Question

49-year-old single Caucasian male with multiple past mental health (PMH) hospitalizations, admitted through ED, secondary to increasing depression with suicidal ideation (SI), and alcohol abuse.  Patient lives alone, has no daytime structure.  Highest level of education is high school.  Past social history indicates possible sexual abuse.  Patient currently denies SI but has had past attempts using knives; details regarding these attempts are unclear. Patient denies any legal history of violent/criminal behaviors.

• Admitting Assessment Data & Mental Status Examination (MSE): Patient appears older than stated age of 49.  He is heavy set with fair grooming.  Mild psychomotor retardation noted.  Maintains eye contact, though at times is staring intently and seems preoccupied.  Concentration is poor.  Mood is reported as depressed and anxious.  Affect is odd, anxious and constricted in range.  Speech halting at times.  Thought process significant for thought blocking.  Denies any visual or auditory hallucinations.  No delusions elicited.  He currently denies suicidal ideation or homicidal ideation.  Judgment and insight are fair.

∙ History of Present Illness (HPI): This is one of multiple hospitalizations for this man who has a diagnosis of schizoaffective disorder.  The patient has a history of alcohol dependence and this intensified after his friend recently died.  Also, the patient’s father died last year on the patient’s birthday, of prostate cancer.  The patient himself was diagnosed with lymphoma in 2010, and underwent biopsy of axillary lymph nodes in 2010; resolved but he states this is contributory to his increasing depression and SI.  He admits to increased drinking of “about 6 beers a day and some vodka”.  He reports having blackouts.  He denies any change in weight or appetite.  He reports his concentration is poor, sleep is decreased. He reports his mood as depressed and he says he feels overwhelmed.  The client self‐admitted to the ED because of feeling unsafe, but upon admission to the unit he denies SI.  He also denies symptoms of psychosis, although he appears preoccupied and guarded during the interview.  He appears to have some thought blocking, but when questioned, reports he is “trying to concentrate”.  No history of withdrawal seizures or DTs.  Patient has been admitted for substance abuse numerous times, at several locations.

Please answer the following questions:

1. Explain how you would perform a brief mental status assessment for client orientation

4. How would you assess potential for withdrawal using CIWA tool

5. Confirm intake information, by asking client additional open‐ended questions pertaining to his HPI and past presentations. What questions would you ask?

6. Assess for SI in patient using therapeutic communication skills: ∙ Assess ideation ∙ Assess plan ∙ Assess means to carry out plan. How would you ask these questions?

7. Educate client on the following topics:

∙ Alcohol use & abuse:  signs and symptoms of alcohol withdrawal (elevated VS, tremors, nausea/vomiting, DTs, diaphoresis, seizures)

∙ substitution therapy using benzodiazepines (side effects, physical assessment indicators of withdrawal)

∙ supportive medications given for alcohol withdrawal and reasons for administration (thiamine, folic acid, magnesium oxide, Wernicke Korsakoff’s encephalitis)

Answer 1

1. MENTAL STATUS ASSESSMENT

Appearance: How is the patient dressed ? Hygiene and body language

ORIENTATION: Check the patient orientation by knowing this four general elements to orientation.

Person, place and time ,situation. Orientation to a person is simply by identifying one's name and is the last element of orientation to be lost.

Time include date, day of week or year

Registration or recall : Registration is the ability to repeat back a piece of information immediately after hearing it. EXAMPLE loud noise . Recall in the ability yo repeat back the information after 3 to 5 minutes.

BEHAVIOUR AND MOTOR ACTIVITY;

Do they make eye contact as you enter into the room.

SPEECH : The most important element of speech ,fluency and the patient content .

THOUGHT PROCESS: Describe the thought process of patient and how they connected

Example of thought process variation, Circumstantial , Tangential , and loose thought content .

THOUGHT CONTENT: Refers to the themes that occupy the patients thought and perceptual disturbances.  

Example , preoccupation : Suicidal or homicidal ideation

COGNITION: Check the patient level of consciousness and attention to a situation . Memory of the patient by asking any questions related to previous incidence.

INSIGHT AND JUDGEMENT: Check the patient insight and JUDGEMENT of a situation

4. USING CIWA TOOL

this have 10 item scale

The maximum score is 67

Mild withdrawal is less than or equal to 15

Moderate is 16 to 20

In severe greater than 20.

Check the items of CIWA scales with patient symptoms

*Nausea or vomiting

* tremor

*Sweating

* Anxiety

* agitation

* Tactile disturbance

* Auditory disturbances

* Visual disturbance

* Headache or head fullness

* Disorientation

A score of 8 to 10 indicates the need for benzodiazepines.

5. OPEN ENDED QUESTIONS

▪WHY YOU ARE HERE?

▪WHAT HAPPENED TO YOUR FRIEND?

▪ WHAT KIND OF PROBLEM HAVE YOU BEEN HAVING RECENTLY?

6. SI QUESTIONS

If any self harm or suicide attempt present Ask the question

▪ Do you think about your own death or about dying

▪Do you think or feel this way presently

If the person Express thought of self harm or suicide ask

▪When did you begin to experience these thoughts and feelings ?

▪ What happened before you had them?

If patient attempted suicide or engaged in self harm

▪ What were your thought just before you harmed yourself ?

▪WHAT HAPPENED IN YPUR PREVIOUS ATTEMPTS TO SELF HARM OR TAKE YOUR LIFE ?

If repeated suicidal thoughts or attempts Ask patient

▪how many times you have tried to harm yourself or tried to take your life ?

Assess reason for living or protective factors for this person Is by asking

▪How do you feel about your own future???