Client appearance: Slouching in chair Hair unkempt Disheveled clothing Withdrawn Avoids eye contact initially Script and Context RN- adjunct clinical faculty SP- standardized patient (trained professional actor) RN: Ms. Deal? SP: (Looks up) Uh-huh? RN: Hello, Ms. Deal, my name is. I'm a nurse and I ll be taking care of you today. May I speak with you about how you are feeling today? SP: I guess so. RN: Thanks, Ms. Deal. May I check your name bracelet? I just want to make sure the information is correct. SP: OK. RN: Thanks. (Checking bracelet). It says here that you're Cynthia Deal and that you were born on...what's your birthday? SP: January 4th, 1975. RN: Well, it looks like the bracelet has your name and birthday correct. What would you like me to call you? Ms. Deal? Cynthia?...(Pause) SP: I don't care. It doesn't matter. My friends call me Cindy. RN: Is it OK if I call you "Cindy"? SP: Yeah. RN: Cindy, anything we talk about today I may share with the treatment team. Do you understand that? SP: Yeah. RN: Ok. First I will be doing a mental status examination with you, Cindy. This will include information about your past medical history. It will take about 45 minutes to complete. Is it alright if we begin? SP: Yes.
RN: Cindy, where are we at right now? Please tell me the building, city and the state? (Assess Orientation) SP: Thomas Jefferson hospital in PA. RN: and the city please. SP: Philadelphia. RN: Ok. What is today s date? SP: October 29, 2015. RN: Ok. Do you have any past medical history? Such as hypertension, diabetes, stroke, seizures? SP: Yes, I have hypothyroidism. RN: Have you ever been diagnosed with a mental illness? SP: Anxiety and Depression RN: Have you ever seen a psychiatrist? SP: No, only my primary care doctor. But I hardly go to him anyway. RN: Ok. Any history of drugs or alcohol use? SP: No. RN: Do you use tobacco? SP: No. RN: Have you ever been hospitalized? SP: Only once when I was 25 years old. I had a break down. RN: Ever attempted suicide? SP: No. RN: Ok. It s important for me to know that. SP: I m not lying. (irritated) RN: Any family history of mental illness? Such as schizophrenia, bipolar disorder, or depression? SP: My aunt is bipolar.
RN: Ok. Do you ever see, hear, smell, taste, or feel things that are not really there, such as voices or visions? (assessing thought content) SP: Umm, no. Well, maybe. (Ms. Deal turns her head and looks up, this makes the nurse investigate further). RN: Tell me more about this. SP: I hear voices that tell me I m worthless. RN: What else do the voices say? SP: Sometimes I can t make out what they are saying. I just hate this one voice. It s a man s voice, he tells me I m a failure. RN: And what do you do when you hear this? SP: I try to distract myself by listening to music. RN. Ok. Does this make the voices stop? SP: Sometimes. RN: How long have you been hearing these voices? SP: Right after my dad fell. I was very sad and I think they started around the same time. RN: I understand that you have not been able to get out of bed and enjoy things you used to like to do. What do you think is causing you to want to be alone? (assessing insight?) SP: I just haven t been feeling well, it s hard to get out of bed. I just don t feel like being around anyone. I was taking care of my father and he recently fell a couple of months ago and broke his hip. RN: I m sorry to hear that you are not feeling well. (Pause. SP appears sad). Is it ok if we continue? SP: Sure. RN: If you found a stamp, addressed envelope on the street, what would you do with it? (Assessing Judgment) SP: Put it in the mailbox. RN: Ok. I will recite a series of numbers to you, and then I will ask you to repeat them to me, first forwards and then backwards. 5,6,7. SP: 5, 6, 7. (pauses) 7, 6, 5.
RN: 1, 3, 4, 5 SP: 1, 3, 4, 5. (pauses) 5, 4, 1. RN: Spell the word world. SP: WORLD RN: Now backwards. SP: (pauses for about a minute) D L R O W RN: If something costs 88 cents and you give the cashier one dollar, how much change should you get back? SP: 11 cents. RN: What year did you graduate from college? (remote memory) SP: 1994. RN: I am going to ask you to remember three words (blue, coffee, and horse) and I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, coffee, and horse. (Immediate Memory and New learning) SP: Blue, coffee, horse. RN: Name the last three presidents. SP: Obama, Clinton, and Bush. RN: How are these following items similar, a watch and a ruler? (Assessing abstract thinking) SP: They both measure things and have numbers. RN: How would you describe the meanings of the following: Two heads are better than one? SP: If you have two heads, then you have two brains, and then that means two can talk twice as fast. RN: Thank you for answering those questions. Next, I d like to talk about how you are feeling today? (Mood) SP: Oh, I don't know...kind of sad I guess. RN: You're feeling sad. SP: Yeah, just kind of down. RN: Could you tell me a little more about what's making you feel sad?
SP: I worry a lot about my dad. RN: Your dad. What sorts of things do you worry about? SP: Oh, I don't know. That he is not being taken care of properly. RN: Can you explain what you mean? SP: I used to live with and take care of my father until my brother put him in a nursing home a few weeks ago. RN: Did you have any help taking care of your father? SP: No, there's just me. My brother never came by to help. I used to do OK with him but he fell and broke his hip. He got out of rehab a few months ago and then my brother put him in a nursing home. He s all I have. I don t think he ever wanted to be in a nursing home. He was happy with me. RN: How is the relationship between you and your brother? SP: Not good, he s never supported anything I have ever done. I don t want to talk about him. He makes me angry. RN: I understand. We do not have to discuss that right now. Let s talk about your father. How much care did he require? SP: I had to do everything for him. I just couldn't do it anymore. I feel bad that I let him down. RN: So you feel that you couldn't take care of him. SP: No, I couldn t (begins to cry). Look, I can't deal with this. It's all my fault. Oh, it's just all my fault. RN: What's your fault? SP: That dad's the way he is. RN: You feel that you're to blame for your father's illness? SP: Well, yeah. If I took care of him better he never would have had his stroke. And now I'm just being punished. RN: You're being punished? SP: Yeah. His fall was just more punishment for me. First it was the stroke and then the fall. Both of them were my fault and now it s all just more punishment. The voices tell me it s my fault. RN: You feel you caused his stroke and his fall? How did you cause them?
SP: By not taking care of him better since my mom died. Even my brother tells me it s my fault! RN: And when did your mom pass? SP: About 10 years ago. Maybe that was my fault too. RN: Would you like to talk about it? SP: Not really. Mom died of cancer. But, I know I caused my dad s stroke. RN: That's really hard to believe. People don't cause other s to have a stroke. What makes you think you caused his stroke? SP: I told you. I know I caused it, that's all. The voices tell me that his fall was just to punish me more. And now my brother and his wife put my dad in a nursing home. (SP becoming slightly agitated and more tearful.) RN: I see this is really upsetting you. Are you upset that you father is in a nursing home? SP: Look, can we talk about something else? (Still agitated) RN: Yes, of course, Cindy. What would you like to talk about? SP: (SP calms down.) Let s talk about when I can leave this place. I don t like it here. RN: Cindy, can you tell me the three words I asked you to remember? SP: blue, table, and horse RN: I understand that you belong to a book club? SP: Yeah, but I stopped going. RN: Cindy, do you have any social support friends or family? SP: Well, I have known Mary, my friend from the book club since I was 20 yrs old. We went to college together. RN: Earlier you stated you were hospitalized before. Can you please tell me more about that? SP: Yeah, years ago. I think, like when I was 25. I just broke off an engagement and I guess I went off the deep end. RN: "Off the deep end"? I'm not sure I understand. SP: Yeah, you know, depression. Like now I guess. RN: And how did that work out?
SP: OK. I was here a little while and finally got things put back together. They gave me meds and some therapy. I was able to get back to normal in a month or so. RN: How long did you take the medication? Do you remember? SP: Oh, for a while. I can't remember, maybe just a few months. It made me dizzy. RN: You said you stopped going to book club. How often did you go? SP: Yeah, every couple of weeks for years. But, you know, it just got to be too much. I stopped going. RN: It got to be too much with caring for your father? SP: Yeah. But I just didn't feel like going anymore. I really don't feel like doing anything much anymore. I don t deserve to do anything. It s my fault my father is in a nursing home. If he can t do anything, then I shouldn t be able to do anything. I think Mary just got worried so she took me to the emergency room. RN: What sorts of things did you do that you don t feel like doing now? SP: Oh. It's so hard to even get up in the morning. I just stopped going to work because it was too hard. I have no energy. I spent all of my energy on caring for my dad, and it still wasn t enough. I failed him. RN: You stopped going to work. Would you like to talk about it? SP: OK. I used to enjoy my job. But it was getting harder and harder to focus. I forgot things and couldn't seem to get anything done. It got to be too hard just to get out of bed. RN: What type of work did you do? SP: I was a supervisor for a car insurance company. RN: That sounds like a job that calls for a lot of responsibility. SP: Yeah, but I just couldn't deal with making the decisions anymore. So I stopped going. RN: Do you feel that we can talk about your feelings about taking care of your father again? SP: Fine, whatever. RN: You said you feel that you're being punished for your father's illness. SP: (Agitated) No! I said I'm being punished for not taking care of my father. I caused his stroke and got punished for it by his fall. And now I can't take care of him even more. RN: But your father is being taken care of now in the nursing home. He'll get care there.
SP: (Teary, agitated) But "I" can't take care of him. What's the use in going on? I'm no good to him. I'm no good to anyone. I'll never be good to anyone. It's no use. RN: Cindy, are you thinking of harming or killing yourself? SP: Maybe. Why not? I just can't deal with it all. I have nothing to live for. Everyone thinks I m worthless, even the voices. I try to not listen to them. But it s true. I am a failure. RN: Have you thought about how you would hurt yourself? SP: Not really. Maybe pills I guess. RN: Do you think you may act on these thoughts? SP: Maybe. RN: You may not believe it right now, but the way you are feeling will change with some help. What has stopped you from killing yourself? SP: I don t want to hurt my father, he would be very sad if I killed myself. He would probably blame himself. RN: Blame himself? SP: Yeah, he could think that because I was taking care of him, that he was making me stressed out and depressed. But that s not true. I liked caring for me. He is a great father. RN: Are you willing to notify staff whenever you have thoughts of harming yourself? SP: Maybe. Why do you even care? RN: I may not be able to understand exactly how you feel right now, but I care about you and want to help. If it's OK with you, we could have an agreement. It would be that you let staff know if you feel like harming yourself. SP: I suppose. RN: Here, I have some notepaper. Let me write out our agreement. You can read it and tell me what you think. RN: Writes and reads the contract "I, Cynthia Deal, will not harm myself in any way. If I have thoughts to ham myself, I will immediately tell staff. RN: Here, Cindy. (Hands the contract to SP). We can have this agreement for 48 hours, and then we can continue to talk and see if we will need to update the agreement. OK. Would you read this and sign it? SP: OK, sure. (SP reads contract and signs). RN: OK, Cindy. I'll make a copy of this for each of us after we're done talking. OK?
SP: OK. RN: You understand that this is a valid contract? SP: Yeah. RN: Is it OK if we continue talking? SP: What about? RN: Whatever you'd like. SP: I really need to get back to my father. He's all alone. RN: You're afraid your father is not being taken care of at the nursing home? SP: I've really got to get out of here. RN: I understand your father is at a nursing home and is being taken care of. Is that your understanding? SP: I don't care. I need to get out of here and get my father back home where I can take care of him. RN: You'll be able to go back home when you get well enough to leave the hospital. SP: When will that be? I'm not waiting forever. I'm getting out at the first chance. RN: You'll doctor will be here today. I'll mention that you'd like to speak to her about plans for going home. SP: OK. Thanks. RN: Are there any other things on your mind that you'd like to talk about? SP: Well, the meds are making me worse. RN: How do the medications make you feel worse? SP: They just seem to be making me sleepy. I still don't have any energy. But I'm still sad all of the time. RN: The medications you're on take a few weeks to really kick in. It could be a month or so before you're feeling really good again. SP: Can't they give me something that works faster? RN: Unfortunately, all the medications for depression take some time before they make you feel better.
SP: But they make me so tired. RN: That's a common effect of the medication. We'll talk to the doctor about getting all of your meds at bedtime. It may help you sleep too. SP: I hope so. I keep waking up. RN: Cindy, can we discuss some of the activities on the unit? SP: I guess. RN: Have you been participating in them? SP: Not really. RN: They have some really useful group activities here. SP: I don't care. RN: For instance, you like to read. Maybe you could get people to discuss books they've read. We could talk to the activities coordinator about it if you'd like. SP: Yeah, maybe. RN: Do you feel that there are reasons why you couldn't? SP: I just don't have the energy. RN: It might be possible to schedule a group after a rest time for you. SP: Never mind. RN: Well, Cindy, our time is almost up. Let's go over what we discussed today. OK? SP: Look, I'm tired. I don't want to talk anymore. RN: OK. I'll bring you back a copy of our contract in a few minutes. Can we meet again tomorrow at 10:00? SP: I won t be here. I am going to leave no matter what. I can t stay here. I need to be with my dad. The voices are telling me something might happen to my father if I am not at his bedside by 8am. If I m not there, I might as well be dead.