations:
Mental Health Alcohol and Other Drugs Services
Risk Screen
Facility: Child and Youth Mental Health Services URN: USQ 112233
Family Name: Smith
Given Name(s): Kate Ebony
Address: 321 Jones Road,
Date of Birth: 12/07/2006
Sex: M F Other
Instruction: this Risk Screening Tool must include consideration of collateral information
Comments: At risk of vulnerability due to ongoing eating disorder related cognitions. Risk of permanent damage as a result of ongoing low body weight.
Treatment non-adherence
Static factors (history of) Y N UK
Absconding:
Previous breach of MHA orders:
Medication non-compliance: Dynamic factors Y N UK
Treatment refusal:
Desire/intent to leave hospital:
Missed medication:
Future factors Y N UK
Foreseeable stress/destabilising situations:
Comment: Due to lack of insight and impaired decision making, Kate is not in agreement with need for admission.
Parental status and/or other carer responsibilities
Y N
Does the person have responsibility for children aged 17 years or less?
Does the person have any contact with children through access visits or shared residence?
Does the person have other carer responsibilities?
Is there a reasonable suspicion or risk of harm/neglect? *
*If yes, contact Child Protection Liaison Officer to discuss Child Protection notification processes d support persons
Mental Health Alcohol and Other Drugs Services
Risk Screen
Facility: Child and Youth Mental Health Services URN: USQ 112233
Family Name: Smith
Given Name(s): Kate Ebony
Address: 321 Jones Road,
Date of Birth: 12/07/2006
Sex: M F Other
Instruction: this Risk Screening Tool must include consideration of collateral information
Details of children and/or other dependents
Full name Relationship Age/date of birth Immediate care arrangements
Protective factors
Protective factors include supportive family.Engaged with primary health care- GPCommunity engagement and support- schoolPersonal protective factors include resilience, strong drive and commitment eg study- academic achievements.
Overall assessment of risk and plans to mitigate risk, including information provided to consumer
and support persons
Risk of suicide/self-harm is moderately elevated above her usual baseline risk due to acute stressors. Currently voicing suicidal ideation. Mitigated by admission to mental health unit with constant observations.
Kates current risk for aggression and violence is low in accordance with her baseline risk level, although may be acutely elevated during acute stressors eg meal times. This is mitigated by providing supportivemeal supervision and active anxiety management/relaxation/distraction post meals.
Kate is at risk of vulnerability due to her impaired decision making and minimal insight. Ongoing treatmentand support of primary health care provider and case management on discharge.Kate is currently at risk of absconding and treatment refusal due to her impaired decision making and minimal insight mitigated by constant observations and engagement in supportive supervision.
Overview/impression Y N UK
Persons level of risk appears to be highly changeable:
There are factors that contribute to uncertainty regarding risk screen:
A more comprehensive risk assessment is required:
Name:. M. Smith Designation CN.
Signature:...M.SmithDate:.22/7/23
Nursing report (documentation entry)
Kate Jones, aged 14, was admitted to the adolescent mental health unit at 1300 after being presented to the emergency department with a letter from her GP requesting admission due to being medically compromised, with ECG changes, pathology abnormalities including being anaemic, and BP and pulse irregularities. She has been placed under the MHA. Kate was diagnosed with anorexia nervosa 12 months ago by her GP and has been supported with community services including a private dietician and psychologist. Over the past 2 months, Kate has reduced her oral intake and increased her physical activity against the advice of her treating team. Her GP had commenced Fluoxetine and recently increased to 40mg without efficacy. Additionally, she is on a multivitamin and folic acid. Collateral from mother is that Kate has been amenorrheic for the past 6 months after reaching menarche at the age of 12. Sleep pattern has been disturbed with initial and middle insomnia.
Kate lives with her mother in a single parent family and is the eldest of 4 children. Her father lives in Brisbane and has infrequent contact as he has remarried and has a new baby. She is in grade 9 at a local high school and obtains A average grade in her studies. Her mother denies that there has been any trauma history. Pathology from the GP indicated that she was anaemic; low blood sugar and albumin levels, and mild hyponatremia and hypokalaemia. Initially difficult to engage with the admission process, she voiced her fear of being fattened up resulting in voicing suicidal ideation if she were to put weight on. Kate perceived that her stomach and thighs have too much fat on them, which results in lower self-esteem.
Her physical appearance is in keeping with an anorexia nervosa diagnosis with cathexic appearance, low body weight at 40kg with a BMI of 14.9. Evidence of lanugo on her face and her hair is brittle. She is wearing oversized and warm clothing as she cited, she is feeling cold all the time, and her current temperature is 35.4.Her judgement with restricting her oral intake and excessive exercising is impaired also correlates with her lack of insight into her current physical condition and need for hospitalisation.
Although she appears tired with some evidence of decline in her concentration, she is orientated with recall of recent and remote memory.
Although she stated she was happy at school, other times she feels very low in her mood and more so now as she perceives that by being forced to be hospitalised, she will not be able to lose more weight to achieve her goal weight of 38kg and has voiced suicidal ideation. Kates current risk is low in accordance with her baseline risk for violence and aggression.
Risk of suicide/self-harm is moderately elevated above her usual baseline risk due to acute stressors. Kate is at risk of vulnerability as she is also at risk of sabotaging her meal program due to her impaired decision making. Due to this, the RMO has ordered constant observations and noted elevated risk periods during and immediately post mealtimes up to 60 minutes. Being under the MHA, daily review by the registrar or consultant, and daily risk assessments.
The medical officer has requested daily weighing, ECGs and BSL and 4/24 physical observations with sitting and standing P and BP measures, along with daily pathology. Time 1400 Date : 22/07/2020 Signed: M. Smith CN
References
Elder, R., Evans, K., & Nizette, D. (2013). Psychiatric and Mental Health Nursing. Elsevier Australia.
Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., Rohde, L. A.,Srinath, S., Ulkuer, N., & Rahman, A. (2011). Global Mental Health 2: Child and adolescent mental health worldwide: evidence for action. The Lancet (British edition), 378(9801), 1515. https://doi.org/10.1016/S0140-6736(11)60827-1
OKane, D. & Henderson, K. (2016). Disorders of Childhood and Adolescents. In Evans, K., Nizette, D., & O'Brien, A. J. (2016). Psychiatric and mental health nursing (4th edition. ed.). Elsevier Australia.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry (ELEVENTH EDITION. ed.).
Townsend M.C., & Morgan K.L.(2017). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-based Practice 9th Edition. (2018). Lamp, 75(11), 43.
Wolters Kluwer., Richards, P. S., Baldwin, B. M., Frost, H. A., Clark-sly, J. B., Berrett, M. E., & Hardman, R. K. (2000). What Works for Treating Eating Disorders? Conclusions of 28 Outcome Reviews. Eating disorders, 8(3), 189-206.https://doi.org/10.1080/10640260008251227
