The mental health act works on people who have to be under compulsory

assessment or treatment if their mental state is dangerous to themself or others

or if they have no ability to take care of themselves.
Section 8a application for assessment and the patient must be an adult.
8b, the medical certificate to support 8a.
9. Arrangement and conduction of the assessment. Duly authorised officer (DAO)
is the person to decide. The process must be witnessed by family or JP
10. Preliminary examine certificate given by psychiatrist
11. Certificate of further assessment after 5 days
12. Certificate of further assessment after 14 days
14. Certificate of final assessment
16. Patient require review by judge
29. Community compulsory treatment order.
30. Inpatient compulsory treatment order.
64. Patients rights to information
75. Patients rights of complaining
Mood disorder:
Clinical depression=major depression = unipolar major depression= symptoms last
more than TWO weeks. Depression might relate to low levels of dopamine,
serotonin, and noradrenaline. Depression is unpreventable. Female incidence
twice than male. Precipitating factors are life events, Chronic disease, Substance
abuse, and Family history.
A patient with more than 5 of the 9 Symptoms lasting longer than 2 weeks has
clinical depression.
 Depressed mood
 Anhedonia (loss of joy or interest in life)
 Weight loss (anorexia) or increase, appetite changes
 Psychomotor retardation, like slow speech and response time, decreased
movement.
 Insomnia or hypersomnia
 Fatigue/anergia
 The feeling of worthlessness or guilt
 Difficult to concentrate
 Suicidal thoughts
In adolescence (10-18), the common symptoms of clinical depression are
irritability/skipping class, appetite change, narcolepsy, and withdrawal from social
activities.
Other types of depression
Dysthymic disorder: long-term depression (>2 yrs) with mild symptoms. Seasonal
affective disorder happens when winter due to lack of Vitamin D. 45 mins light
source exposure. Pre/postpartum depression happens during gestation or four
weeks after birth.

Nursing intervention
Encourage and invite the patient to participate in structured program group
activities (OT activities).
Assist with ADLs
Spending time and sit with the patient and doing MSE
Suicidal risk
NEVER LEAVE the patient ALONE!!!. Nurses should watch for sudden, pretended
calmer or positive mood changes and increased changes in energy. It's a sign of
Suicide. Usually shows two weeks after starting antidepressant treatment.
Additionally, the Clients would express suicidal ideation like “I won't be a problem
anymore or this will be over soon”. Nurses need to perform one on one
observation and keep assessing the risk by asking if the patient has any thoughts
of harming himself after a patient shows a high risk of suicidal ideation.
A patient expressing clear plans regarding his future, including personal goals,
family, and friends, is the indicator of low suicidal risk indication.

Malnutrition
Offer high-caloric fluids like ensure, assist patients in ordering on menu to
encourage food intake, and frequently offer snacks (a couple of tea and biscuits)

Therapeutic communication
Therapeutic communication refers to stating facts by giving closed-ended
comments and then using open-ended questions to obtain more information
about the patient's mental status. The nurses should reiterate to show
understanding and empathy for the patient's statement and then ask what's the
client's concern.
For instance, "as you mentioned, I understand being unemployed is very
stressful." or "it must be very hard to accept. I think you are being responsible to
your family. “Tell me more about your current concerns, and do you think
attending group activities can help? If not, what else? What thing did you use to
enjoy the most?" Or "I understand the voices are terrible to you, but I really can't
hear them".
NEVER give opinions, judge, or personal experiences. Like, "I know how you feel, I
had worse", or "everything goanna be all right." Never ask WHY, which upsets
patients.
Treatments
Electroconvulsive therapy
ANTIDEPRESSENT, in depression psychotherapy= antidepressants.
Psychotherapy like cognitive behavioral therapy (CBT).
Mood disorders:
Anxiety
Anxiety disorder is the most common psychiatric disorder, which refers to
extreme fear and apprehension regarding current or future events. Anxiety
disorder lasts longer than six months and affects 15% of Kiwis. Risk factors are
elevated noradrenaline level, family history, substance, and life events. Females
are twice prevalent in anxiety. Low suicidal risk. Prone to adolescents and starts
before 25 yrs. Anxiety symptoms start to relieve after 55yrs.

General anxiety disorder

Patients with GAD have excessive, persistent, and unreasonable anxiety towards
ADLs. The symptoms include restlessness, irritability, difficulty concentrating,
insomnia, and fatigue.
Diagnosis criteria of GAD
 Excessive anxiety presents for more than THREE months in a SIX months
period.
 The patient found it difficult to control his anxiety.
 Adults have more than three symptoms and 1 for 6-18 years.
 Impaired with daily tasks
 The anxiety is not induced by medication or other medical conditions like
hyperthyroidism.
 Not caused by other mental health disorders.

Acute stress disorder

Acute stress disorder refers to sudden, unexpected panic attacks with excessive
dysfunctional anxiety. Patients develop elevated noradrenaline-related
symptoms, including hyperhidrosis, tachycardia, angina, hyperventilation, SOB,
hypertension, dizziness, gastrointestinal disturbance, nausea, and choking within
a month of exposure to precipitating events. The acute episode usually lasts 10
mins, and patients with acute stress disorder can have the episodes intermittently
from days to <four weeks.
Post-traumatic stress disorder, PTSD, has the same (sympathetic) symptoms plus
recurrent thoughts, dreams, or flashbacks, but lasts more than four weeks. The
clients with PTSD need encouragement by the nurse to exploring the meaning of
the traumatic event and consequent losses. Otherwise, symptoms may worsen,
and the client may become depressed.
Agoraphobia is a severe form of ASD that the patient is extremely fearful of going
to public places or events, so they keep staying at home.
Social phobia refers to asoliality.
Specific phobia like trypanophobia which fears needles. Exposure& response
therapy works for specific phobia and PTSD by exposing the patient to the afraid
thing in a gradual manner like showing a photo until the patients get used to it.

Treatment
Cognitive behaviour therapy is the primary and most effective treatment.
Antidepressants like SSRIs are the first-line meds. Then anxiolytics like buspirone
which takes 2 to 4 weeks to work and then Benzo or barbiturates are only for
acute episodes. Sometimes using beta blockers, which are contraindicated to
asthma and COPD or typical antipsychotics.
Bipolar
1% of people have bipolar. People with bipolar disorder experience major
depression that lasts more than two weeks, and mania that lasts more than one
week, or hypomania that lasts more than four days. However, bipolar diagnosis
criteria do not include depression. If a depression episode happens, then 90% of
mania incidence afterwards. 50% of bipolar patients have psychosis. Same ration
between male and female. Family history increases the incidence of bipolar
disorders ten times, and substances like SSRIs trigger bipolar. Bipolar disorder is
usually concurrent with anxiety, OCD or ADHD (not depression because it's a
separate disorder). Bipolar induces a high risk of homicide during mania or suicide
when depressed or having a mixed states. They both have significantly higher
suicide risk than major depression disorder.
Patients with nonstop hyperactivities, constant delusions, and malnutrition
require immediate medical support.

Dipolar one and two, depression (MD lasts around two weeks), cyclothymia
(similar and milder to bipolar two but lasts more than two years), and dysthymia
(milder than but lasts two years) can only be present one at the time of diagnosis.
The symptoms of a mania episode are
 More energy, great intention to show off, flight of ideas (thought from),
hallucinations, a delusion of grandeur (I'm the god), and grandiosity (I'm
the best and the rest are shit, thought content)
 Agitation and irritability.
 Nonstop talking, pressure talking
 Insomnia, the patient would feel no need to sleep.
  Attention deficit causes the patient easily to be distracted and can't even
finish a sentence. This distractibility seriously impairs daily task
performance.

Types of bipolar disorder:

 Bipolar one has at least one mania for a week and does impair daily life.
Depression happens but not necessarily.
 Bipolar two has hypomania, which lasts more than four days and does not
impair daily life. But bipolar two have more frequent depression episodes
than bipolar one, and the high frequency of depression episodes increases
the risk of suicide.
 Cyclothymia refers to less depression and hypomania that lasts more than
two years. Cyclothymia is rarely diagnosed because cyclothymia overlaps
with depression as manic episodes are mild, and the symptoms are
relatively mild.
 Rapid cycling refers to more than four episodes of depression and
mania/hypomania in a year.
 Mixed states refer to depression concurrent with the hyperactivity part of
mania. This disorder has a significantly high risk of reckless activities or
suicide.

Treatment
 Provide quite a calm environment, like a private room close to a nurse's
station. Eating inside the room and no group activity to reduce stimuli.
 Try to make the patient physically busy or do aerobic exercises to exhaust
the client.
 Clearly set a behaviour limit to the patient, like you can't be aggressive, or
you have to be here by yourself. However, when the patient is interacting
with other patients, distracting the patient and bringing he home.
 The mood stabilizer, Lithium
 Anticonvulsants but used as a mood stabiliser for treating mania like
carbamazepine (agranulocytosis) and Sodium Valproate (Epilim).
Lamotrigine is used for treating depression.
 Antidepressants treat depression but also trigger mania episodes and
leading to rapid cycling, so they are not the first-line treatment option.
 Anxiolytics like lorazepam. Take extra cautions for respiratory depression
when concurring with medications that are sedative like antipsychotics
haloperidol, fluphenazine, clozapine, olanzapine, quetiapine or opioids.
Contraindicate to ethanol.
 Antipsychotics all indicate to acute mania until the mood stabiliser starts to
work from 7-21 days.
 Performing cognitive behaviour therapy after a manic episode may help
prevent future episodes, but the therapy is not the primary treatment
approach.
Personality disorders:
Obsessive compulsive disorder
Patients with OCD have obsessions like unwanted recurrent and intrusive
thoughts like forgetting to lock the door leading to anxiety and compulsions that
perform actions to reduce the anxiety from obsessions and impairing daily life.
OCD criteria are obsession and compulsion, time-consuming and not induced by
substances. OCD occurs during adolescence. Examples are being a tidy freak or
mental rituals like four is bad, and 6 is good. OCD is related to low serotonin
levels. Cognitive behavioural therapy, like exposure and response therapy (ERP),
combines with meds like fluvoxamine (SSRI) or clomipramine (TCA) but
medications are only transient for OCD treatment.
Borderline disorder
Borderline disorder has similar and milder symptoms to bipolar 2 but the
personality switching only taking seconds to maximum few hours. No need for
medications. Dialectical behaviour therapy is a form of CBT specialised for BPD.
Psychosis refers to the positive symptoms of schizophrenia, delirium, and
dementia. Schizophrenia is the distortion of thinking. Patients with schizophrenia
can't distinguish the difference between reality and imagination and the patients
have a High suicide risk. Lineage or brain lesions are the potential epidemiology.
Schizophrenia is related to the massive secretion of dopamine D2 and serotonin
5-TH. Male (18-25) is 1.5 times more prone to schizophrenia than female (25-35),
and males have a higher incidence of severity. After the first-time positive
symptoms show, unlike mood disorders, the baseline of the patient's social and
occupational functioning will keep deteriorating every time the psychosis
relapses.
A patient has symptoms of hallucinations and delusions or disorganized speech
plus either one of disorganized behaviour, catatonia, or negative symptoms
lasting one month and a total time is more than six months meets schizophrenia
criteria. These symptoms make patients more likely to be a victim.
DSM 5
Hallucinations are perceptions without stimuli. Auditory hallucination is the most
common type, and the voice is always clear. Auditory hallucinations are most
troublesome when environmental stimuli are diminished and there are few
competing distractions. Using distractions like watching tv or listening to music
can help. Patients tend to hide the voice but physically respond to it (Responding
to internal stimuli).
Delusions refer to fixed false beliefs. Delusions include delusion of reference (I
think the TV is talking about me), delusion of persecution (paranoid delusions
usually are related to the defence mechanism. When paranoid ideation shows,
providing the client with activities in which success can be achieved), delusion of
control (my mind is manipulated) and delusion of grandeur (I'm the king).
Disorganized thinking, speech, and actions. Thoughts forms are not linear but also
a loss of associations. Flight of ideas (a bunch of random short sentences making
the conversation no sense), clang associated (a bunch of random short sentences
that sound like a rhythm but make the conversation no sense), word salad (a
bunch of random words making the sentence no sense), neologisms (making up
new words), circumstantiality (meandering), and tangentiality (the answer has no
relation to the question). Also acting hyperactively, randomly and bizarrely or
immobility for hours. Either way, the actions are purposeless. Disorganized
schizophrenia is characterized by regressive behaviour with extreme social
withdrawal and frequently odd mannerisms
Negative symptoms
Asociality
Anhedonia (can't feel pleasure)
Alogia (poor speech)
Apathy/avolition (not interested in doing anything)
blunt/Flat affect
Catatonia:
Psychomotor retardation like Immobility, alogia, anergia, with flat affect. Very
exaggerated postures and keeping the posture for hours like catalepsy caused by
muscle rigidity (the major sign of catatonia). Grimacing (staring).
Treatments:
Never judge or argue about the patient's sensation; nurses should always
acknowledge the patient’s feeling then presenting reality verbally. Tell the patient
I acknowledge your perception and how the perceptions make you feel awful, but
I can't hear it.
Try to give more space to patients with schizophrenia as they are irritable, and
don't ask too much to upset them.
Encouraging food/fluid intake is the priority as they are at risk of dehydration and
malnutrition. Physiological needs are always superior to psychiatric needs.
Antipsychotics
Typical antipsychotics like haloperidol and fluphenazine work on the positive
symptoms by targeting d2 receptors. Expecting extrapyramidal syndrome (muscle
rigidity). Watch for NMS (hyporeflexia, high vitals, mental status deteriorating)
Atypical antipsychotics work on both negative and positive symptoms by targeting
D2 and 5TH receptors. Atypical antipsychotics like clozapine (sedating,
agranulocytosis, metabolic syndrome), olanzapine (sedating, metabolic
syndrome), and Risperidone (less sedative, orthostatic hypotension). Quetiapine
(similar to Risperidone, orthodontic hypotension, very sedative, obesity).
Ziprasidone causes hypotension and widened QT intervals (torsade de pointes,
medical emergency); therefore requires regular cardiac monitoring. Aripiprazole,
light potency.
Ratings disorders:

Anorexia nervosa
Anorexia is ego-syntonic means the client views behaviours as congruent with her
self-image (satisfied by her behaviours) by anorexia (not eating), which makes the
disorder difficult to cure. Anorexia has the highest mortality (20%) of all
psychiatric disorders. Female morbidity is ten times than males.
Patients with anorexia nervosa have lower than average BMI <17.5. they have
intense anxiety about gaining weight. Distorted perceptions of weight and
patients would never be satisfied no matter how much weight has been lost.
Patients either do excessive exercise or restricted diet. This malnutrition would
lead to fatigue, amenorrhea, infertility, electrolyte abnormalities, arrhythmia, and
osteoporosis. The patients would refuse to eat and deny hunger during
hospitalisation. The priority of hospitalisation is to initiate a refeeding program.
Involving family members in therapy is the key, not medications.

Bulimia nervosa
Bulimia nervosa is an ego-dystonic disorder. The clients view their behaviours
(binge eating) as incongruent with self-image and therefore feel guilt, shame, and
distress about the binge eating.
Patients with bulimia have no self-control when binge eating and feel extremely
ashamed afterwards. Unlike anorexia, bulimia patients extremely care about how
others judge their weight, although bulimia patients have a normal BMI or are
slightly overweight. Therefore, patients purge by self-induced vomiting or abusing
laxatives/diuretics. The frequent vomiting causes gastric alkalosis, gastric ulcers,
rapturing oesophagus (borehaave syndrome), and dental enamel erosion. To be
diagnosed, Binge-purge episodes need to be a minimum of once a week
continuously for three months. Female morbidity is ten times than males.
Hospitalised patients with eating disorders should be observed during mealtimes
and for 1 hour after eating.

Eating disorders need

Electrolyte supplements. Electrolyte repletion is necessary in patients with
profound malnutrition, dehydration, and purging behaviours; repletion may be
done orally or parenterally, depending on the patient’s clinical state.
Fat-soluble vitamins. Vitamins are used to meet necessary dietary requirements.
They are utilised in metabolic pathways, as well as in deoxyribonucleic acid (DNA)
and protein synthesis.

CBT which is the primary treatment, combined with antidepressants, has a

superior effect than CBT itself. Bupropion is contraindicated to all eating disorders
as bupropion increases epilepsy risk.
Substance abuse:
Stimulant withdrawal causes massive parasympathetic effects, and depressant
withdrawal causes more than massive sympathetic effects, which are more
dangerous.
Smoking cessation takes 5-7 times attempts on average. Varenicline is more
effective in smoking cessation than bupropion, but varenicline has a risk of
causing depression, and varenicline is contraindicated to the history of psychosis.

Ethanol is a GABA agonist. Ethanol is hepatotoxic, manifested as high AST than

ALT. Delirium tremors (DTS) has 5-15% of mortality by epilepsies or cardiac arrest.
mild DTS usually starts 2-3 days of abstention. DTS symptoms are delirium which
refers to drastic fluctuations of mental status change, Irritability, heightened
alertness, jerky movements inattention, disorganised thinking and
unconsciousness, tremor, seizures, extreme vital signs instability, and visual
hallucinations (delirium). Patients might develop epilepsy due to sympathetic
overstimulation during alcohol withdrawal. The total mortality of alcohol
withdrawal is 35%.
Alcohol withdrawal treatments:
Benzodiazepines are used during withdrawal to counteract sympathetic effects.
Acamprosate is a GABA agonist but milder than benzodiazepines.
Disulfiram breaks down alcohol metabolism and increases acetaldehyde causing
ethanol intoxication symptoms like vomiting and headache. Metronidazole has
similar effects to disulfiram.
CBT, family support groups emphasise the importance of changing one’s own
behaviour rather than trying to change the behaviour of the individual with a
substance abuse problem.
Delirium is not a psychiatric disorder but a manifestation of underlying physical
issues or substance intoxication/withdrawal (depressants like ethanol).
Precipitating factors are infection, intoxication, pain, dehydration (electrolyte
imbalance), and constipation. Delirium is a medical emergency. For patients in
ICU, the prevalence of delirium may reach as high as 80%. Patients who develop
delirium during hospitalisation have a mortality rate of 22-76%, with high
mortality after discharge.
Delirium is a syndrome characterised by the rapid onset and fluctuation of altered
mental status (disorientated), attention and consciousness. Delirium typically can
last from several hours to several days. The three subtypes of delirium are based
on psycho-motor features, including hyperactive, hypoactive, and mixed
presentations. Hypoactive patients are at the greatest risk.
The Confusion assessment method (CAM) tool assists in differentiating between
dementia and delirium. Patients with dementia are five times more likely to
develop delirium. Dementia and delirium are similar, but delirium has drastic
fluctuations and high vitals. Not sure? Treat as delirium.
CAM consists of assessing the following four features, and Delirium diagnosis is
made when there is a positive response to Features 1 and 2 plus 3 or 4
1. Acute onset mental status change or fluctuating course (patients prone to
experience visual hallucinations instead of auditory.)
2. Inattention
3. Disorganised thinking (delusions)
4. Altered level of consciousness
The CAM assessment should be completed on admission and on every shift for
the first 5 days. CAM assessment continues until 48hours of scoring zero on the
CAM tool". Additionally, CAM can be initiated when a change in cognition, altered
mental status, or attention is identified.
Treatment includes nutrition to help with electrolyte balance and assisting with
the immune system against underlying medical conditions. Antipsychotics,
anxiolytics or hypotonic are used for mental status fluctuations.
Medication Treatments

Check if it's the right patient by checking name, DOB, and NHI, and staying with
the patient and making sure they swallow it.
Check if it's the right medication by checking the generic name, indication,
standard dose, and contraindications. For Non-PO medications (IM, IV, SC) or
controlled drugs, MUST be crossed checked
Check if it's the right dose.
Check if it's the right route.
Check if it's the right time of administration against prescription and when the
medication was last given.
Patients' medications must be stored in the ward/unit medication area. If patients
refuse the medication, the medication name, the reason for refusal, and the
informed prescriber's name must be recorded on clinical notes.

ANTIDEPRESSENT:
SSIRs safety
 SSRIs increase suicidal thoughts, especially 18-24 yrs, from the first few
weeks of treatment. More energy (serotonin) without changing in
depression is a significant suicide risk. Always identify suicidal thoughts,
including unusual behaviours, worsening depression, and sudden mood
changes.
 SSRIs have a slow onset and slow taper-off. Educate pts the meds take 2 to
4 weeks at least to work, and a decreased sexual desire might happen.
 Never mix SSRI with St john wort, MAOIs (at least two weeks washout
period or even food like cheese, organ, pickles, chocolate or beer), and any
other antidepressants. High levels of serotonin induce serotonin syndrome.
  All psych drugs decrease bp, so monitor regular vital signs and risk of falls
(orthostatic hypotension), might weight gain.
 Extra cautious for bipolar as SSRIs trigger mania
SSRIs are
Citalopram- the first line but affects cardiac rhythm. ECG for elderly patients.
Escitalopram- first line and twice potent as citalopram. Cleanest enzyme reaction.
Fluoxetine- long half-life of around seven days. Five weeks washout time, and
other antidepressants are two weeks. Aware of serotonin syndrome when
switching to other medications.
Paroxetine – short half-life, contraindicated during pregnancy.
Sertraline should be administrated with food to lower GI disturbance. Sertraline is
the safest for breastfeeding but causes sexual dysfunction.
Fluvoxamine - OCD
SSRI usually does not cause sedation but insomnia and nausea. A/Es are all
related to an increased level of serotonin and usually improve after three months.
 Weight gain
 GI disturbances. Most of serotonin is in GI for digestion.
 Insomnia as serotonin is associated with energy.
 Sexual dysfunction like sertraline as serotonin is associated with
satisfaction.
 Suicidal thoughts, especially for patients aged 18-24 yrs, report more
energy but unchanged depression; that’s a considerable risk factor for
suicide.
 Might be anti-platelet.
  Slow onset as antidepressants usually takes two weeks to work and four
weeks to reach full effects. Always taper off and never stop abruptly.
 Serotonin syndrome. Serotonin syndrome is a medical emergency.
CONTRAINDICATION SSRIs+ST JOHN WORT+TRAMADOL+MAOIs. Serotonin
syndrome symptoms are vitals instabilities, Hyperthermia (> 40°C),
diarrhoea, clonus (heaps of reflex in a short time), and hyperelexia.
Subsequently, serotonin syndromes cause muscle breakdown.
Rhabdomyolysis manifests as a high creatine kinase level or CPK where
muscle breaks down and myoglobin travels intravascularly and blocks
tubules of the kidneys causing renal failure. Concurrent with a statin, which
lowers LDL and triglyceride or fenofibrate, which lowers triglyceride,
increases the risk.) and coma and death.
SNRIs
Same A/Es as SSRIs also have symptoms related to overactive sympathetic effects
like tachycardia and hypertension (noradrenaline).
 Duloxetine for depression also neuro/chronic pain (fibromyalgia). Some pts
could only have fibromyalgia, not depression, so pt education is essential.
 Venlafaxine can cause hypertension due to noradrenaline caused
sympathetic stimulation.
 Mirtazapine is good for increasing appetite and insomnia (antihistamine
effects).
DNRIs
Bupropion is good for mood lifting and not causing sexual dysfunction. Mainly
indicate for quit smoking. High seizure risk and contraindicated to bulimia.
TCA
Tricyclics increase the reuptake of noradrenaline, serotonin, and antagonist
acetylcholine and histamine (parasympathetic).
 Amitriptyline- indicated for migraine, neuropathic pain and insomnia, can
cause orthostatic hypotension; get tripped! So slow position changes. Also,
other anticholinergic effects like dry mouth, blurred vision, and
constipation.
 Nortriptyline- same as above
 Imipramine inhibits urination (anticholinergic), so indicated for bedwetting.
 Clomipramine- indicate to OCD
 Desipramine
 Doxepin
 amoxapine
TCAs indicate fibromyalgia too. A/Es are tachycardia, blurred vision, urinary
retention, dry mouth, and constipation (anticholinergic=physical sympathetic
effects). TCAs are sedatives. Contraindicated to MAOIs and other antidepressants
due to the risk of causing serotonin syndrome. Sodium bicarbonate is the
antidote.
MAOIs are the big gun but the last line due to the massive hypertension risks.
 1. isocarboxazid
 2. phenelzine
 3. tranylcypromine
 4. Selegiline only involves dopamine (MAO B), indicated to Parkinsons
Monoamine oxidase kills dopamine, serotonin, adrenaline and noradrenaline.
MAOI inhibits monoamine oxidase. MAOIs’ set of action of approximately 3 to 5
days. A full clinical response may be delayed for 3 to 4 weeks. The therapeutic
effects may continue for 1 to 2 weeks after discontinuation.
M-massive hypertension and stroke risks. The key sign is a massive headache.
A-Avoid tyramine, an amino acid, is a kind of hormone to regulate BP. Combined
with MAOI would cause extreme hypertension. The combination causes IHD or
stroke. So BIG NO TO FERMENTED/AGED FOODS like WINE, CHEESE, BEER,
ORGANS, SAUSAGE, and CHOCOLATE. Two weeks before MAOI and TWO weeks
after MAOI stop.
O- avoid other meds like calcium, antacids (aluminum, calcium, and magnesium),
paracetamol, NSAID and other antidepressants. Two weeks washout period.
I-increased suicidal risks. No change in depression, but more energy is a
significant suicidal indicator.

Mood stabiliser:
Lithium salts are given for the long-term treatment of depression, mania or
hypomania and prophylaxis in bipolars and schizophrenia. Lithium is great for
suicide prevention. Lithium therapeutic ranges are between 0.6 to 1.2, and >1.5 =
lithium toxicity. Lithium takes 2 weeks to work.
The risk factors of lithium toxicity are
 Impaired renal function as being elderly or kidney disease
 less tissue perfusion to the renal system by NSAIDs/diuretics and
dehydration, causing less lithium to be excreted.
Both factors lead to more lithium concentration in the blood and increasing the
incidence of lithium toxicity. Signs of impaired renal function are tinnitus, BUN 5-
20, and creatine 0.6-1.2.
Lithium is contraindicated to
 Pregnancy as lithium is teratogenic.
 All NSAIDs, like ibuprofen or aspirin, swap to paracetamol instead.
Ipratropium is a short acting anticholinergic bronchodilator that causes
dehydration.
 All diuretics, coffee or being hyponatremia (135-145) as they cause
dehydration-related issues.
Common A/Es are drowsiness (avoid driving), thirst, mild GI disturbance,
therefore, risks to anorexia/malnutrition.
Encouraging patients to increase sodium and water intake to 1-3L/D.
Report symptoms of lithium toxicity. Early symptoms include GI disturbances like
vomiting or diarrhoea (dehydration), and late signs are related to neuromuscular
excitability such as polyuria(overparathmpathetic), ataxia, tremor, tics, and even
mood change. Active charcoal is the antidote.
Severe A/Es of lithium are tremors, nephrotoxicity, especially during dehydration,
hypotension, hypothyroidism causing depression, and teratogenic.

Anticonvulsants used as a mood stabilizer:

 Anticonvulsants inhibit sodium channels and agonist GABA. They are
effective for preventing switching to mania, like carbamazepine, which is
also for trigeminal neuralgia. However, carbamazepine can cause
agranulocytosis, which increases the risk of infection. Watch
WBC/neutrophils 4.5-11 and signs for infection flu-like symptoms like fever
sore throat. Also, watch for Steven Johnson syndrome manifested as rush,
 which is a medical emergency. Carbamazepine disables contraceptive
meds. carbamazepine takes 2 weeks to work.
 Sodium Valproate (Epilim) is an anticonvulsant, used for treating mania.
Valproate agonists GABA like benzo. Sodium Valproate (Epilim) is liver-toxic
(hepatotoxic), teratogenic, and hyponatremia (with lithium). Therefore,
watch for increased bilirubin (<1 RBC by-product, signs of jaundice are
yellow eyes, face, and skin but not in stool and urine), ammonia (15-45,
protein digestion by-product, cause coma), ALT/AST, and
thrombocytopenia (like heparin, low platelets number and tiny platelets
blocks vessel, therefore, no tissue perfusion). Sodium Valproate (Epilim)
disables contraceptive meds and is contraindicated to pregnancy. Valproate
takes 1-2 days to work.
 Lamotrigine used for treating depression and cause itchiness.

Anxiolytics/hypnotics:
Anxiolytics indicate anxiety and insomnia.
Agonist GABA causes sedation, euphoria, muscle relaxation, and lower RR.
Benzodiazepines indicate anxiety, insomnia, antiseizure, and alcohol withdrawal.
Benzodiazepines are CNS depressants that increase the frequency of GABA
channels opening. Usually, the names include AZE, LAM and PAM. Midazolam
short half-life 1-12hrs. Alprazolam, temazepam, and lorazepam 12-40 hrs.
Diazepam 40-250 hrs.
Benzodiazepines are strongly sedative, so they impair motor coordination.
Benzodiazepines have HIGH risks of abuse and respiratory depression. Therefore,
benzodiazepines are Contraindicated to respiratory infections, ethanol or opioids.
Take extra caution for elderly patients or when patients are concurrent with
antipsychotics like haloperidol, fluphenazine, clozapine, quetiapine, and
olanzapine. Flumazenil is the benzo antidote.
Barbiturates increase the duration of GABA channels open. They are rarely used
now.
Buspirone is an anxiolytic that works as a partial serotonin agonist. Buspirone has
no sedating effects, no sexual dysfunction, no weight gain, and no addiction. But
buspirone takes two to four weeks to work.

Sedatives/hypnotics
Temazepam
Zopiclone indicates short-term (< 10 days) insomnia treatment. Zopiclone is less
addictive than benzodiazepines, causes sleepwalking and haves no anxiolytic
effects. Zopiclone can give biteer tastes for a extended time.

Antipsychotics
Typical antipsychotics inhibit dopamine D2 receptors but can induce Parkinson's
disease and worsen negative symptoms that Generally make people dumber. So
Typical antipsychotics are used when atypical antipsychotics fail. Haloperidol (IM)
or fluphenazine are high-potency typical antipsychotics. Haloperidol and
fluphenazine indicate positive symptoms, and they are strongly sedative. So,
Haloperidol and fluphenazine are often used in acute agitation or aggressiveness
concurrent with lorazepam to alleviate positive symptoms. However, nurses need
to be cautious regarding respiratory depression.
The unharmful A/E is extrapyramidal syndrome which affects muscle
rigidity/tremors. The manifestations of ESP are similar to Parkinson such as
muscle spasms of the face and tongue. Extrapyramidal symptoms include acute
dystonia (muscle spasm or rigidity like can't close the mouth, starts after 4 hrs of
administration), akathisia (motor restlessness like coffee jittery, 4 weeks), akinesia
(forzen, 4 months), and tardive dyskinesia (involuntary movements like blinking,
lip smacking, or chewing)
Serious side effects are:
The neuroleptic malignant syndrome is a medical emergency caused by typical
antipsychotics and clozapine. Criteria are symptoms of Hypertension, Tachycardia,
Tachypnoea, Hyperthermia (> 40°C), diarrhoea, and decreased reflex., plus recent
typical antipsychotic drugs or clozapine use. The treatment includes dantrolene
which is a muscle relaxant for the rigidity or dopamine agonists like
bromocriptine.
 Haloperidol and fluphenazine give anticholinergic effects like the physical
part of sympathetic effects such as tachycardia, dry mouth, constipation,
and urinary retention.
 Strongly sedative, especially when Haloperidol and fluphenazine are
concurrent with a benzodiazepine like lorazepam. Monitor RR depression.
 Haloperidol and fluphenazine cause widened QT intervals (torsade de
pointes, medical emergency); therefore require regular cardiac monitoring.
 Haloperidol easily causes sun burn.
 Zuclopenthixol/clopixol strong agranulocytosis
Atypical antipsychotics inhibit dopamine and serotonin receptors. They have
lower risk of causing extrapyramidal syndrome but cause metabolic syndromes
such as weight gain, hyperlipidaemia, and hyperglycaemia. Especially in clozapine
and olanzapine.
Olanzapine is the first-line atypical antipsychotic. Olanzapine causes obesity and
sedation. Zyprexa Relprevv is the IM version of Olanzapine
Clozapine is used for refractory cases and great for suicide prevention. Common
A/Es are hypersalivation and sedation. Clozapine is the only atypical antipsychotic
causing agranulocytosis=low WBC<4.5-11, sore throat, fever, and flu-like
symptoms. Regular weekly CBC for 18 weeks, then monthly check. Clozapine is
contraindicated to dementia and severe renal and cardiovascular disorders.
Clozapine can cause extrapyramidal syndrome (muscle rigidity/tics/tremors),
neuroleptic malignant syndrome (medical emergency, hyperpyrexia, muscle
rigidity), obesity, orthostatic hypotension and sedation.
Risperidone is less sedative but causes orthostatic hypotension.
Quetiapine is similar to risperidone but very sedative and causes increased
appetites/obesity.
Ziprasidone causes hypotension and widened QT intervals (torsade de pointed,
medical emergency); therefore requires regular cardiac monitoring.
Aripiprazole, light potency
Non-medical treatment:
Electroconvulsive therapy
ECT indicates clinical depression, schizophrenia, and bipolar disorder if
medications don't work, or if the patient has a high suicidal risk. ECT performs
with general analgesia and lasts 15-20s, deliberately causing seizures. So ECT is
contraindicated to anticonvulsant medications. The regimen is 2-3 times weekly
for 6-12 ECTs in total. NBM 6-8 hours before ECT performing. Access if the patient
has a history of MI or neoplasm presents. Remove dentures or eye contact lenses.
suxamethonium will be administered suxamethonium is a depolarizing muscle
relaxant causing paralysis. It is used to reduce the intensity of muscle contractions
during the convulsive stage, thereby reducing the risk of bone fractures or
dislocation. A/Es are temporary memory loss and potential suffocation. Needs
ECG, oxygenation, suction, and red trolley ready before performing ECT. The
patient is not allowed to drive during the whole treatment period.
Psychotherapy:
Cognitive behavioural therapy (CBT) can improve functioning both during and
after depressive episodes and CBT has long term effects. CBT sessions take 1 hr
and 4 times weekly. CBT works on thoughts (im worthless)-feeling (depression)-
behaviour (stay on bed) cycle and hit the thought part. The patient expresses
their thoughts, including free associations, fantasies and dreams for correction.
The patients would be taught to modify their thoughts and therefore mood and
actions to alleviate anxiety and worrying and avoid them in future.
Exposure& response therapy works for specific phobia and PTSD by exposing the
patient to the afraid things in a gradual manner like showing a photo until the
patients get used to it.
Why imi clopixol=zuclopenthixol, paliperidone=respiridone

Glossary
Neurotransmitters are monoamines, amino acids, purines, and peptides.
Monoamines are:
 Serotonins and catecholamines. Catecholamines are dopamine,
adrenalines, and noradrenaline.
 Serotonin =5-HT comes from raphe nuclei. Increased serotonin levels are
related to satisfaction, sociality, migraine, antiplatelet effects, high GI utility
and nausea. Low in anxiety, impulsivity, and sex drive.
 Noradrenaline is released in the brain for fight and flight, so it helps with
concentration.
Amoni acids are:
 Glutamate is excitatory, is the on switch of brain. Excessive glutamate
causes neuro death and epilepsy.
 GABA is inhibitory, is the off switch of the brain.
Peptides are:
 Oxytocin is crucial for interpersonal bonding and intimacy like Mon and kids
or sexuality. MDMA gives a lot of oxytocins.
  Endorphins are released to bind with opioid receptors for pain reliving.
Purines:
 Adenosine supressing arousing and improving sleeping
Acetylcholine:
 Acetylcholine works on the parasympathetic system and causes
bradycardia (anticholinergic for COPD), increasing GI mobility, salivation,
lacrimation, urination (anticholinergic for bladder overactive), libido, and
muscle contraction (orphenadrine for muscle pain). Acetylcholine can be
exciter by works on the hippocampus for positive cognition effects.
Anticholinergic=anti acetylcholine and its similar to the psychical part of
sympathetic effects
Opioids cause analgesia, potential respiratory depression, miosis (constricted
pupil is a typical sign of opioid toxicity), drowsiness, and constipation.
1st histamine works centrally and peripherally, indicating insomnia, and 2nd
histamine only works peripherally, so it won't cause sleepiness.
Before administrating medications:
5 Rights of Medication administration
Right Time
Right Dose
Right Drug
Right Route
Right Patient
+3
Right to refuse,
Right indication
Right documentation

Term Meaning
Mane Meaning
Midi Midday
Nocte Night
OD Once daily
BD Twice daily
TDS Three times daily
QID Four times daily
Q4hrly 4 hourlies
Q6hrly 6 Hourly
Once Once A week (specified
Weekly day)
PRN As required
STAT immediately
A Absent
F Fasting
R Refused
V Vomiting
N Not available/Not given
W Withheld
SAM / SM Self-administered
INH Inhaled
IM Intramuscular
Intranasal Intranasal
IV Intravenous
INJ Injection
NEB Nebuliser
NG Nasogastric
PO Per Oral
T 1 x Tablet
TT 2 x Tablet
Tab tablet
Cap Capsule
PEG Per percutaneous
enteral gastrostomy
PR Per Rectum
PV Per Vagina
PICC Peripherally inserted
central catheter
SC Subcutaneous
T Topical
R) Right
L) Left
g Grams
mg Milligrams
mcg Micrograms
L Litres
mL Millilitres

MDI Metered dose inhaler

Pess Pessary
Supp Suppository
PCA Patient controlled
analgesia
mmol Millimoles
% Percent
Oint Ointment

Mental status exam

 Appearance
 Behaviours
 Speech
 Mood
 Thoughts form and content
 Perception
 Cognition
 Insight
 Risk
Appearance
1. Personal hygiene/grooming, is the patient taking care of themselves
 2. Weight, is the patient taking care of themselves and also eating disorders
like anorexia or bulimia.
3. Clothing, is patient’s clothing appropriate to the whether
4. Distinguished features like signs of using intravenous drugs or stare-like
feature (masked face) for Parkinson
5. odor
Eg, mid age male maori, patient is well groomed, clothing is appropriate to the
whether. Nil distinguished feature noticed.
Behaviours
1. Is the rapport established? General interaction between client and nurse.
2. Eye contact
3. Facial expression
4. Posture, relax, stooped,
5. Gait, fast/slow
6. Coordination of movements
7. Psychomotor activity like psychomotor retardation (patient is not moving at
all ) or restlessness (another extreme)
8. involuntary movements like tics, tremors (Parkinson or lithium side effect).
Eg, moderate rapport established, limited interaction and eye contact between
the client and the nurse. Facial expression is apathetic. Normal psychomotor
activity. Tics noticed.
Speech
1. Rate of speech, fast or slow
 2. Amount (quantity) of speech, excessive and difficult to interrupt
(schizophrenia), limited or minimal (depression or dementia), is speech
spontaneous?
3. Tone of speech, Monotonous speech refers to flat and boring speech,
everything sounds same and hard for the listener to access the speaker’s
mood. Monotonous speech is associated to depression, dementia, and
negative symptoms of schizophrenia. Tremulous voice refers to shaky
voice/anxiety.
4. Volume of speech
5. Fluency of speech. Any stammering or slurry.
Eg. The rate of speech is fast, excessive amount of speech and hard to interrupt.
High speech volume.
Eg.2 slow speech with low volume. Non fluent, minimal amount, monotonous
speech noticed.
Mood
Mood is how the patient describes their emotional status. Mood subjectively
refers to how the patient describes their feelings. Asking the patient how would
they use a word to describe their mood or asking patients to scale their mood
from 1 to 10 based on a specific object like anxiety or sadness, but not happiness.
Mood objectively refers to the nurse’s observation. Mood can be euthymic
(normal), angry, euphoric, apathetic (dull/flat), dysphoric (sad), and apprehensive
(anxious). Mood and affect are not necessarily congruent. Only write objective
mood if not congruent with subjective mood.
Eg, patient subjectively worrying and describing his anxiety 5 of 10. but
objectively euthymic.
Affect is patient’s facial expression. Don’t use the words to describe mood for
affect.
1. Appropriate or inappropriate- is patient a weirdo? a
2. Intensity
3. Mobility- how quickly the affect is changed
4. Range. Fixed affect refers to no facial expression changes at all. Restrict
affect refers to limited changes. Labile affect means patient’s facial
expression changes like a roller coaster.
Eg, inappropriate, high intensity and mobility. Labile range affect noticed.
Thoughts
Thoughts form supposed to be linear and logical.
1. Circumstantial thoughts, patients can eventually reach the wanted answer
but talks a lot of irrelevant things (meandering)
2. Tangential thoughts- patients answer get more and more far away from the
topic. Flight of ideas is worse and then knights move.
3. Thought block, patient stops in the middle of sentence and unable to carry
on.
Thoughts content refers to the ideas or beliefs in patients mind. Asking patients
whats in your mind lately or do you have any idea of harming yourself or others.
1. Overvalued ideas, eg I'm too fat anorexia
2. Compulsion, I know its wrong but I cant stop thinking about it.
3. Obsession, similar to compulsion but worse
4. Delusional thoughts. Patient can’t distinguish the difference between
reality and his mind and he strongly believes it like oh the tv is talking about
me. My wife cheated. FBI is watching me.
 5. Suicidal/homicidal thoughts/ideation.
Eg, patient thought form is linear and overvalued thought noted that she thinks
she is overweighted but actually BMI 12. Nil suicidal or homicidal ideation
noticed.
Perception
Perception refers to sensation or ability to accurately take information in
surroundings.
1. Auditory or visual hallucinations. Patient sensors something non exist or
without stimuli. Auditory hallucinations are common among schizophrenia
and visual hallucinations are common in delirium.
2. Illusion, see a thing in an exaggerated approach. Like see a leaf as a cat.
3. Depersonalization, patient thinks himself non exist,
4. Déjà vu, thinks something happened already happened before.
5. Continuity and affecting behavior.
Eg, visual hallucinations subjectively. “i heard someone tells me to do something
and the voice is always there.” patient then scrammed.
Cognition
1. Is patient orientated to time, place, and people.
2. Is the short and long term memory intact.
3. Concentration
4. Can the patient reads the clock?
Eg, patient is orientated to time, place, people. Short and long term memory
intact. Patient can concentrate during the conversation.
Insight
Do you know why you are here?
How do you think about the disease？
Judgement
What would you do if the house is on fire?
Eg. Patient aware the reason of admission and can answer questions with normal
judgment.
Nursing clinical notes:
Notes written by S/N Yaoling Wen and supervised by RN xxx.
Shift activity:
Patient spent the majority of time in … doing … attended group activity etc.
Mental state examination
appearance/behavior:
Mid age male Māori. patient was well groomed. Clothing was appropriate to the
whether. Nil distinguished features noticed. Moderate rapport established, with
limited interaction and eye contact between the client and the nurse. Facial
expression is apathetic. Normal psychomotor activity. Tics noticed. Slow speech
with low volume. Non-fluent, minimal amount, monotonous speech noticed.
Mood/affect:
Patient subjectively worrying and describing his anxiety 5 of 10. but objectively
euthymic. Affect was inappropriate, high intensity and mobility. Labile range
affect noticed.
Thought form/content:
Patient thought form was linear and overvalued thought noted that she believes
she is overweight but actually low BMI. Nil suicidal or homicidal ideation noticed.
cognition/memory:
Audial hallucinations subjectively. “I heard someone telling me to do something,
and the voice has been there mostly.” patient then screaming. Patient was
orientated to time, place, and people. Short- and long-term memory intact.
Patient could concentrate during the conversation.
Insight/judgment:
Patient was aware of the reason for admission and could answer questions with
reasonable judgment.

Current risk management/risk factors:

History of self-neglect, self-harm and nutritional deficit
Risk of self-neglect
Risk of malnutrition
History of drug abuse.

Physical assessment:
Patient is underweight, BMI 16.
Accepted meds as charted.
Reported constant lightheadedness and BNO since two days ago (11/02).

Covid status:
Nil covid symptom

Summary/plan:
Offer XX x mg BO/PO
Increase mirtazapine to 30mg Nocte/PO
Encourageing physical exercise
Dr X will call X’s family and the next in person consultation will be on 17/03
Key worker looking for support persons, social worker following up

Activity: Clinical Intervention Location: Cornwall House

Catherine was seen at CWH with her CSW. RN Priyanka and SN Yaoling presented. Notes reviewed by RN
Priyanka.
Appearance: Clothing appropriate to the weather. Moderate self-cares. There are areas that are lacking.
She presented as slightly malodorous. K/w advised this is her baseline.
Behaviour: Moderate rapport established with limited interaction but good eye contact. Euthymic facial
expression and normal psychomotor activity noticed.
Speech: fluent and moderate tone, volume, rate of speech. Limited amount and non-spontaneous.
Mood: subjectively "good". Restricted affect during the conversation.
Thought form: linear and logical
Thought content: Catherine stated she is now working closely with "workwise" to be employed as a
cleaner. Her older daughter visits her weekly, not the younger daughter as she has a busy life. She
believes her younger daughter has been achieving in her career. Expressed concerns about shopping
and solving her dental issue as the support worker is unavailable. She believes the problem will be
solved once her car registration is done. The client states she has been adherent to the current regimen
without affecting her sleeping.
Nil evidence of any psychotic symptoms. Questions around risk not assessed although, Catheirne has
reported mood to be “ok” and she is future-focused (plans to get work, clean house etc).
Cognition: patient orientated to time, place, people. Short term memory intact. Patient can concentrate
during the conversation.
Insight/Judgement: partially intact as the client is not aware of the relationship between keeping the
house clean and her mood.
RN Priyanka suggested she stop Zopiclone, continue with 75mg quetiapine for a week, and see her
sleeping quality without Zopiclone.
Current risk management/risk factors:
History of self-neglect, noncompliance to medications, and substance abuse. There is risk to self in the
context of her delusional beliefs at the time. Her beliefs however, are now in remission. There is on-
going risk of neglect in the form of the unclean, unhygienic status of her house- which appears to have
become an issue again.
Physical assessment:
Adhere to meds as charted.
oedema noticed on her fingers and feet.
Plan:
k/w review in 4-5 weeks
Stop taking Zopiclone for a week and see if the client can sleep well without it.

Activity: Clinical Intervention Location: Home

IMI risperidone consta 25mg administered by RN Priyanka to right dorsogltueal muscle without issue
and with Kim's consent. Notes reviewed by RN Priyanka.
Appearance: A mid-age Asian female presented and moderately groomed. Clothing appropriate to the
season. Nil distinguished features noticed.
Behaviours: Moderate rapport established with limited interaction but good eye contact. Euthymic
facial expression and normal psychomotor activity noticed.
 Speech: fluent and moderate tone, volume, rate of speech. Limited amount and non-spontaneous.
Mood: subjectively the patient denied any current issues/ concerns. She also reports mood to be good.
Restricted affect during the conversation.
Thought form: linear and logical
Thought content: Kim stated she is happy with her mental status and the support received from her
sisters. Reduced mobility. Nil delusions/suicidal thoughts noticed.
Perceptions: didn’t assess for voices or other perceptual disturbances, however she also didn’t present
as distracted or responding to NAS.
Cognition: patient orientated to time, place, people. Short and long term memory intact. Patient can
concentrate during the conversation.
Insight/Judgement: The client aware the reason for taking medications.
Current risk management/risk factors:
History of self-neglect, self-harm, noncompliance to medications, and nutritional deficit. Can be
triggered by the symptoms of extrapyramidal syndromes like akathisia or feelings of hopelessness or
due to poor sleep, which usually results in an increase in voices/ and other symptoms like headaches-
these are all very distressing for Kim.
Physical assessment:
Accepted injection as charted.
The client stated good compliance with the drug and nil complaint with arthritis.
Summary/plan:
Encouraged with outdoor activities at least twice a week, and client agreed.
Next IMI risperidone consta due in 3 weeks

Michael was seen at CWH with his CSW. RN Priyanka and SN Yaoling presented. After gaining
the client’s consent, IMI Paliperidone 75mg was administered by RN Priyanka to the right
dorsogltueal muscle without issue. Notes reviewed by RN Priyanka.
Appearance: The client wears more layers than necessary as he wears a sweater with a puff
jacket and a beanie. Moderate self-cares. He presented as slightly malodorous and scratching
due to scabies. Dirty nails noticed. Michael disclosed he showered twice a week. He expressed
that he would like to have more showers, but getting in and out of the bath tab is discomfort.
Behaviour: Moderate rapport established with limited interaction and eye contact. When not
talking the client often kept his eyes closed. Euthymic facial expression.
Speech: Slow and a bit slurred with a moderate tone, volume, and rate of speech. Limited
amount and non-spontaneous. Informed by K/W, this is because Michael had a long session
before, and he was probably tired.
Mood: subjectively "a bit anxious" due to the housing issue. Restricted affect during the
conversation.
Thought form: linear and logical
Thought content: The client stated he often eats only two meals, often weebix. He may have a
low appetite and might prioritise other things than food intake. The client also stated he gets
enough sleeping at most of the time. He still uses cannabis daily and asked his GP to prescribe
him medical cannabis. He admitted he used methamphetamine a week or four weeks ago but
could not give a specific timeline. K/W informed it was possibly 3 or 4 weeks ago as he did not
present in a depressed mood. Regarding his housing issue concern, he explained moving to his
friend is not optimal, but he has no choice. He is unsatisfied with his current residence as he has
to climb up and needs more support. On the other hand, the current place is stable and has a
long-term plan to support him, but the funding needs to be solved.
Perception: Nil evidence of any psychotic symptoms. Questions around the risk of self-harming
or others were not assessed.
Cognition: patient orientated to time, place, and people. Impaired short memory noticed
multiple times. Sometimes could concentrate on the conversation.
Insight/Judgement: The client has he is still using cannabis daily but does have limited
awareness of how methamphetamine has affected his mood and sleeping.
History of self-harm and aggressiveness, actively seeking and using cannabis daily and using
methamphetamine sometimes, and risk of self-neglect/malnutrition.
Physical assessment: Accepted injection as charted.

Summary/plan:
Next IMI Paliperidone 75mg due in 4 weeks
CSW will bring the client’s IDs to reception next week regarding the name changing.
Reassuring the client of his accommodation issue with Kainga Ora.

How is your sleeping pattern and energy level like. Do you think your energy level has been increasing or
decreasing? Are your able/are you motivated to attend any outdoor activities like walking. SOB?
Daily Food/fluid intake (he has been improving in appetite in a monthly manner)? Constipation (now
laxative reduced)? Chest pain? ECG yearly? Heart beating? Do you feel Dizziness during afternoons (so
less caused by clozapine) When? Other Vitals? EWS? Notice any swelling on anywhere?
How’s your talking and sociality/reactivity? Concerns with his driving? Explaining the benefits of BRC and
Occupational activities. How does the mom think about the BRC idea? Asking the awareness of
occupational activities and the necessity and dates for the next FBC
When not adhere to meds with psycho stressors he has SI/HI so asking does the client feel benefited
from clozapine? Do you want to stop taking clozapine? Why? Would the hypersalivation be a reason for
you to stop taking clozapine? Have you been skipping/forgetting taking any medication due since last
visit?
How is your hypersalivation? Do you think any better with the terazosin and benzatropine combination?
Any thoughts about the meds like Have you noticed any new unwanted effects by the medications? Do
you want to have them both or just one?
How is your memory like (he could not remember attending appointment)
Signs for visual/audio hallucinations? What’s the content?
OCD handwashing? questions Delusional thoughts as the bizarre ideas/religious delusion/delusion of
persecution were noticed by families?
Signs of Self-neglect? Still no responding to eating and showering when mom pushing?
Wanna talk about what happened in your otago uni life?
Selective mutism so mostly will the families to answer
he seems enjoys the sedative effect?

Mariper was seen at CWH. Doctor Zerisha, RN Priyanka and SN Yaoling presented. Notes
reviewed by RN Priyanka.
The patient presented with appropriate grooming. Objectively euthymic. The patient
mentioned she had a “lapse” four days ago but it did not affect her ADLs. Other than that things
are going well. The patient complained of impaired cognitive functioning that she needs to read
multiple times to fully understand. The patient disclosed with Aripiprazole, her sleep time
increased from six hours to 8-9 hours, usually from 9 pm to 6 am, and she had a good energy
level. Patient education was provided regarding her diet for T2DM. Confirmed with the patient
that the next IMI will due on 25/3.

Indu was seen at CWH with her CSW Cheyne. Doctor King, and SN Yaoling presented. Notes
reviewed by RN Priyanka.
Appearance: A South Asian female presented and moderately groomed. Clothing appropriate to
the season. Nil distinguished features noticed.
Behaviours: Moderate rapport established with good interaction and eye contact. Normal
psychomotor activity noticed.
Speech: Fluent and moderate amount, tone, volume, and rate of speech. Spontaneous.
Mood: Subjectively the patient denied any current issues/ concerns. She also reports her mood
to be good. Objectively euthymic facial expressions and laughs sometimes. Affect congruent
during the conversation.
Thought form: linear and logical
Thought content: Indu stated she is generally happy with her mental status and believes her
father passed at a good age. CSW stated Indu expected the situation of her father and did not
overly present with grieving. Indu and her CSW disclosed Indu sleeps from 2015 to 0730 and
has a good energy level during day times. Indu mentioned she attends gym sessions and goes
for a walk on a regular basis. Indu denied any delusional thoughts or thoughts of
self-harm/harming others. CSW mentioned Indu’s mood has been good with occasional
agitation, no slurred speech and a smooth train of thought. Additionally, CSW said Indu did not
need to take her PRN quetiapine to maintain her mood. Indu mentioned her son might will take
Indu to Australia for a 4-6 weeks holiday.
Perceptions: Indu denied any psychotic symptoms.
Cognition: patient orientated to time, place, and people. Patient could concentrate during the
conversation.
Insight/Judgement: The client showed fair insight and judgement.
Current risk management/risk factors: History of self harm/harm others.
Physical assessment: Nil
Summary/plan:
Next IMI due Tuesday 04/04

Kolila was seen at her residence with her husband. RN Priyanka and SN Yaoling
presented. Notes reviewed by RN Priyanka.
Appearance: Clothing appropriate to the weather and good grooming.
Behaviour: Moderate rapport established with interactions and good eye contact.
Euthymic facial expression with occasional smiles. No extrapyramidal syndrome
symptoms were noticed or reported.
Speech: fluent and moderate tone, volume, rate, amount of speech. Sometimes
spontaneous.
Mood: Subjectively "concerned about the pain and the referral issue with the
rheumatology team". Objectively Kolila was frustrated when she hear that her
referral was not successful. Although Kolila has been calm during most of the
time. Affect congruent during the conversation.
Thought form: linear and logical
Thought content: The client stated the pain on her lower back and neck is still the
major concern and affecting her ADLs. The client and her husband mentioned her
mobility has been increased. Kolila’s sleeping quality has been improved. Since
last visit, she usually take her zopiclone around 8pm. She has been sleeping from
10pm to 6am. She has been waking up around 3am for her analgesics sometimes
and managed to fall asleep afterwards.
Perception: Nil evidence of any psychotic symptoms. Kolila denied any psychotic
symptoms.
Cognition: Patient orientated to time, place, and people. Short term/long
memory intact. Patient could concentrate during the conversation.
Insight/Judgement: Intact as the patient showed a fair understanding of her
condition (surrounding her pain) and the importance of being referred to the
rheumatology team. Unsure about insight into taking medications for voices
although they confirm she takes her haloperidol.
Current risk management/risk factors:
History of aggressiveness towards others.
Physical assessment:
Kolila has been taking the prescribed medications.
Patient disclosed that she has been taking paracetamol 4 hourly at most of the
time.
Plan:
RN Priyanka will email Kolila’s GP with details regarding referring Kolila to the
rheumatology team. RN Priyanka will review the client by telephone next time
and informing the husband about the time. RN Priyanka suggested Kolila’s
husband to call the GP and discovering more details regarding the referral.

IMI risperidone consta 25mg administered by SN Yaoling to left dorsogltueal muscle without issue and
with Kim's consent. Notes reviewed by RN Priyanka.
Appearance: A 64 yrs old Asian female presented and moderately groomed. Clothing appropriate to the
season. Nil distinguished features noticed.
Behaviours: Moderate rapport established with limited interaction but good eye contact. Euthymic
facial expression and normal psychomotor activity noticed. Limping gait noticed without complaining of
pain. RN Priyanka has noticed the limping during previous meetings.
Speech: fluent and moderate tone, volume, rate of speech. Limited amount and non-spontaneous.
Mood: subjectively the patient denied any current issues/ concerns. She also reports her mood to be
good. Restricted affect during the conversation.
Thought form: linear and logical
Thought content: She stated she usually sleeps well from 10pm to 7am and has a good energy level
during day times. Kim disclosed she did chores and gardening. However Kim stated she only goes out
walk sometimes. Writer and RN Priyanka sought clarification multiple times and Kim was later released
once a week or fortnight. Nil delusions/suicidal thoughts noticed. Kim denied any signs of EPS.
Perceptions: Writer didn’t assess for perceptual disturbances, however she also didn’t present as
distracted or responding to NAS.
Cognition: patient orientated to time, place, and people. Short memory intact and long term memory
was not accessed. Patient could concentrate during the conversation.
Insight/Judgement: The client aware the reason for taking medications.
 Current risk management/risk factors:
History of self-neglect, self-harm, not taking prescribed medications, and nutritional deficit. Can be
triggered by the symptoms of extrapyramidal syndromes like akathisia or feelings of hopelessness or
due to poor sleep, which usually results in an increase in voices/ and other symptoms like headaches-
these are all very distressing for Kim.
Physical assessment:
Accepted injection as charted.
The client stated she has been taking her medications as prescribed and nil complaints about her sore
knees. The client now called the sore knees “rheumatism” instead of arthritis. Writer and RN Priyanka
do not know if the “rheumatism” was diagnosed by a clinician. She said even during the flare-ups, she
was able to perform ADLs with “medication patches on”. Kim said the soreness occur sometimes and
writer asked for clarification with options of the frequency. Then Kim said the flare-ups happen 4-5
times yearly.
Summary/plan:
Encouraged with outdoor activities at least twice a week, and the client agreed.
Next IMI risperidone consta due in 3 weeks (06/04).

Paul was seen at his residence. RN Priyanka and SN Yaoling presented. Notes
reviewed by RN Priyanka.
Appearance: Clothing appropriate to the weather and good grooming.
Behaviour: Moderate rapport established with interactions and good eye contact.
Euthymic facial expression. The client denied any extrapyramidal syndrome
symptoms. Tics were noticed on the left arm, but it might be because the client
felt cold as he wore fewer layers than writer.
Speech: fluent and moderate tone, volume, rate, amount of speech. Sometimes
spontaneous.
Mood: Subjectively “mood is ok” and rated 5 out of 10. 5 is the baseline for the
client. Objective depressed. Affect was congruent during the conversation.
Thought form: thought blocking but mostly linear and logical
Thought content: The client stated the sleep pattern remains the same that he
sleeps 6-7 hrs from 11pm to 6am. The client reported thought insertion has been
there longer than his auditory hallucinations. The client believes his mood and
behaviours would be manageable with less frequency of the “voice”. He
mentioned that “I won’t let the voice control me over.” The client said when the
“voices” show up, he would go to a quiet place and doing transcendental
meditation. Paul said he has been doing the meditation for years and he found
meditation helps with his mood.
 Perception: the client mentioned the length of each auditory hallucination has
reduced to 5-10 minutes from 15-20 minutes last meeting. The auditory
hallucination happens 2-3 times a day and 5 days out of seven with same content
mentioned during the last meeting.
Cognition: Patient orientated to time, place, and people. Short term memory
intact and long term memory was not accessed. Patient could concentrate during
the conversation.
Insight/Judgement: fair insight as the patient stated “I won’t let the voice control
my behaviour”
Current risk management/risk factors: Risk assessment was not performed. Nil
risk factors were identified during the meeting.
Physical assessment: Patient denied any signs of orthostatic hypotension or GI
disturbances. Patient mentioned he drinks 3L of water to prevent lithium toxicity.
Na was seen at respite. RN Penny and SN Yaoling presented. Notes reviewed by RN Penny.
Appearance: Clothing appropriate to the weather and good grooming.
Behaviour: Moderate rapport established with interactions and good eye contact. Euthymic facial
expression. However, the client was being emotional when talking about her family.
Speech: fluent and moderate tone, volume, rate, and amount of speech. Sometimes spontaneous.
Mood: Subjectively, “mood is ok” and “feeling much better”. Rated 4 out of 10. Affect was congruent
during the conversation.
Thought form: linear and logical
Thought content: The client stated a good sleep pattern from 11pm to 9am. She disclosed she has been
eating well and goes for walks sometimes. The client denied any current suicidal ideation and said she
only overdosed because she felt so overwhelmed. She also stated real-life pressure, road noise and
thinking about moving house are the potential stressors. The client states her mood and energy levels
change in days, and yesterday she felt very positive, but not today. She described her mental status as
“vulnerable”. Nil delusions were identified during the meeting.
Perception: Writer didn’t assess for perceptual disturbances, however she also didn’t present as
distracted or responding to NAS.
Cognition: Patient was orientated to time, place, and people. Short-term memory may not be intact as
she could not remember how long she has been staying in the respite and if she has any
benzodiazepines left in her house. Long-term memory was intact. Patient could concentrate during the
conversation.
Insight/Judgement: fair insight but Na shows low self-esteem regarding her achievements and when
talking about receiving help from other.
Current risk management/risk factors: History of suicide. Risk assessment has been performed. Nil acute
risk issues were identified during the meeting. She agreed to stay in respite for now but risk might
increase once going home.
Physical assessment: Nil and Na committed to taking medications as prescribed in future treatment.
Plan:
21/03 review
Call her company to talk with HR Abby (Mike Downs? is the company name) to discuss her employment
status.
Katerina was seen at her respite residence. Dr Zerisha (please refer to her notes
for details of assessments), RN Penny and SN Yaoling presented. Notes reviewed
by RN Penny.
Katerina stated she felt happy with the euthymic impression. However, after Dr
Zerisha told her she has to stay under the mental health act for further treatment,
she disclosed she did not take medications as prescribed. She also mentioned she
feels anxious. She denied any auditory hallucinations. The team has talked with
the respite care manager to help her with taking medications and Katerina
committed to do so.
Plan: R/V on 21/03 and communicate with other parties (her mother, emerge,
and Oranga Tamariki) to discover her options for future residence.
Section 14 due on or before 03/04.