Leroy Case Study Nursing Assessment

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 influencingfactors 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 correctterminology. Students will also develop patient-focused documentation skills in reporting the identified MSE and risk assessment findings concisely and accurately within the nursingreport.

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.

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 correctterminology. Students will also develop patient-focused documentation skills in reporting the identified MSE and risk assessment findings concisely and accurately within the nursingreport. 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.

Instructions: Please include the following client details on the appropriatedocumentation. 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. MENTAL STATE EXAMINATION ASSESSMENT DUE 23 September, 2019 prior to 23:55 hours

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 mustsupport 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 assessmentform will be accepted. Upload as a PDF document with your MSE, mental health nursing interventions and nursing report.

11. Together with your findings from the MSE and the risk screening assessment, students will be required to write a one-page nursing report as if you were documenting your findings into a patient chart. This will require you to gather the relevant and pertinent details and combine this into your 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. This is to be typed in Times New Roman 12 font, and 1.5 line spacing. Asthis is report style writing, references are not required for the nursing report as you have gathered the details from yourfindings.

12. There is a page limit to this assessment. Two pages for the MSE, one page for the mental health nursing interventions, a completed two-page risk screening tool and a maximum of one page for the nursing report. This will complete a six-page assessment. Past six pages in the content or outside the individual allocated page length requirements will not be read or considered in the marking. The reference page is not included in the page limit. Pages must be numbered, and a name and student number are to be included on each page. Refer to the assessment rubric for overall marking criteria. Marking of this assessment will take place electronically. Therefore, the rubric is a guide to indicate the expectations and marks assigned to each area/category of this assessment.

13. Submit the assignment via the Moodle Assessment Submission link on the study desk by the due date and time. The assessment must be submitted to Turnitin before finalising your submission. No assignments will be accepted via USQ email. Assignments will be deemed a late submission upon the due date and time provided; therefore, a late penalty of 5% per day or thereof is applied to this assessment.

14. Upload the MSE, interventions and nursing report as one file as a word document and upload both pages of the risk screening tool as a PDF document. No photos will be accepted. The system will allow for two file uploads. The assessment rubric sheet is not required to be uploaded or submitted.

15. Please read carefully: Extensions for the submission of this assessment may only be considered due to extenuating circumstances. A student must provide the teaching team with current working drafts/documents and provide supporting documentation as per the USQ extension policy at the time of an extension request to be considered for an extension. Extensions will not be provided after the due date and time nor provided for reasons such as on clinical placement, other assessments due around the same time or unable to access the internet as the majority of students are currently or will be on clinical placement throughout the semester