Oraka assessment

Safety Check: Patient reports no current suicidal ideation or intent, and denies any self-harm intent. She also denies any intent to harm others. There were no immediate safety concerns identified during the initial assessment. Immediate actions taken: * Ensured a safe and confidential environment for the assessment. * Confirmed patient's understanding of confidentiality limits. Mental State: Patient presented as alert and oriented to person, place, and time. Affect was congruent with mood, which was reported as low but stable. Speech was clear, coherent, and at a normal pace. No evidence of psychosis, hallucinations, or delusions was noted. Thought content primarily focused on recent life stressors and feelings of overwhelm. Taha Tinana – Physical Wellbeing * Past Medical History: Type 2 Diabetes Mellitus, controlled with medication; Mild Hypertension. * Current Physical Health: Reports occasional fatigue, otherwise good health. * Current Medications: * Metformin 500mg, twice daily * Lisinopril 10mg, once daily * Physical wellbeing concerns: Patient expressed concern about recent weight gain, attributing it to stress-related eating patterns. She also noted feeling generally more tired than usual. Taha Whānau – Family Wellbeing Patient lives with her husband and two children (aged 10 and 14). She described her relationship with her husband as supportive, though he often works long hours. She has a close relationship with her sister, who lives nearby and provides some emotional support. Patient is actively involved in her children's school activities and feels a strong connection to her local community through her church group. Taha Hinengaro – Emotional and Mental Wellbeing Patient discussed feelings of increased stress and anxiety over the past few months, primarily due to financial pressures and concerns about her elderly mother's health. She reported difficulty sleeping, often waking up early and struggling to fall back asleep. Coping strategies currently include watching TV and occasionally talking to her sister. She acknowledged these aren't always effective and expressed a desire for healthier coping mechanisms. She identified feelings of being overwhelmed and a lack of motivation to engage in previously enjoyed activities. Taha Wairua – Spiritual Wellbeing Patient identifies as Christian and finds comfort and guidance in her faith. She regularly attends church services and participates in a weekly prayer group. She mentioned that her faith provides her with a sense of hope and purpose, especially during challenging times. Taha Whenua – Wellbeing of the Land and Home Patient lives in a rented three-bedroom house, which she described as generally stable, though she would ideally like to own her own home. She expressed significant worry about increased living costs and her husband's fluctuating income, which is causing considerable financial strain. She mentioned concerns about being able to afford school trips for her children. Her home environment is generally tidy and supportive for her family, but the financial stress permeates the atmosphere. Action Plan * Patient: Explore healthy coping mechanisms, such as mindfulness exercises or light physical activity, daily. Research local community support groups for financial guidance. Schedule a follow-up appointment with her GP to discuss fatigue. * Clinician: Provide resources for stress management techniques. Refer to a community financial advisor. Schedule a follow-up mental health assessment in two weeks. Safety Check Recap No changes in the patient's safety status were noted since the initial safety check. Patient remains stable and denies any current risk. Book Next Meeting 15 November 2024 at 10:00 AM Goals: * Short-term: Identify and implement at least two new coping strategies for stress. Attend one session with a financial advisor within the next month. * Long-term: Reduce feelings of overwhelm and improve sleep quality. Achieve a greater sense of financial security and stability. General Notes from Encounter: Patient engaged well in the assessment, providing detailed and reflective responses. She appeared motivated to address her current challenges and was receptive to suggestions. Her overall presentation suggests an adjustment disorder with mixed anxiety and depressed mood, largely influenced by current life stressors. Further assessment will focus on developing a comprehensive care plan.