Week 3 practicum
2Assessing ClientsA comprehensive assessment of the patient who presents for psychotherapy is necessary to develop an appropriate treatment plan. This assessment is a relational process that sets the tone for subsequent sessions (Wheeler, 2014, p. 131). As a future Psychiatric Mental Health Nurse Practitioner, it is essential to be able to accurately assess clients to determine whether yourtherapeutic approach would contribute to improved clinical outcomes. The purpose of this assignment is to select a client that was observed or counseled at my practicum site and completea comprehensive client assessment and genogram for the client selected.Comprehensive Client AssessmentDemographic information for the client chosen is as follows: The client is a 27-year-old African female who resides in Maryland. She is a single, heterosexual, mother of fraternal twins,a boy and a girl. She was referred by her psychiatrist to the current counselor for psychotherapy and is primarily followed by the psychiatrist for medication management. The client has been receiving psychotherapy for the past two years. Her presenting problem revolves around learning how to be independent while coping with her mental illness. She stated, I need help with figuring out my finances. History of present illness: Client has a history of bipolar and presented to the office with complaints about her baby daddy not wanting to help her out with their children and about how difficult its going to be when her cousin stops keeping her twins because daycare is expensive. She also expressed discontent towards her father interfering in herpsychiatric care because he shares the same Nigerian ethnicity as her psychiatrist and she wants to be on less medication and receives more psychotherapy. The clients past psychiatric history includes two psychiatric hospitalizations for manic episodes with psychosis. Medical history includes a previous diagnosis of hypertension (HTN), but that diagnosis was later removed. The
3client never took any medications for HTN diagnosis, and HTN resolved through life modifiers. Currently takes Lithium and Cogentin. The client has no substance use history, and developmental milestones were reached as expected. No family psychiatric history reported. Psychosocial history: She currently lives with her father. Her youngest brother and cousin, who is married, also reside in the same house. She works a full-time minimum wage job and is recently single. She has been in contact with her ex-boyfriend who is trying to hook up with her to have sex. She is the mother of fraternal twins, a boy and a girl. No history of abuse or trauma.Psychiatric Review of SystemsClient denies shortness of breath, heart palpitations, panic attacks, sweating flushing, hyperventilation, sense of doom, fear of death or collapse, cold or clammy skin, and tingling sensations in extremities (Wheeler, 2014, p. 140). Client denies feeling sad, irritable, tired, having a decreased appetite or energy, changes in sleep or libido, suicidal ideation, homicidal ideation, s/s of hypomania, and feeling of hopelessness. The client did not present with hallucinations, delusions, flight of ideas, thought insertion, thought blocking and thought broadcasting in sessions (Wheeler, 2014). Physical Assessment Vital signs: BP128/72; P 78 and regular, R 18 and regular; Temp 98.3 orally. Current weight is215 pounds. Height is 59 General: She is a well-developed, well-nourished African American female who is alert and cooperative. Se is a good historian and answers questions appropriately. HEENT: No loss of vision or hearing. No nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Nasal mucosa pink and moist. No enlarged tonsils.Neck: No enlarged lymph nodes.Chest: Thorax symmetrical.Lungs: Breath sounds clear throughout all lung fields; no rhonchi or wheezes noted.Heart: Heart rate is regular with good S1, S2; S3 auscultated.Peripheral Vascular: 2+ edema present to bilateral ankle. Abdomen: Nondistended and nontender with active bowel sounds auscultated x4 quadrants.
4Genital/Rectal: Not assessed. Denies vaginal/rectal discharge and bleeding.Musculoskeletal: No joint pain or discomfort present.Neurological: Awake, alert, and oriented to person, place, and time.Skin: Cool and dry Intact. No ecchymosis or edema. Skin turgor good. No cyanosis, pallor, or jaundice present.Mental Status ExamAppearance/Attitude: Pleasant groomed African American female sitting up on the couch, good hygiene.Psychomotor Behavior: Good eye contact, appears comfortable. No abnormal movements, normal speed.Speech/Language: Fluent, appropriate quantity, volume, rate, latency.Affect: Euthymic.Mood: “Im good.”Thought Process/Form of thought: Goal-directed and logical. Thought Content/Perceptions: No delusions, hallucinations, or SI/HI.Sensorium/Level of awareness: Fully awake and alertAttention/Concentration: Fully intact and attentive. Can name days of week backward. Memory/recent/remote: Intact for immediate, recent, and remote. 3/3 delayed recall.Fund of knowledge: Appropriate for educational level. Executive Functions: Intact.Insight/Judgment: fair/fairDifferential DiagnosisDifferential diagnoses that could be considered for this client include anxiety, obsessive-compulsive disorder (OCD), and attention deficit hyperactivity disorder (ADHD). Everyone experiences occasional anxiety, but for a person with anxiety disorder, it doesnt go away and can worsen over time (National Institute of Mental Health, 2013). Anxiety was selected as a differential diagnosis due to this disorder being prevalent in Bipolar disorder (BD) patients, and these patients have particularly high rates of lifetime anxiety disorders (Yuen, Miller, Wang, Hooshmand, Holtzman, Goffin, Shah, & Ketter, 2016, p. 101). ADHD is an early-onset neurodevelopmental disorder characterized by developmentally inappropriate symptoms of inattention, hyperactivity, and impulsivity, that affects 5% of childhood population and persists into adulthood in up to 50% of the cases (Torres, Garriga, Sole, Bonnn, Corrales, Jimnez,
5Sole, Ramos-Quiroga, Vieta, Goikolea, & Martnez-Aran, 2018, p. 118). ADHD was chosen as a differential diagnosis due to its presence in clients that have a BD diagnosis. It is known that between 10 to 30% of adult patients with BD present comorbidity with lifetime ADHD (Torres et al., 2018, p.118). Not only are their clinical correlations between BD and anxiety but the treatment approaches overlap with them (Torres et al., 2018). OCD was chosen as a differential diagnosis due to the prevalence in individuals with BD. The estimated prevalence of BD in OCD has been reported to be 656% in various studies (Saraf, Paul, Viswanath, Narayanaswamy, Math, & Reddy, 2017, p. 70). Case FormulationThe client is an African American 27-year-old female and mother of twins learning how to become independent and cope with her mental illness. She has had a history of being hospitalized for mania with psychosis twice. Her mother recently passed away with whom she was very close. She is currently having financial difficulties and issues with the father of her children not contributing to her childrens lives and experiences anxiety related to these issues. She lives at home with her father but is trying to prepare herself for independent living. She would like to be in control of her mental health as it pertains to receiving more psychotherapy and decreasing the doses of her current medications because she stated they maker her slow especially at work. She has impairment with her occupational functioning and has concerns about with management not being understanding of her mental illness. She also voiced that she did not want her father involved in her treatment plan any longer. Treatment PlanThe current plan is for the client to continue the medication regimen of Lithium and Cogentin and report any side effects. Individual psychotherapy will continue and goals
6discussed with the client regarding her employment, financial planning, and familial changes andoverall management of her concerns
