Appearance Age: Caucasian, early 40s (no wrinkles, minimal sign of

Age: Caucasian, early 40s (no wrinkles, minimal sign of wrinkles and aging, she is married, with 2 young
Body Build: hard to distinguish appears to have medium frame (she is wrapped in blanket) no sign of
physical abnormalities.
Eye Contact: and minimal eye contact during conversation with nurse (appears to be have less selfconfidence “feeling of Burdon on husband and kids”. As a result of therapeutic relationship towards the
end, it reflects she maintained good eye contact when she is giving detailed response directed to
therapeutic questions asked by nurse.
Attire:wearing a dull grey sweatshirt (no pattern)
Grooming/Hygiene: Hair not combed, no makeup on, clothing appears to be clean (no stains or
Nutritional/General health status: Swabbing and tearing eyes evident by `red and puffy eyes, she also
said she is “tried”. No mention of nutritional status
Pupils: appears to be normal
Posture: Lying down, facing the nurse. Right hand supporting head .Open body language throughout the
interview with the nurse ceclned when talking about intense stressors.
An unusual posture noted,
Rate: overall low delayed speech (evident by her re-electing on what made her feel better when rating
herself on a scale of 0 -10)
Rhythm: speech is regular and syntactically correct, order of words and phrases were organized.
Volume: she spoke softly
Quantity: she was consistency responsive, throughout the interview.
Characteristics: her speech is understandable, clear and coherent doesn’t appear to have lisp
Motor Activity
Level /rate of movement: Not active at the moment (laying in the bed, no hand gesture used)
But she mention participating in group activity which requires movement out of the bed.
Unusual movement: No repetitive movement, tics or tremors noted
Coordination: In laying position she is supporting her head right hand, no shaking no tremor no
accidentalty leaning forwards noted
Interaction during Interview
Attitude: she is cooperative and responsive throughout the interview. She was polite. Engaging with
nurse in conversation, and that is evident by therapeutic relationship and trust being build. Her
cooperation is seen through her willingness of opening up when interacting, and cooperating with nurse
on doing her homework)
Emotional State
Mood: She feels hopeless, “I feel my family and friends are better off with me “
She feel Burdon “I feel I am Burdon to my kids and family”
She rates herself on 2-3 on a scale of on scale of 0 to10 , 0 is when she attemped suide that shows she is
improving a bit better
“I feel washed out and too depressed
Quality: feeling despair
Range: small rage of emotion (evident by the change in her emotion throughout the interview example
she had tearing eye towards more balance mood (not crying, but still in a state of despair)
Intensity: balanced intensity (not overly emotional)
Stability /Duration: constant state of despair (however with decrease intensity due to the therapeutic
Congruence: her flat facial expression, her slow speech and prolonged breathing in congruent with her
reported mood being tried.
Hallucination/ illusion none noted
Depersonalization: Claire have Poor self-perception about herself evident by her hopelessness
Thought Content
No delusion noted
Yes suicidal thoughts are present evident by her statement “they will be better off without me “, “why
did my husband have to find me, why couldn’t he let me die in peace, why can’t it all be over”. Claire
thoughts of suicidal are still present evident by her statement “why can’t it all be over”
Thought Process
Claire had consistent flow of ideas, however she took time to processing in answering the questions
asked by the nurse
Sensorium and cognition
Level of conscious: she is alter evident by her responsive to the nurse
Orientation: Claire is oriented to person as she know she is conversing with nurse , she is aware of her
place as she say she is goes to group activity.
Recent memory recalls her relationship with husband and kids, AND IS ABLE TO RECALL HER MAJOR
Immediate memory: recalls memory of rating herself on 2-3 on the scale of 0when she is promptly to
answer the other question.
Level of concentration and calculation
The level of concentration was present when the nurse ask Claire to rate herself, on 0 to 10 scale and
she rated herself 2-3
Calculation is not formally tested
Information and Intelligence
Claire was able to communicate her feeling using proper grammar. She was able to recall information
regards to past event (suicidal attempt) and process information when questioned by the nurse. We can
pin point her level of education, however she is effectively communicating with the nurse throughout
the interview shows that she is educated.
Claire feels better associating with the group activity, because they are going thought same experience
as her and they can relate, this suggests she is open to progressing because she is willing to adhere to
nurses instruction on taking baby step, to improve in the mood.
Claire is awere of her suffuring from depression and it is impacting herself and people around her
“ she is too tried of taking care”
Claire Safety is are concern as a student nurse.
Because of the patient suicidal ideation as evident by
her statement “friends and family are better off
without me”.
1. Claire attempted suicide a week ago, which puts her
at high risk for re-attempting suicide, this is why she
requires intense supervisions. Determine the level
suicide precautions needed, by suicide assessment risk,
because this will give us more insight on how much she
is re -contemplating.
2. Encourage Claire to talk about her feelings,
disappointments,anger, and ways to handle frustration
by creating a therapeutic relationship. This way Claire
can learn alternative ways of dealing with her
overwhelmingemotional and gain a sense of control
over her life.
3. Develop a safety plan for Claire, because in case she
feels tempted to self-harm, a nurse could provide with
alternative manners of channeling her emotions such
as writing her feelings in a journal, or creating art. Also
remove any kind of source such as pill,jewellery, sharp
objects that could allow her to self-harm.
4. Contact and educate family on suicidal behaviour
and provide external resource which links to self-help
group, this important because re-establish social ties
and.If Claire feeling extremely anxious and has not
slept in days, then anti-anxiety agent might me
prescribed, So Claire get relief from anxiety and there
is restoration of sleep loss can help the her think more
clearly and might restore some sense of well being
Self esteem
In Claire‘s situation self –esteem is an issues, because it
hinders her from acknowledging her strengths, and
positive attributes which prevent her being able to
progressing to a healthier state mind . as she stated “ I
am so washed up , and depressed”, and I feel I am
Burdon to my husband and kids”.
1) Work with the patient to identify cognitive
distortion that encourages negative self -appraisal. for
example overgeneralization and self blame. this is
important in Claire situation, because cognitive
distortions reinforce negative, inaccurate perception of
the self and the world. for example Claire statement (
direct quote from video). " they are better off without
me" assuming husband thinks without any evidence.
2) teach visualization techniques that help patient
replace negative self images with more positive
thoughts and images. this is important to promote
healthier and more realistic self - image by helping
Claire choose more positive actions and thoughts.
Social isolation
3)work with Claire, on areas that she would like to
improve using problem-solving skills and patient's need
for assertiveness training. Evaluate need for more
teaching in this area. this will help Claire with her
feeling of low self esteem which interfere with usual
problem solving abilities.
Social interaction is essential in Claire situation ,
because she feels hopelessness it enables her to
understand that others are also going through similar
shared emotions like despair, hopelessness , guilt,
frustrated And may have similar emotion and
normalization her own feeling and seeing that how it
relates to her own experiences. This will help Claire to
develop sense of relief and support from seclusion as a
result of interaction.
Intervention pg. 167
1. Since Claire , is severely depressed as she states " I
am washed up and depressed", involve her in one to
one activity. this activity can maximize the potential
for interactions while minimizing anxiety levels.
2. Assess what spiritual practices have offered comfort
and meaning to Claire's life when not ill. this
assessment will evaluate neglected areas in patent's
life that, if reactivated, might add comfort and
meaning during a painful depression.
3. Discuss what has given meaning and comfort to
Claire in the past. this is important because when
depressed there is often a struggle for meaning in life
and reason to go on when feeling hopeless and
4.Encourage Claire to write in a journal every day,
expressing daily thoughts and reflections . Journal
writing can help the patient to identify significant
personal issues and thoughts and feelings surrounding
spiritual issues. Journal writing is an excellent way to
explore deeper meaning of life.