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NRNP 6540 Week 8 RaymondYoung Paper

CC: Mrs. Derrick is a 78-year-old female who comes to the office with complaints of increasing symptoms of lethargy; fever, night sweats, a 15 lb. weight loss over 6 months; bleeding gums when she brushes her teeth; purplish patches in the skin; and shortness of breath.HPI:

She states that she has had a sensation of deep pain in her bones and joints.

She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)

PE shows enlarged lymph nodes and swelling or discomfort in the abdomen.

You diagnose this patient with acute lymphoblastic leukemia (ALL).

Address the following in your SOAP note:

What additional history about her past work environment would you explore?

What additional objective data will you be assessing for?

What tests will you order? Describe at least four lab tests.

What are the differential diagnoses that you are considering? Describe two.

List at least two diagnostic tests you will order to confirm the diagnosis of ALL.

Will you be looking for a consultation? Please explain.

As the primary care provider for this patient with ALL:

• Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
• Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.

To prepare:

• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.

Also Read: NRNP 6540 Week 9 Assignment

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

NRNP_6540 Week 8 Assignment Rubric

Criteria Ratings Pts
This criterion is linked to a Learning Outcome Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems

10 to >9.0 pts

Excellent

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.

9 to >8.0 pts

Good

The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.

8 to >7.0 pts

Fair

The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.

7 to >0 pts

Poor

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.

10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

10 to >9.0 pts

Excellent

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

9 to >8.0 pts

Good

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

8 to >7.0 pts

Fair

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

7 to >0 pts

Poor

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

25 to >23.0 pts

Excellent

The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

23 to >20.0 pts

Good

The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.

20 to >18.0 pts

Fair

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

18 to >0 pts

Poor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.

30 to >27.0 pts

Excellent

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.

27 to >24.0 pts

Good

The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.

24 to >21.0 pts

Fair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.

21 to >0 pts

Poor

The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.

30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.

10 to >9.0 pts

Excellent

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

9 to >8.0 pts

Good

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

8 to >7.0 pts

Fair

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

7 to >0 pts

Poor

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan.

10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts

Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.

2 to >0 pts

Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good

Contains a few (one or two) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair

Contains several (three or four) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor

Contains many (? five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors.

4 to >3.0 pts

Good

Contains a few (one or two) APA format errors.

3 to >2.0 pts

Fair

Contains several (three or four) APA format errors.

2 to >0 pts

Poor

Contains many (? five) APA format errors.

5 pts
Total Points: 100

Also Read: Reengineering in Healthcare Sample Paper

NRNP 6540 Week 9 RaymondYoung Assignment

To prepare:

• Review the case study provided below
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessment results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential is in or out. Explain the critical thinking process that led you to your primary diagnosis. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

HPI: Ms. Juggenmeir is a 71-year-old Female who comes into your office with concerns about fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets.  She is also concerned that she may need to come off one of her meds because her hair is thinning.  She had labs done and was informed they would review the results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed.

RESOURCE FOR THIS WEEK: Review Endocrine-related Evidence-Based Practice Guidelines.

Ms. Juggenmeir is a 71 y/o female who is AAOX4.  She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.

(All other Review of System and Physical Exam findings are negative other than stated.)

Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1

PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency

Allergies: I.V. Contrast, ACE Inhibitors

Medications:

Women’s One A Day-Multivitamin daily

Chlorthalidone 25mg daily

Fish Oil 1  tablet daily

Amlodipine 5mg p.o. daily

Losartan 100mg p.o. daily

Atorvastatin 40mg p.o. at bedtime daily

Aspirin 81mg p.o. daily

Ergocalciferol 50,000 units PO once a month

Social History: as stated in the Case Study

ROS: as stated in the Case study

Diagnostics/Assessments done:

1. CXR – The last CXR showed no cardiopulmonary findings. WNL
2. TSH/Free T4, T3 – as noted below in lab results
3. Basic Metabolic Panel and CBC as shown below
4. Vitamin D Level – as noted below in lab results

NRNP_6540_Week9_Assignment_Rubric

NRNP_6540_Week9_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint• History of present illness (HPI) • Current medications, checked against Beers Criteria• Allergies• Patient medical history (PMHx) • Review of systems

10 to >9.0 ptsExcellent

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.

9 to >8.0 ptsGood

The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.

8 to >7.0 ptsFair

The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.

7 to >0 ptsPoor

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.

10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

10 to >9.0 ptsExcellent

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

9 to >8.0 ptsGood

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

8 to >7.0 ptsFair

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

7 to >0 ptsPoor

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

25 to >23.0 ptsExcellent

The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

23 to >20.0 ptsGood

The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the conditions selected.

20 to >18.0 ptsFair

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

18 to >0 ptsPoor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.

30 to >27.0 ptsExcellent

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.

27 to >24.0 ptsGood

The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.

24 to >21.0 ptsFair

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains inaccuracies. Reflections on the case demonstrate adequate understanding of course topics.

21 to >0 ptsPoor

The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.

30 pts
This criterion is linked to a Learning outcome of at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.

10 to >9.0 ptsExcellent

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

9 to >8.0 ptsGood

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

8 to >7.0 ptsFair

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

7 to >0 ptsPoor

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based or do not support the treatment plan.

10 pts
This criterion is linked to a Learning outcome Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long, rambling, short, and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 ptsExcellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 ptsGood

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. The assignment’s purpose, introduction, and conclusion are stated, yet are brief and not descriptive.

3 to >2.0 ptsFair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. The assignment’s purpose, introduction, and conclusion are vague or off-topic.

2 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning outcome Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGood

Contains a few (one or two) grammar, spelling, and punctuation errors.

3 to >2.0 ptsFair

Contains several (three or four) grammar, spelling, and punctuation errors.

2 to >0 ptsPoor

Contains many (? five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning outcome. Expression and Formatting – The paper follows the correct APA format for the title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 ptsExcellent

Uses the correct APA format with no errors.

4 to >3.0 ptsGood

Contains a few (one or two) APA format errors.

3 to >2.0 ptsFair

Contains several (three or four) APA format errors.

2 to >0 ptsPoor

Contains many (? five) APA format errors.

5 pts
Total Points: 100

NRNP 6566F Week 4 Scenario: 84 Year Old Female

NRNP 6566F Week 4 Scenario: 84 Year Old Female

Week 4

Posted on: Monday

Greetings Students,

Welcome to week 4.

Great job on your 1st knowledge check. If anyone would like to review, please send me an email and I will be happy to go over your answers.

This week you all will be learning more about arrhythmias, shock and hypertension. Please utilize the information provided under the learning resources.

For your assignments there will be another branching exercise and your second knowledge check. Both of these assignments are due 

Please remember to review the rubric and the comments I have made on your previous branching exercise to improve and receive maximum points.

Here is the information for your branching exercise:

84 y/o Female

Code Status: DNR

PMH: HTN, DM

Home meds: Metoprolol/Insulin/ASA/ Calcium

Wt: 62kg, Ht 5’5

NKDA

Critically think about where you would send this patient from the ER and write admissions orders for that unit. Remember to be specific with your orders. Especially with your nursing orders.

Remember Oxygen is a drug. We shouldn’t be placing oxygen on patients just to place it or if they have a normal O2 sat, ie: 94%. If they have an O2 sat of 92% and above O2 is not indicated. Remember if you just put oxygen on a patient routinely, if something really is going on, it could mask a problem that may warrant an investigation. 

Please email me with any you have any questions, comments, concerns. If you would like to have a zoom meeting or phone conference, please email me and we can schedule a time.

Best,

Scenario #3 84 year old female

BACKGROUND

• An 84-year-old female is brought in by family with complaints of increased confusion and lethargy.
• Patient usually lives alone and is fully functional.
• Son reports that she has been increasingly confused and sleeping a lot at home.
• Son denies any fever.
• Patient complains of pain “all over” and responds to repeated questions with “I think I’m sick”

VITAL SIGNS

• BP 105/64, HR 115, RR 24, T 96°F, SpO2 92% Room Air
• Patient is alert, and oriented to person but thinks is it 1990
• PMH: HTN: Metoprolol
• DM: Insulin
• Other meds: ASA, Calcium

Decision Point One

12 lead EKG, CBC, CMP, urinalysis, Chest x-ray

RESULTS OF DECISION POINT ONE

•  Correct!
•  Initial 12 lead EKG to assess myocardial function
•  CBC to assess WBC and potential anemia
•  BMP to assess electrolyte disturbance and potential for DKA
•  Urinalysis to assess for potential infection
•  Chest x-ray to asses for potential infection

RESULTS OF INDICATED TESTS

Complete Blood Count (CBC)

Basic Metabolic Profile (BMP)

Urinalysis (U/A)

Decision Point Two

RESULTS OF DECISION POINT TWO

•  Urinalysis shows hematuria, positive nitrate, positive leukocyte esterase which all are indicative of a UTI.
• Elderly frequently have a low WBC and low body temperature in the presence infection.
• Chest x-ray is clear and EKG shows tachycardia but no arrhymia or myocardial hyposia.
•  The patient remains confused and is becoming more lethargic. Follow up BP is 82/42. Serum lactate level is 4.5. What is your diagnosis now?

Decision Point Three

Guidance to Student

Correct!

SIRS (systemic inflammatory response syndrome) requires the presence of two of the four factors:

• Temperature less than 36.0 C or greater than 38.0 C
• Heart rate greater than 90 BPM
• Respiratory rate > 24 breaths per minute or PaCO2 < 32
• WBC less than 4,000 or greater than 12,000; or Bandemia>10%

Week 4: Hypertension and Shock

Issues with the heating and cooling system of your home can be relatively benign matters that are addressed easily enough with the help of a visiting technician. But in cases of extreme weather conditions or delayed attention, these matters can seriously threaten the health of the home or its occupants.

Similarly, extreme cardiovascular conditions can pose very serious health risks. Hypertension can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Shock can damage the body’s organs and can also be life-threatening. Effective diagnosis and treatment of hypertension and shock can, therefore, be a critically important and even life-saving endeavor.

This week, you will assess and develop management plans for patients with hypertension, including urgent and emergent conditions. You will review how to differentiate shock states and examine hemodynamic values for those shock states when evaluating treatment goals.

Learning Objectives

Students will:

• Distinguish between hypertensive urgencies and emergencies
• Develop a management plan for hypertensive emergencies
• Apply current clinical practice guidelines to address acute and chronic management of hypertension
• Distinguish shock states
• Develop patient treatment plans for shock
• Analyze pharmacologic treatments of shock
• Evaluate normal and abnormal hemodynamic monitoring values
• Develop appropriate treatment plans, including diagnostics and laboratory orders for patients with hypertension and shock
• Identify concepts related to hypertension and shock

Learning Resources

Required Readings (click to expand/reduce)

Barkley, T. W., Jr., & Myers, C. M. (2020). Practice considerations for the adult-gerontology acute care nurse practitioner (3rd ed.). Barkley & Associates.

• • Chapter 12, “Hypertension” (pp. 131–145)
  • Chapter 15, “Adjunct Therapies” (pp. 185–200)
  • Chapter 76, “Management of the Patient in Shock” (pp. 982–1012)

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., … Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), 1269-1324. doi:10.1161/HYP.0000000000000066

Document: Admission Orders Template (Word document)

Required Media (click to expand/reduce)

MedCram. (2018, August 19). Vasopressors explained clearly: Norepinephrine, Epinephrine, Vasopressin, Dobutamine… [Video file]. Retrieved from https://www.youtube.com/watch?v=zf28Rjbu3VM

MedCram. (2017, November 19). Hypertension guidelines explained clearly – 2017 HTN guidelines [Video file]. Retrieved from

MedCram. (2017, November 9). Shock and sepsis explained clearly (remastered) symptoms, causes, and pathophysiology [Video file]. Retrieved from https://www.youtube.com/watch?v=sTdrIlOGnfI

MedCram. (2014, December 23). Hypertension explained clearly, 2 of 2 [Video file]. Retrieved from https://www.youtube.com/watch?v=NgMfZVEWQd8

MedCram. (2012, September 12). Hypertension explained clearly – causes, diagnosis, medications, treatment [Video file]. Retrieved from https://www.youtube.com/watch?v=OmKVteeuQj0

MedCram. (2012, July 17). Shock explained clearly – cardiogenic, hypovolemic, and septic [Video file]. Retrieved from https://www.youtube.com/watch?v=CbM4UihE1TQ

Walden University (Producer). (2019b). Branching exercise: Cardiac case 2 [Interactive media file]. Minneapolis, MN: Author.

Assignment: Branching Exercise: Cardiac Case 2

For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented.

Photo Credit: yodiyim – stock.adobe.com

To prepare:

• Review the interactive media piece/branching exercise provided in the Learning Resources.
• Reflect on the patient’s symptoms and aspects of disorders that may be present in the interactive media piece/branching exercise.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the interactive media piece/branching exercise.
• You will be asked to develop a set of admission orders based on the patient in the branching exercise.

The Assignment

Using the Required Admission Orders Template, write a full set of admission orders for the patient in the branching exercise.

• Be sure to address each aspect of the order template
• Write the orders as you would in the patient’s chart
• Make sure the order is complete and applicable to the patient
• Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
• Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is appropriate standard of care for this patient.
• A minimum of three current, evidenced based references are required.

By Day 7 of Week 4

Submit your completed Assignment by Day 7 of Week 4 in Module 2.

Admission orders: Cardiac Case 2 Example

Primary Diagnosis: 

Hypertension is the primary diagnosis. Patient is also known to be diabetic.

Status/Condition (Critical, Guarded, Stable, etc.):

The patient walks in the hospital in a stable condition.

Code Status: 

The patient is of Do-Not-Resuscitate (DNR) status.

Allergies: 

The patient has no known food or drug allergy (NKFDA)

Admit to Unit: 

To be admitted to the medical-surgical unit.

Activity Level:

The patient has no restrictions to activity.

Diet: 

The patient is on carbohydrate-controlled diet and input output control.

IV Fluids: 

• Critical Drips (If ordered, include type and rate. Do not defer to ICU protocol.): 

Maintain patent IV access.

 0.9% sodium chloride 3-10mls flush in every 12 hours.

0.9% sodium chloride 3-10mls flush before and after every IV drug infusion.

Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings: 

Oxygen via nasal canula for SPO2 below 92%.

Discontinue for saturation above 93% on RA.

Medications (include ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc., dose and route):

Metoprolol:( 50mg – 400mg/day). 50mg administered twice a day Taken orally after meals. Increase the dose on weekly or longer intervals on need basis.

Insulin: (0.2-0.4 units/kg/day). Administer subcutaneously after measuring the glucose level. Maintain patent IV line for emergency cases. Adjust doses according to blood glucose control.

Aspirin: 162.5mg oral dose once/day. Assess for bleeding disorders and contraindications such as surgery.

Nursing Orders (vital signs, skin care, toileting, ambulation, etc.):

Maintain an input and output record every four hours, blood pressure recording every 4 hours, AC glucose monitoring before every meal and perform daily weight checking (Jian-Hong et al, 2020), prevent falls while in hospital.

Follow-Up Lab Tests:

Perform lipid profile, electrolytes level, kidney function test, BUN, KUB and Creatinine clearance.

Urine protein, urinalysis and urine drug level.

• Diagnostic testing (CXR, US, 2D Echo, etc.):

Cardiac: echocardiogram and EKG.

Consults:

Cardiology consult: hypertensive management

Nutritionist consult: review of diet plan and weight gain

Social worker consult: conducive home-based care before discharge

Pharmacist consult: antihypertensive management

NOTE: (Do not defer management to a specialist. As an ACNP, you must manage the patient’s acute needs for at least a 24-hour period]. Include indication for consult. For example: “Cardiology consult for evaluation of new-onset atrial fibrillation,” or “Nutrition consult for TPN recommendations.”

Patient Education and Health Promotion (address age-appropriate patient education. if applicable):

Diet: the patient needs to reduce on sodium related products such as salt that are likely to increase water retention. She is encouraged to take fruits and vegetables, and lower portions of carbohydrates to manage her glucose levels (Whelton et al, 2017).

Medication: She is discouraged on the use of over-the-counter drugs without review of her regimen by the pharmacist. This will intend to reduce cases of toxicity that could stress the kidney. She is also educated on importance of drug compliance, in presence of the primary caregiver.

Lifestyle: Although she is expected to ambulate while at home, precaution by the patient and the caregiver is needed to avoid any skin injury. This could expose the patient to risks of heavy bleeding due to the use of ASA, and poor wound healing due to diabetes. Prevention of falls is also a priority since her old age relates with weak bones due to bone structure breakdown.

Discharge Planning and Required Follow-Up Care:

The patient must be educated on blood pressure measurement with the help of the caregiver and mode of recording. High blood pressure values should be shared for easy identification by the caregiver. The caregiver and the patient are educated on need for compliance since at her age, she is likely to forget medication regimen frequently. The caregiver should also check with the doctor before using any additional drug to avoid possible detrimental interactions.

The patient should avoid caffeine intake, salt intake, and increase potassium rich diets. The caregiver should be educated on compliance on follow-up clinics as directed by the doctor (Franklin & McCoy, 2017). The caregiver should also be aware of signs that warrant immediate medical checkup such as unresponsiveness, sudden confusion, sweating, skin cut or fall, severe headaches and sudden changes in vision.

References

Franklin, M. & McCoy, M. (2017). A transition of care from hospital to home for patients with hypertension: Wolters Kluwer Health. 

Jian-Hong, M., Hai-Shan W., Na, L. (2020). The evaluation of a nurse-led hypertension management model in an urban community healthcare, Medicine: Volume 99 – Issue 27 – p e20967.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., … Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary. Hypertension, 71(6), e136-e139. 

NRNP 6566F Week 4 Scenario: 84 Year Old Female Rubric Detail

Point range: 90–100 Good

Point range: 80–89 Fair

Point range: 70–79 Poor

Point range: 0–69
Using the Admission Orders Template, write a full set of admission orders for the patient in the branching exercise. Be sure to address the following:
· Identify the Correct Diagnosis.
5 (5%) – 5 (5%)
The order set includes an accurate and correct diagnosis.
4 (4%) – 4 (4%)
The order set includes a diagnosis that is an appropriate differential diagnosis.
3 (3%) – 3 (3%)
The order set includes a diagnosis that is incorrect and not supported by patient data.
0 (0%) – 2 (2%)
The order set includes and inaccurate / dangerous diagnosis.
· Identify the ‘Status/Condition’, ‘Code Status’, ‘Admit to Unit’
for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for condition, code status, and admission location.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Describe the “Allergies’, ‘Activity Level’ and “Diet” for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for allergies, activity level, and diet.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Identify any ‘IV Fluids’ needed for the patient in the presenting case.
9 (9%) – 10 (10%)
The order set clearly and accurately identifies a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 element of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 2 elements of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous fluids or flow rate, incorrect parameters for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
· Identify any ‘Respiratory’ needs for the patient in the presenting case. Be specific about oxygen (if ordered, include type and rate), pulmonary toilet needs, and ventilator settings.
5 (5%) – 5 (5%)
The order set clearly and accurately identifies a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 element of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 2 elements of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is incomplete, includes wrong / dangerous orders, or incomplete parameters for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
· Describe the ‘Medications’ including any IV drips for the patient in the presenting case.

Be specific about medications related to the reason for admission and any chronic medications the patient may be taking (ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc.). Be sure to include name, dose, route of administration, and frequency of each medication.
13 (13%) – 15 (15%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. Orders are complete, account for all conditions, and are appropriate to treat the patient.
10 (10%) – 12 (12%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. There are incomplete orders, missing medications, or missing elements in the orders.
5 (5%) – 9 (9%)
The order set is missing essential elements of a medication order, missing medications, or are inappropriate to treat the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous orders, or inappropriate medications to treat the patient in the presenting case.
· Explain any ‘Nursing Orders’ for the patient in the presenting case. Be specific about vital signs, skin care, toileting, and ambulation.
9 (9%) – 10 (10%)
The order set includes a full set of nursing orders that provide essential direction to provide care, monitor, assess, ensure safety, prevent complications and promote healing.
7 (7%) – 8 (8%)
The order set include inaccurate or is missing 1 or 2 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
5 (5%) – 6 (6%)
The order set include inaccurate or is missing 3 or 4 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
0 (0%) – 4 (4%)
The order set include inaccurate, missing, or provides dangerous nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
· Explain the ‘Follow-Up Lab’ tests for the patient in the presenting case. Be specific about diagnostic testing (e.g., CXR, US, 2D Echo, etc.).
9 (9%) – 10 (10%)
The order set includes complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
7 (7%) – 8 (8%)
The order set includes most (missing 1 or 2) laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
5 (5%) – 6 (6%)
The order set includes some (missing 3 or 4) complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
0 (0%) – 4 (4%)
The order set is missing essential laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
· Explain the ‘Consults’ for the patient in the presenting case. Be specific about how you, as an ACNP, would manage the patient’s acute needs for at least a 24-hour period. Include indication for consult (e.g., “Cardiology consult for evaluation of new-onset atrial fibrillation,” “Nutrition consult for TPN recommendations”).
5 (5%) – 5 (5%)
The order set includes clear, accurate, and essential consults for the patient in the presenting case including complete rationale for the consult.
4 (4%) – 4 (4%)
The order set is missing one of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
3 (3%) – 3 (3%)
The order set is missing 2 or more of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
0 (0%) – 2 (2%)
The order set is missing multiple consults, rations, or accurate descriptions for consults needed to manage the presenting patient.
·.
9 (9%) – 10 (10%)
The order set provides clear, accurate, and complete patient education and health promotion recommendations for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 or 2 essential elements of patient education and health promotion for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 3 or 4 essential elements of patient education and health promotion for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is missing multiple essential elements of patient education and health promotion for the patient in the presenting case.
· Explain the ‘Discharge Planning and Required Follow-Up Care’ for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set provides clear, accurate, and complete discharge planning and necessary follow up care for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 or 2 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 3 or 4 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is missing multiple essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
· Identify a minimum of three ‘References.’ Be sure that they are timely and support the admission order in following current standards of care.
9 (9%) – 10 (10%)
The order set includes a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. References are formatted in APA format.
7 (7%) – 8 (8%)
The order set does not include a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. APA format is incorrect.
5 (5%) – 6 (6%)
The order set does not include a minimum of three references or includes non-professional level resources to support their admission order set. APA format is incorrect.
0 (0%) – 4 (4%)
The order set is missing minimum number of references or includes poor sources that do not reflect professional writing or current standard of care information. APA format is not followed.
Written orders include all elements, address all the needs of the patient, are complete, logical, and meets the complete needs of the patient.
5 (5%) – 5 (5%)
Written order set is complete, addresses all the needs of the patient, and are based on current literature.
4 (4%) – 4 (4%)
Written orders are mostly complete only missing 2 essential elements in addressing the needs of the patient.
3 (3%) – 3 (3%)
Written orders are missing 3 to 4 essential elements are reflect an incorrect standard of care.
0 (0%) – 2 (2%)
Written orders are incomplete, do not address the needs of the patient, or reflect an outdated standard of patient care.
Total Points: 100
Name: NRNP_6566_Module2_Assignment2_Rubric

Select Grid View or List View to change the rubric’s layout.

Admission Orders Sample Paper

A 68-year-old female is brought to the hospital from the acute rehabilitation facility. She complains of shortness of breath and a productive cough. The symptoms have been there for the past one week. The patient was started on ciprofloxacin three days, but her condition has just worsened. The patient is hypertensive and has a history of hypothyroidism. She recently underwent knee replacement surgery about two weeks ago. She is currently on lisinopril, ciprofloxacin and rivaroxaban. She is presently experiencing fever, chills, productive cough with green purulent sputum, and worsening shortness of breath. On examination, her vitals are recorded as T 102.6, HR 92, RR 22, and BP 128/82. Oxygen saturation is recorded as 96% on four liters of oxygen. A chest X-ray done indicates consolidation in the right lower lobe. The patient’s CBC and CMP are within the normal range. This essay aims to write down admission orders for this patient.

Treatment of the patient.

I would immediately discontinue the ciprofloxacin and initiate piperacillin/tazobactam, 5g IV every six hours, tobramycin, 5mg/kg IV every 24 hours, and vancomycin, 15mg/kg every 12 hours. The patient meets the criteria for hospital-acquired pneumonia (HAP). This is because of her surgery two weeks prior and her inpatient admission at the rehabilitation facility. A chest X-ray done shows a consolidated right lower lobe. This further increases the risk of a diagnosis of pneumonia. It is important to commence a three-drug combination for broad-spectrum coverage until a culture and sensitivity report of the patient’s sputum is available to begin de-escalation of antibiotics. This is because the patient is at risk of drug-resistant bacteria and MRSA.

In 2007, the Infectious Diseases Society of

NRNP 6635 Case History Reports Example 2

Week 4: Anxiety Disorders, PTSD, and OCD

Training Title 15

Name: Mr. David Jackson Gender: male

Age:19 years old

T- 98.8 P- 89 R 18 110/62 Ht 5’7 Wt 133lbs

Background: Lives in Minneapolis, MN with both of his parents, only child. Works part time at Starbucks. Not currently partnered. No previous psychiatric history. Symptoms began in the last

1.5 months when he discovered he is being activated with the Navy Reserves. His MOS is SK1 Storekeeper; no medical illnesses Allergies: NKDA; sleeps 6.5 hrs; appetite good

Symptom Media. (Producer). (2017). Training title 15 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-15

Training Title 21

Name: Sergeant Patrick Flanrey Gender: male

Age:27 years old

T- 97.4 P- 84 R 18 B/P134/88 Ht 5’8 Wt 167lbs

Background: He entered the military just after high school and did three long tours of duty in warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) less than a year ago after eight years of service. He is engaged to be married (no date set) and is currently working as a furniture salesman. He said he grew up poor and would not do much else if

he didn’t go into the military. He denies ever using any drugs and avoids alcohol because his

father was “sloppy drunk.” Father is still alive, unwell (DM, liver disease, HTN), still

drinking. Paternal grandfather was also a veteran and suffered depression at times though he never told anyone except the patient because of their combat connection. Mother is alive and well, still “caring for dad.”  He has one younger and one older sister. He lives in a different state, approximately five hours from his parents and siblings. After the military, he and his fiancé moved because she got a much better opportunity. They want kids someday and hope to marry

in a year or two. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment.

Symptom Media. (Producer). (2016). Training title 21 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-21

Training Title 37 Name: Mr. Tony Patelli Gender: male

Age:18 years old

T- 98.8 P- 94 R 20 126/88 Ht 5’4 Wt 131lbs

Background: Lives alone in New York, raised by parents in New Jersey, only child. He is a full- time student at local community college for graphic design. Has a girlfriend from high school. No previous psychiatric history. No medical illnesses; no history of psychiatric treatment; denied drugs or alcohol; Allergies: NKDA; sleeps 7.5 hrs; appetite eats 3 meals/day, likes to keep a routine schedule.

Symptom Media. (Producer). (2016). Training title 37 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-37

Training Title 40

Name: Ms. Barbara Weidre Gender: female

Age: 56 years old

T- 99.0 P- 99 R 24 132/89 Ht 5’4 Wt 168lbs

Background: Lives with her husband in Knoxville, TN, has one daughter age 23. She has never worked. Raised by mother, she never knew her father. Mother with hx of anxiety; no substance hx for patient or family. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 10-12 hrs; appetite decreased. Has overactive bladder, untreated. Allergic to Phenergan; complains of headaches, takes prn ibuprofen, has diarrhea once weekly, takes OTC Imodium.

Symptom Media. (Producer). (2016). Training title 40 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-40

Training Title 55 Name: Matilda Johnson Gender: female

Age: 9years old

She refused vitals, ht and wt

Vaccinations are up to date; on target with developmental milestones. Appetite, she is a picky eater per mom. NKDA

Symptom Media. (Producer). (2017). Training title 55 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-55

Training Title 85

Name: Mrs. Carol Holliman Gender: female

Age: 42 years old

T- 98.0 P- 77 R 18 132/72 Ht 5’0 Wt 127lbs

Background: Born and raised in Northern Ireland, parents brought her and her 5 sisters to U.S. when she was 15 to go to U.S. university where she met her husband. They live in Charleston, SC. She obtained her bachelor’s degree in education; no history of mental health or substance use treatment, no family history. Her husband reported a recent school shooting nearby 3 weeks ago “flipped a switch” in her. She is watching the news 24/7, barely sleeping, and even when she does, it is only a few hours, Appetite is decreased. Hx of hysterectomy, NKDA, no legal hx.

Symptom Media. (Producer). (2017). Training title 85 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-85

Training Title 95

Name: Ms. Zahara Williams Gender: female

Age: 23 years old

T- 97.5 P- 86 R 18 112/64 Ht 5’2 Wt 130lbs

Background: Born and raised in Jacksonville, FL with her mother and 2 older brothers; her mother has hx of anxiety, brothers hx of cannabis; no previous mental health treatment, no medications; NKDA; no legal hx;  sleeping 7 hrs; Appetite is good.

She has an associate of arts degree and works for Amazon warehouse. She has DX of diabetes since age 5. She recalls having great difficulty with her medical condition (uncontrolled blood sugar, fighting with mother over needle sticks, “kids want candy, and I was so different because of my diet”). She recalls having a difficult relationship with her mother who was a nurse and

really worked hard to control her daughter’s diabetes. She is not in a relationship, identifies as lesbian but has not come out to the family. Only her closest co-workers know she is gay, and she doesn’t plan to come out in the near future. She stated, “I don’t see why I would, they wouldn’t understand, and this is not important right now.”

Symptom Media. (Producer). (2018). Training title 95 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-95

Week 7 Schizophrenia and Other Psychotic Disorders; Medication- Induced Movement Disorders

Training Title 9

Name: Ms. Nijah Branning Gender: female

Age: 25 years old

T- 98.4 P- 80 R 18 128/78 Ht 5’0 Wt 120lbs

Background: Raised by parents, lives alone in Santa Monica, CA. Only child. Works in office supply sales, has a bachelor’s in business degree. Has medical history of hypothyroidism, currently treated with daily levothyroxine. Guarded and declined to discuss past psychiatric history. Denied family mental health issues, declined to allow you to speak to parents for collaborative information. Allergies: medical tape; menses regular

Symptom Media. (Producer). (2016). Training title 9 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-9

Training Title 24

Name: Ms. Jess Cunningham Gender: female

Age: 28 years old

T- 98.6 P- 86 R 20 120/70 Ht 5’2 Wt 126lbs

Background: Jess is brought for evaluation by her 2 roommates who are concerned with behaviors that began 12 days after Jess’s younger brother committed suicide in front of her via GSW after his girlfriend broke up with him. She is estranged from her parents and her brother was her only sibling. She is only sleeping 1–2 hours/24hrs; she will only canned foods. She smokes cannabis daily since she was 16, goes out on weekdays 2–3 times with her roommates and has couple drinks of beer. She was prescribed alprazolam 1mg twice daily as needed by her PCP for 15 days. She works as a bartender.

Symptom Media. (Producer). (2016). Training title 24 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-24

Training Title 29 Name: Mr. Jay Feldman Gender: male

Age:19 years old

T- 98.3 P- 69 R 16 106/72 Ht 5’7 Wt 117lbs

Background: European-American male. He has two younger brothers, one with history of ADHD, the other with history of anxiety. His mother has anxiety; his father has paranoia schizophrenia. He is home for spring break. He has no previous medical problems.

Developmental milestones met as child. Appetite is inconsistent and it seems he has lost 18lbs since first going back to school in the fall. Jason has not acted this way before but did have a short trial of aripiprazole in the last six months of high school for mild paranoia. He stopped the medication after graduation as he could not tolerate due to side effects of akathisia. Jason has several friends but has not kept in touch with them since being back home. He has not been showering. Sleeping 4–5 hrs.

Symptom Media. (Producer). (2016). Training title 29 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-29

Training Title 134

Name: Mrs. Bunny Warren Gender: female

Age: 33 years old

Background: Bunny was brought in by her best friend, Patty, after the police responded to her home the fifth time today. The police was threatening to arrest her for misuse of the 911 system, Bunny called you and you informed the police she needed to go the emergency room.

She has been calling 911 saying people are looking in her windows, standing across the street watching her, stated they are watching for her husband to return home so they can hurt him. Today, she has a stomachache. She believes there is a snake inside of her stomach which she would like to have removed. She stopped eating 2 days ago because of this.

During the assessment, the patient seemed on edge, anxious, and paranoid. The patient has history of scoliosis. This is her third presentation to this hospital, she had one psychiatric admission 2 years ago. No self-harm behaviors but has been physically aggressive toward others in the past. She is guarded and refuses to answer questions whether there are memory or concentration problems. She denies any recent head injuries. She states that she has been sleeping nightly, one or two hours at a time and waking up throughout the night. Refuses labs, refuses to have her vital signs obtained.

She obtains SSDI. She lives in Atlanta, GA. Bunny denies ever using any drugs and drinks occasionally, once a month. She has a sister who is ten years older, both parents deceased in the last two years. She has no children, her husband is out of town, truck driver. Family history includes that her father had two previous inpatient psychiatric hospitalizations after bad drug experiences in the 1970s, for one week each time. Mother had diagnosis and ongoing treatment for depression. Her paternal grandmother was state hospitalized for several years.

She denies any past history of traumatic experiences, but her friend does say that losing her parents was hard for her emotionally. No history of military service. No legal issues currently. Has HS diploma. Allergies: haloperidol

Symptom Media. (Producer). (2018). Training title 134 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-134

Week 8 Substance-Related and Addictive Disorders

Training Title 82 Name: Lisa Pittman Gender: female Age: 29 years old

T- 99.8 P- 101 R 20 178/94  Ht 5’6 Wt 140lbs

Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She has been smoking crack cocaine, approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”), and 2–3 alcohol drinks once weekly. She has past drug possession and theft convictions; currently on 2 yr probation with randomized drug screens.

She tries to find the pattern for the calls in order not to test dirty urine. Her admission labs abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for cocaine, THC. Negative for alcohol or other drugs. BAL 0; other labs within normal ranges. She reports sexual abuse as child ages 5–7, perpetrator being her father who went to prison for the abuse and drug charges. She is estranged from him. Mother lives in Alabama, hx of anxiety, benzodiazepine use. Older brother has not contact with family in last 10 years, hx of opioid use. Sleeps 4-5 hrs, appetite decreased, prefers to get high instead of eating. Allergies: amoxicillin

She is considering treatment for her Hep C+ but needs to get clean first.

Symptom Media. (Producer). (2017). Training title 82 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-82

Training Title 114 Name: Ally Patel Gender: female Age: 48 years old

Background: Only child, raised by parents in San Francisco, CA. Has PhD in biology and

master’s degree in high school education (8–12). Her supervisor has asked the school EAP

counselor to intervene with concerns regarding potential substance use in effort to facilitate getting her help and be able to retain her.

Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-114-2

Training Title 151 Name: Katarina Bykov Gender: female Age:41 years old

T- 97.4 P- 74 R 120 100/70 Ht 5’8 Wt 117lbs

Background: Moved to Washington State from Russia with her parents when she was 12 years old. She has 2 brothers, 2 sisters. Denied family mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx; Menses regular. Has chronic pain issues. She works part time cashier at Aldi Grocery Store. Dropped out of high school in 11th grade. Sleeps 4–9 hours on average, appetite good.

Symptom Media. (Producer). (2018). Training title 151 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-151

Week 10 Neurocognitive and Neurodevelopmental Disorders

Training Title 48 Name: Sarah Higgins Gender: female

Age: 9 years old

T- 97.4 P- 62 R 14 95/60 Ht 4’5 Wt 63lbs

Background: no history of treatment, developmental milestones met on time, vaccinations up to date. Sleeps 9hrs/night, meals are difficult as she has hard time sitting for meals, she does get proper nutrition per PCP.

Symptom Media. (Producer). (2017). Training title 48 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-48

Training Title 50 Name: Harold Griffin Gender: male Age:58 years old

T- 98.8 P- 86 R 18 134/88 Ht 5’11 Wt 180lbs

Background:

Has bachelor’s degree in engineering. He is homosexual and dates casually, never married, no children. Has one younger sister. Sleeps 4-6 hours, appetite good. Denied legal issues; MOCA 27/30 difficulty with attention and delayed recall; ASRS-5 20/24; denied hx of drug use; enjoys one scotch drink on the weekends with a cigar. Allergies Morphine; history HTN blood pressure controlled with losartan 100mg daily, angina prescribed ASA 81mg po daily, metoprolol 25mg twice daily. Hypertriglyceridemia prescribed fenofibrate 160mg daily, has BPH prescribed tamsulosin 0.4mg po bedtime.

Symptom Media. (Producer). (2017). Training title 50 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-50

Also Read: NRNP 6635 Case History Reports

NRNP 6635 Case History Reports

Week 3: Mood Disorders

Training Title 2

Name: Ms. Julie Houston Gender: female

Age:19 years old

T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs

Background: Recently started a business undergraduate program in Boston, MA after growing up and living in South Carolina her whole life. Grew up with both parents, two brothers, and one sister. Currently lives in off-campus housing with two other female roommates. Currently a full-time student, not employed. Not married, currently single. She has no previous psychiatric history; takes no medications. There is no psychiatric or substance use history for her or family. No legal hx NKDA

Symptom Media. (Producer). (2016). Training title 2 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-2

Training Title 8

Name: Mrs. Leslie Tilman Gender: female

Age: 32 years old

T- 97.6 P- 97 R 22 149/98 Ht 5’3 Wt 245lbs

Background: Recently had her first child two months ago. Currently married; stay at home mother after working in retail for 5 years. Grew up with both parents, one sister in Omaha, NE. Completed education through bachelor’s level, studying physics. Previous employment included research science as well as high school substitute teaching for 5 years prior to birth. No previous suicidal gestures; has uncle who committed suicide via GSW. She denied drugs/alcohol; uncle was opioid abuser. Hx of HTN-prescribed labetalol 100mg twice daily, admits to missing doses due to forgetting. No legal hx. Allergies: codeine

Symptom Media. (Producer). (2016). Training title 8 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-8

Training Title 18

Name: Ms. Ashley Domingo Gender: female

Age:20 years old

T-97.9 P-68 R-18 118/82 Ht 5’1 Wt 120lbs

Background: Currently living off-base in California, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in Houston, TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; NKDA

Symptom Media. (Producer). (2017). Training title 18 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-18

Training Title 28

Name: Mrs. Louise Carson Gender: female

Age: 49 years old

T- 98.8 P- 99 R 20 150/88 Ht 5’5 Wt 135lbs

Background: Currently living in Indianapolis, IN, working full-time as a logistics buyer in a medical facility. Has an MBA. Lives with her husband and three children, three boys who are all teenagers. Born and raised in Indianapolis, IN with her mother and two sisters. Father deceased in MVA when she was 2 years old. Sister has depression; mother has history of being a “functioning alcoholic”. Recently informed by her PCP she has a “fatty liver.” Allergies: latex

Symptom Media. (Producer). (2016). Training title 28 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-28

Training Title 38

(same patient in video 43 but presentation of his illness pre-hospitalization) Name: Mr. Will Loman

Gender: male Age:19 years old

T- 98.6 P- 94 R 24 128/78 Ht 5’7 Wt 152lbs

Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no

family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies: PCN

Symptom Media. (Producer). (2016). Training title 38 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-38

Training Title 43 – NRNP 6635 Case History Reports

(same patient in video 38 but presentation of his illness with hospital treatment)

Name: Mr. Will Loman Gender: male

Age:19 years old

T- 98.2 P- 74 R 18 120/70 Ht 5’7 Wt 156lbs

Background: Currently lives with his sister and two parents in Jacksonville, FL. Not currently employed. Completed high school, not currently in school. Hx of treatment for mood disorder began age 15, previous trials of Depakote, Olanzapine off and on, side effects of wt. gain. Has hx of a three-day hospitalization one year ago after found wandering on the side of the freeway, but he signed himself out ‘against medical advice.’ He refused medication due to previous experiences. Not currently partnered. He has been sexually inappropriate with comments to female neighbors; pulled his pants down in the mall. He is currently in hospital admitted one week ago, was initiated on lithium 300mg po three times daily and risperidone 1mg at bedtime. Denies any recent alcohol or substance use. Father has history of bipolar disorder. No history of self-harm behaviors, no family suicides. Mother reports he has slept 2–3 hours in past week, up spending money buying and playing new video games and says he is writing a book on how others can be a video game master. Appetite is decreased. No medical hx; hospital admission labs within normal ranges, UDS negative; Hx of trespassing as a juvenile. Has pending court date for indecent exposure. Allergies PCN

Symptom Media. (Producer). (2016). Training title 43 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-43

Training Title 150 Name: Ms. Liliana Ball Gender: female Age:16 years old

T- 97.4 P- 84 R 18 134/88 Ht 5’3 Wt 118lbs

Background: Currently living with her parents in Tacoma, WA along with two young siblings. She is a sophomore in high school, not currently partnered, reports she is bisexual, lately having lot of unprotected sex that her parents don’t know about. She has been stealing money out of her mom’s purse to buy clothes, makeup, “and just other things.” She has history of treatment since age 7 for conduct disorder, depression, history of taking sertraline which worsened her irritability, aggression, impulsivity.

She has been in a 3-month teen residential mental health facility discharged one month ago with lithium 300mg in am and 600mg at bedtime, aripiprazole 10mg in the morning. When discharged, her labs were within normal ranges and urine toxicology negative. She was positive for cannabis upon admission. Her parents believe she is hiding her medication as she has made comments “they slow me down; they crush my creative art.”

She has hx of domestic violence toward her mother and 2 younger sisters as juvenile. No current legal issues. Her grandmother has hx of bipolar disorder; her mother and her maternal aunt have anxiety. She is sleeping 3–4hrs/24 hrs. Reports her appetite “is great.” She has no medical issues; has Nexplanon implant; hx of self-harm with cutting.

Symptom Media. (Producer). (2018). Training title 150 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-150

Training Title 118 Name: Mr. Oscar Luna Gender: male

Age: 52 years old

T- 98.6 P- 90 R 24 140/84 Ht 5’8 Wt 170lbs

Background: Born and raised in Leopold, IN. Is staying at a shelter after being homeless in MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time as a dishwasher. Enjoys playing music. He has long hx of mental health treatment since age 14. Previous medication trials include lithium (toxicity), Depakote (wt gain), aripiprazole (akathisia), risperidone (dystonia), haloperidol (didn’t give a fair trial), quetiapine (wt gain), reports in past helpful medication was lurasidone, lamotrigine, olanzapine but states “they really squash my creative song writing though.”

Poor historian. Never married, reports he is gay, no children; estranged from only living sister, parents deceased. He is not sure of his family mental health or substance use history but feels like he is most like his aunt, she has history of mental health treatment “but I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits to 1–3 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of overdose at age 28, history of 3 inpatient psychiatric hospitalization, most recent was 1 year ago. Allergies: doxycycline; hx of rosacea.

Symptom Media. (Producer). (2018). Training title 118 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-118

Training Title 144 Name: Ms. Amy Hartford Gender: female

Age: 32 years old

T- 98.2 P- 74 R 18 120/70 Ht 5’1 Wt 150lbs

Background: Currently lives in Phoenix, AZ, divorced with two children ages 10 and 8. Born and raised in Tucson, AZ with her mother and four sisters NKDA; no legal hx

Symptom Media. (Producer). (2018). Training title 144 [Video]. https://video-alexanderstreet- com.ezp.waldenulibrary.org/watch/training-title-144

NRNP 6635 Week 3: Assignment

ASSESSING AND DIAGNOSING PATIENTS WITH MOOD DISORDERS

Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

TO PREPARE:

• Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
• Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document. 
• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Identify at least three possible differential diagnoses for the patient. 

BY DAY 7 OF WEEK 3

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 
• Objective: What observations did you make during the psychiatric assessment?? 
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Reflection notes: What would you do differently with this client if you could conduct the session over??Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Video Case Selections for this Assignment

Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected. 

• Symptom Media. (Producer). (2016). Training title 2.[Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-2
• Symptom Media. (Producer). (2016). Training title 8 https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-8
• Symptom Media. (Producer). (2017). Training title 18. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-18
• Symptom Media. (Producer). (2016). Training title 28.[Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-28
• Symptom Media. (Producer). (2016). Training title 38. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-38
• Symptom Media. (Producer). (2016). Training title 43. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-43
• Symptom Media. (Producer). (2018). Training title 118. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-118
• Symptom Media. (Producer). (2018). Training title 144. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-144
• Symptom Media. (Producer). (2018). Training title 150. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-150
• Document: Case History Reports

NRNP 6635 Case History Reports Week 3: Assessing and Diagnosing Patients with Mood Disorders Example

Subjective:

CC (chief complaint): “Yeah, yesterday I was a little bit depressed, but it was just because I was in a bad mood.”

HPI: Ms. C.L. is an 18-year-old female who presents to the psychiatric clinic for a psychiatric evaluation for depression. She had been admitted to a mental health facility and discharged on lithium 300 mg in the morning and 600 mg during bedtime, and aripiprazole 2.5 mg in the morning. She has a history of taking citaprolam, which worsened her impulsivity, aggression, and irritability symptoms.

The patient agrees that the previous day she left a little depressed, as it is human nature to change moods. The parents reported that she had started crying and said she did not want to participate in more school plays. Additionally, they reported that she had lost her energy and had said she was worthless, thought she was destroying everyone’s life, and wanted to die. She refers to these reports as ancient history. These symptoms had only lasted for almost a week.

Past Psychiatric History:

•       General Statement: She entered treatment for depression and conduct disorder at 9 years. She was also admitted to a residential mental health facility and discharged three months ago.
•       Caregivers (if applicable): N/A
•       Hospitalizations: Residential Mental Health Facility
•       Medication trials: N/A
•       Psychotherapy or Previous Psychiatric Diagnosis: Conduct disorder, depression

Substance Current Use and History: She tested positive for cannabis on admission.

Family Psychiatric/Substance Use History: The grandmother has a history of bipolar disorder. Her mother and aunt have a history of anxiety.

Psychosocial History: The client lives in Locust Grove, Oklahoma, with her parents, two younger sisters, and an older brother.

Medical History:

•       Current Medications: She is on lithium 300 mg in the morning and 600 mg during bedtime, and aripiprazole 2.5 mg in the morning.
•       Allergies: N/A

• Reproductive Hx: She is not partnered and has no children. She is bisexual, and lately, she has been hyper-sexual with increased incidents of unprotected sex.

ROS:

•       GENERAL: No apparent signs of loss of weight, fatigue, chills, or weakness.
•       HEENT: Eyes: No loss of vision, diplopia, or yellowing of the sclera. Ears: No loss of hearing or discharge from ears. Nose & Throat: No sore throat, runny nose, congestion, or sneezing.
•       SKIN: No itching or rash.
•       CARDIOVASCULAR: No reports of chest pressure, chest pain, or chest discomfort. No edema or palpitations.
•       RESPIRATORY: No cough, shortness of breath, or sputum.
•       GASTROINTESTINAL: No reports of nausea, vomiting, diarrhea, abdominal pains, or blood in the stool.
•       GENITOURINARY: No odd urine color, odor, or burning sensation on urination.
•       NEUROLOGICAL: No reports of dizziness, paralysis, ataxia, headache, or tingling sensation of the extremities. Bowel and bladder control has not changed.
•       MUSCULOSKELETAL: No back pains, joint pain, muscle pain, or stiffness of joints.
•       HEMATOLOGIC: No history of bruising, bleeding, or anemia.
•       LYMPHATICS: No history of splenectomy or enlargement of the lymph nodes.
•       ENDOCRINOLOGIC: No reports of heat or cold intolerance. No reports of sweating. No polydipsia or polyuria.

Objective:

Physical exam: N/A

Diagnostic results: Toxicology reports indicates traces of Cannabis sativa

Assessment

Mental Status Examination:

The patient is well-groomed and dressed appropriately for the weather outside. She is clothed appropriately for her age. She has good hygiene. During the interview, the patient had a laid-back and obedient demeanor. She speaks clearly, with enough volume, at a regular tempo, and with a wealth of vocabulary. She seems dysphoric in her overall mood.

Observation reveals that the client is uneasy; she constantly moves and looks around the space. No reported cases of delusion exist. The patient is quickly distracted by other outside occurrences and is not totally engaged in the inquiries. She enquires about the wall decorations and the interviewer’s preference for travel. Her apparent flight of ideas is evidenced by the fact that she swiftly diverts the conversation from the current topic. She does not have any perception issues.

The patient is alert and oriented X4 (to person, time, place, and situation). She is having trouble concentrating; she cannot name the months of the year backward. She mentioned November and December but could not say whether June or July came next. She could recall all the numbers she was asked to repeat: 4, 6, and 9. Her short-term memory is still intact. She answered accurately that she had eaten oats, milk, and pancakes that morning, demonstrating that her memory for the recent past was outstanding. 

She remembered her favorite character from an animation she had watched in the past because her long-term memory was still intact. Her ability to reason abstractly was excellent. She correctly identified the book when asked to choose the odd item from bread, butter, and a book list. The fact that butter and bread were considered foods, while the book was not, was another strong argument for her belief that it was odd. The patient has no understanding of her condition. She made wise decisions. When asked what she would do if she discovered her dog stuck behind a door, she replied that she would contact her parents for assistance in releasing the dog.

Primary diagnosis

Major depressive disorder

The patient has not been happy lately and self-reported that she has been a little depressed. The parents also report that she is uninterested in attending the school plays. She also sleeps an average of 2 to 3 hours in 24 hours, indicating insomnia. The parents also reported that she had a loss of energy. She is also experiencing feelings of worthlessness and recurrent thoughts of death. All these symptoms point to a definite diagnosis of major depressive disorder. 

The DSM V TR requires that five or more of the definite symptoms of MDD exist in the same 2-week period and should indicate a change in functioning. One of the symptoms must be a loss of interest in activities or a depressed mood. The five symptoms that make the diagnosis pertinent are a depressed mood for most of the day, diminished interest, insomnia, loss of energy, feelings of worthlessness, and recurrent thoughts of death (American Psychiatric Association, 2022). All these criteria are indicative of Major Depressive Disorder.

Critical thinking process

My critical thinking considered several important factors while deciding on Major Depressive Disorder as the significant diagnosis. I carefully examined the client’s past, taking note of any history of self-harm or other depressive symptoms, including poor mood, feeling unworthy, and wanting to die. I also looked at the client’s psychosocial issues, such as their history of conduct disorder, drug use, and mental health illnesses in the family.

I could recognize a pattern of symptoms compatible with the diagnosis of Major Depressive Disorder by fusing these pieces of information and contrasting them with the diagnostic standards for this condition. I chose to diagnose the client with major depressive disorder using my critical thinking process to assess their presentation in the context of their psychosocial history and symptoms.

Differential Diagnoses

Substance-induced depressive disorder

Criteria A for this diagnosis requires that the client presents with a persistent and prominent mood disturbance characterized by a depressed mood or a diminished interest in all or almost all activities (American Psychiatric Association, 2022). She presents with a loss of interest in participating in school plays and admits that she is a little depressed, making this differential diagnosis probable. Criteria B requires that the evidence from the findings show that the client developed the symptoms due to withdrawal or after exposure (American Psychiatric Association, 2022). However, the client does not present with withdrawal symptoms despite the toxicology report showing that she had consumed cannabis sativa.

Borderline personality disorder

The client presents with unstable interpersonal relationships; she has a history of domestic violence against her brother and self-harm, which she engaged in 6 months ago. Medications had worsened her impulsivity. Her parents also believe that she has been hiding her medications because she thinks they slow her down and make her not think fast, showing instability in her self-image.

The diagnostic criteria for this condition require a history of identity disturbance and impulsivity in two potentially self-damaging areas; she is engaging in substance abuse and unprotected sex and has a history of self-mutilating behavior (Boland et al., 2022). She also feels empty as she says she is worthless and wants to die. All her symptoms meet the criteria for Borderline personality disorder as a differential diagnosis.

Disruptive mood dysregulation disorder (DMDD)

The client has a history of conduct disorder and domestic violence towards her sibling, probably because of anger outbursts. The history of taking citalopram worsened her irritability, aggression, and impulsivity, making DMDD to be a potential differential diagnosis. Severe recurrent temper outbursts three or more times per week, a hallmark of DMDD, are absent. Although the client has a history of violence, irritability, and conduct disorder, the evidence does not particularly point to severe recurrent temper outbursts as defined by the criteria for DMDD.

Reflection

Working on this case study has taught me more about the intricacy of mood disorders and how they affect a person’s life. This case demonstrated the value of a thorough evaluation that takes the client’s history, family relationships, and consumption of drugs into account. I have also understood the importance of a therapeutic alliance in fostering openness and trust. I would ensure regular interaction and collaboration with the interdisciplinary team to understand the client’s needs comprehensively.

I would prioritize continuing my education in mood disorders, particularly the diagnostic standards and research-supported treatments. To effectively serve the client, I would also focus on developing my therapeutic communication and crisis management abilities. Overall, this experience has highlighted the necessity for a caring and tailored approach to care and the constant learning process.

Working with this client has increased my awareness of the ethical and legal concerns surrounding providing for them. Handling these issues while upholding the client’s dignity, liberty, and privacy is critical. Along with confidentiality and informed consent, it is essential to carefully manage issues like required reporting of domestic abuse and self-harm risk while maintaining the client’s best interests in mind (Ventura et al., 2020).

To provide comprehensive care, it has become essential to comprehend the social determinants of health. Interventions should assist the client’s passage to adulthood and address the educational requirements, given that she is a senior in high school. Their ethnicity may also impact their cultural values and health-seeking habits, necessitating culturally competent treatment to build rapport and successful communication.

Disease prevention and health promotion strategies should be adapted to the client’s risk factors. Substance abuse treatment options, access to contraception, and education about safer sexual practices are all necessary because of substance use and unsafe sexual behaviors. Given the history of conduct disorder, interventions emphasizing anger management and coping mechanisms may be advantageous.

It is crucial to consider any financial limitations that can limit the client’s access to services and treatment while also considering their socioeconomic background. Collaboration with community organizations and social service agencies could offer extra assistance. A supportive atmosphere can be fostered, and family difficulties, such as the reported domestic abuse, can be addressed by including the client’s family in the care process.

Reflecting on this incident, I recognize the need for a thorough, patient-centered strategy. It necessitates a thorough awareness of risk factors, socioeconomic determinants of health, and legal/ethical issues. I may enhance the client’s general well-being and enhance the results of their health therapies by critically assessing these elements.

NRNP 6635 Case History Reports References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Boland, R. J., Verduin, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Ventura, C. A. A., Austin, W., Carrara, B. S., & de Brito, E. S. (2020). Nursing care in mental health: Human rights and ethical issues. Nursing Ethics, 28(4), 096973302095210. https://doi.org/10.1177/0969733020952102

Also Read: Borderline Personality Disorder Sample Paper

NRNP 6635 Week3 Assignment Mood Disorders

NRNP 6635 Week 3: Mood Disorders Example

Patient Information:

Patient Initials: N. C                 Age: 17   Gender: Female Race: White American

Subjective:

Chief Complaint (CC): The patient’s mother expressed concern about her daughter’s moodiness during this time of year and requested an evaluation.

History of Present Illness (HPI): Ms. N. C, a 17-year-old White American female, presents with a chief complaint of feeling down and not doing well. Her mother expressed concern about her mood worsening during this time of year. She left the business program at school and is struggling with her academic projects, including a mock company assignment. She has difficulty concentrating, experiencing memory lapses, and has gained weight. Ms. N. C has also been sleeping through some of her classes and has experienced a decline in her social activities. She initially made friends and enjoyed outings, but lately, she has found her friends annoying and feels less motivated to engage in social activities. She dislikes the cold weather and describes the city as dark, grey, and miserable, contributing to her negative mood.

Past Psychiatric History:

• General Statement: The patient has no previous psychiatric history.
• Caregivers (if applicable): N/A
• Hospitalizations: No history of past hospitalizations
• Medication trials:  No previous history of medication trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient does not have a previous psychiatric diagnosis or history of psychotherapy.
• Substance Current Use and History: She denies any history of substance use for herself, including nicotine, illicit substances (including marijuana), or alcohol. However, she reports taking caffeine daily. The patient does not report any withdrawal complications, such as tremors, delirium tremens, or seizures.

Family Psychiatric/Substance Use History: The patient acknowledges a known history of depression within the family but denies any history of substance use.

Psychosocial History: N.C. is a 17-year-old White American female born and raised in New Orleans, Louisiana. Growing up, N.C. lived with both of her parents and four brothers. However, her residence is a specialty high school dormitory in Chicago, Illinois. Among her siblings, N.C. is the only girl and the youngest. Presently, she is not married and remains single, without any children. Being a full-time high school student, Natalie prioritizes her studies in the business program. In addition to her academic pursuits, she also holds a part-time job at a local coffee shop. She enjoyed socializing and participating in recreational activities in the past, but her interest in them has waned. Notably, N.C. has a clean record with no history or current legal issues.

Medical History: No history of hospital admission

• Current Medications: She takes no medications
• Allergies: NKDA

Reproductive History: She experienced menarche at 14 and continues to have regular menstrual cycles within a 28-day cycle without complications such as dysmenorrhea or menorrhagia. At present, she is unmarried and remains single, without any children. Furthermore, there is no record of her using contraceptives, and she confirms not being sexually active.

Review of Systems (ROS):

GENERAL: Ms. N. C is a 17-year-old White American female with a height of 5’2? and a weight of 192 pounds. She presents with a downcast mood, slouched posture, and signs of decreased engagement, such as a lack of eye contact, reflecting her reported feelings of not doing well and exhibiting a low mood.

HEENT:

• Eyes: She has no loss of vision, double vision, painful eyes, or jaundice.
• Ears, Nose, and Throat: She does not experience any auditory impairments, such as hearing difficulties. Additionally, she is unaffected by symptoms like sneezing, congestion, a runny nose, or a sore throat. Furthermore, no recent nasal polyps, nosebleeds, or sinus infections have occurred. She exhibits no challenges related to chewing or swallowing, and there are no indications of gingivitis or bleeding gums.
• Skin: She denies experiencing any skin rashes or lesions. Her hair appears evenly distributed, showing no signs of hair loss. Additionally, her nails remain intact, and there are no indications of clubbing.
• Cardiovascular: The patient denies experiencing chest discomfort, palpitations, tightness, arrhythmias, or elevated blood pressure. There is also no indication of varicose veins, edema, or claudication.
• Respiratory: No shortness of breath, cough, or sputum.
• Gastrointestinal: The patient denies any presence of abdominal pain, tenderness, distention, or discomfort. There is no reported incidence of heartburn, constipation, diarrhea, or indigestion.
• Genitourinary: She denies dysuria, urinary frequency, urgency, and abnormal vaginal discharge.
• Neurological: She denies experiencing symptoms such as headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Additionally, there have been no observed alterations in bowel or bladder control.
• Musculoskeletal: No back pain, myalgia, joint pain, or stiffness
• Hematological: No anemia, bleeding, or bruising.
• Lymphatics: No enlarged nodes or splenectomy
• Endocrinologic: She denies sweating, cold, or heat intolerance: no polyuria or polydipsia.

Objective:

Vital signs: Temperature (T): 97.4°F, Pulse (P): 82 beats per minute, Respiration rate (R): 20 breaths per minute, Blood pressure (BP): 128/84 mmHg, Height: 5’2? (62 inches), Weight: 192 lbs.

General: The patient mentions feeling down and not doing well.

Neurological: The patient mentions difficulty concentrating, memory problems, and changes in sleep patterns.

Diagnostic results: Comprehensive psychiatric evaluation, laboratory tests, including a complete blood count (CBC), thyroid function tests, and other relevant investigations, may be recommended to rule out any underlying medical causes for the patient’s symptoms.

Assessment:

Mental Status Examination:

Ms. N. C, a 17-year-old White American female, presents with a slightly overweight appearance, indicated by her weight of 192 lbs and height of 5’2?. During the interview, she appears disinterested and exhibits a passive attitude. Her behavior is characterized by a subdued manner and occasional sighing. Furthermore, her mood remains consistently low, and her affect is congruent with her depressed mood, displaying minimal variability and limited facial expressions.

Regarding speech, Ms. N. C’s responses are brief and lack elaboration. Her thought processes appear slowed, with delayed responses and occasional pauses. She expresses feelings of sadness and states that she is not doing well. Specifically, Ms. N. C reports leaving her program at school and struggling with her coursework, particularly in a special business program where she is required to create a mock company. She describes difficulty concentrating, memory problems, and detachment from her studies. Furthermore, she mentions being late on two projects and expresses frustration with her teachers.

Regarding her perceptions, Ms. N. C does not report any hallucinations, pseudo hallucinations, or illusions during the interview. However, she acknowledges difficulty sleeping, weight gain, and excessive daytime sleepiness. She also reports a decline in her social activities and expresses annoyance toward her friends, whom she finds dull. Additionally, she attributes her dislike for the current time of the year to the dark, grey, and miserable weather, which she believes has changed the city she once loved. She describes the snow in the city as grey and black, contrasting it with her previous expectation of white and beautiful snow.

In terms of cognition, Ms. Crew demonstrates impaired concentration and memory. This is evident in her difficulty remembering what she reads and forgetting the content of her classes shortly after leaving the room. Her insight into her current state is limited, as she attributes her struggles to external factors, such as her teachers and the weather, rather than considering internal emotional or psychological factors. At this time, Ms. Crew denies any suicidal or homicidal ideation. However, given her low mood, decreased interest in activities, social withdrawal, and negative perception of her environment, further exploration of her risk for self-harm is warranted.

Differential Diagnoses:

1.     Major Depressive Disorder (MDD)

The patient’s presentation is consistent with MDD. She exhibits symptoms such as persistent low mood, loss of interest in activities, difficulty concentrating, memory problems, changes in sleep patterns (oversleeping), weight gain, social withdrawal, and negative perception of her environment (Bains & Abdijadid, 2022). A comprehensive psychiatric evaluation is recommended to assess the severity of her depressive symptoms and rule out other possible causes.

2.     Seasonal Affective Disorder (SAD)

The patient’s symptoms worsen during a specific time of the year (winter) and are associated with a dislike for the cold weather and the perception of the city as dark, grey, and miserable. These features suggest the possibility of SAD, a subtype of depression that occurs cyclically with the change in seasons (Munir & Abbas, 2022).

3.     Adjustment Disorder with Depressed Mood

The patient’s symptoms, such as low mood, difficulty concentrating, changes in sleep and appetite, and social withdrawal, maybe a reaction to a specific stressor or life event, such as leaving the business program at school and struggling with academic projects (O’Donnell et al., 2019). If the symptoms are considered to be a direct response to this stressor and do not meet the criteria for a major depressive episode, an adjustment disorder with a depressed mood may be a possible diagnosis.

Reflections:

I agree with my preceptor’s assessment and diagnosis of Major Depressive Disorder (MDD) for this patient. The patient presents with several hallmark symptoms of MDD, which have been present for a significant time, causing impairment in multiple areas of her life. The patient’s family history of depression also supports the possibility of a genetic predisposition. A comprehensive psychiatric evaluation, ruling out other possible medical causes, would be necessary to confirm the diagnosis.

This case taught me the importance of considering seasonal factors in mood disorders, specifically Seasonal Affective Disorder (SAD). The patient’s worsening symptoms during a specific time of the year and her negative perception of the weather and environment indicate the need to explore these factors and assess whether the symptoms meet the criteria for SAD (Munir & Abbas, 2022). Psychosocial factors such as the patient’s adjustment to a new environment and academic stressors must also be evaluated. Legal/ethical considerations, including confidentiality and obtaining appropriate consent for treatment, as well as the patient’s autonomy and involvement in treatment decisions, should be considered.

Social determinants of health, such as the patient’s age, ethnicity, and socioeconomic background, may influence her access to resources, and it is vital to address these factors when developing a treatment plan (Phuong et al., 2022). Health promotion and disease prevention efforts should involve educating the patient and her family about depression, strategies for managing symptoms, and encouraging healthy lifestyle behaviors. Additionally, a more thorough assessment of the patient’s social support network and psychosocial stressors and evaluation of any history of trauma or adverse childhood experiences could provide valuable insights into her current mental state.

NRNP 6635 Week3 Assignment Mood Disorders References

Bains, N., & Abdijadid, S. (2022). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Munir, S., & Abbas, M. (2022, January 9). Seasonal depressive disorder. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568745/

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Phuong, J., Riches, N. O., Madlock?Brown, C., Duran, D., Calzoni, L., Espinoza, J. C., Datta, G., Kavuluru, R., Weiskopf, N. G., Ward?Caviness, C. K., & Lin, A. Y. (2022). Social determinants of health factors for gene–environment: Challenges and opportunities. Advanced Genetics, 3(2), 2100056. https://doi.org/10.1002/ggn2.202100056

Week 3: Mood Disorders

While most people experience the sadness or grief at some point in their lives, it is typically of short duration and may occur in response to some type of loss. Clinically significant depression, on the other hand, is more disruptive and serious. It lasts longer and has more symptoms that interfere with daily functioning.

This week, you will explore the differences among mood disorders such as depressive, bipolar, and related disorders, and you will examine challenges in properly differentiating among them for the purpose of accurately rendering a diagnosis. You also will look at steps that can be taken to increase the likelihood that patients who are diagnosed with these disorders benefit from treatment and refrain from physically harming themselves or others.

Learning Objectives

Students will:

• Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
• Formulate differential diagnoses using DSM-5 criteria for patients with mood disorders across the lifespan

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Bipolar and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm03

American Psychiatric Association. (2013). Depressive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.).

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

• Chapter 8, Mood Disorders
• Chapter 31, Child Psychiatry (Section 31.12 only)

Document: Comprehensive Psychiatric Evaluation Template

Document: Comprehensive Psychiatric Evaluation Exemplar

Required Media (click to expand/reduce)

Classroom Productions. (Producer). (2015). Bipolar disorders [Video]. Walden University.

Classroom Productions. (Producer). (2015). Depressive disorders [Video]. Walden University.

_________________________________________________________________ 

00:00:00BEGIN Transcript: 

00:00:00DIAGNOSING MENTAL DISORDERS 

00:00:00DSM-5® AND ICD-10 

00:00:05DEPRESSIVE DISORDERS 

00:00:10JIM HARRIGAN Our mood can often shape our perception of our own situation. The perceptions of our world can influence our overall state of happiness and wellbeing just as much, if not more than the circumstances we find ourselves in. For those people with mood disorders, this can be a harrowing concept, since the individual psychological disorder can make it hard or even impossible for a person to see their circumstances in a favorable light. This is especially true of patients with depressive disorders, a subset of mood disorders, in which the individual experiences episodes of sorrow, lethargy, and even a complete lack of energy and excitement about life. 

Mood is defined as the prolonged emotions that color a person’s perceptions of the world. Within this category of mood disorders, are two groups of disorders. These are depressive disorders, and bipolar and related disorders. Both of these groups share the common trades of mood disorders. However, well, bipolar and related disorders feature manic or hypomanic episodes and symptoms, in which the individual feels elated and energized. Depressive disorders are marked by major depressive episodes or symptoms, in which the individual has difficulty enjoying life. These symptoms can manifest themselves in a variety of disorders, differing in duration, timing, underlying causes, and other more subtle specifics. 

00:02:00DSM-5® AND ICD-10 CODING 

00:02:05JIM HARRIGAN The depressive disorders grouping in the fifth edition of the Diagnostic and Statistical Manual of mental disorders or DSM-5 contains a number of distinct disorders, each given it’s own unique diagnostic code. These codes correspond to the codes used by the World Health Organization in the International Classification of Diseases or ICD. In DSM-5, each disorder is first linked to the coding system from the ICD-9 with the codes for the ICD-10 listed in parenthesis after. Hence, all of the DSM codes crosswalk to the ICD codes, including the newest iteration ICD-10.

For instance, major depressive disorder with a single episode, mild, is assigned the code 296.21 from the ICD-9 and F32.0 in parenthesis from the ICD-10. This is because the ICD-9 system was still in use when DSM-5 was first released. ICD-10 was released in the fall of 2015, in the United States, although it was adopted previously in other countries. However, because ICD-10 is now the standard in the United States, this program will be listing the newer code from ICD-10 first, followed by the ICD-9 codes in parenthesis.

The coding for other specifications of major depressive disorder depends on, if the episode is single or recurrent, and can be further delineated by descriptors to indicate the episode’s severity, if it had psychotic features, the stage of remission that it is in, or if it is unspecified. The appropriate order is, the name of the disorder, if it is a single or recurrent episode, severity psychotic remission specifiers, followed by any additional specifiers. Sometimes, when relevant, we will also delineate the ICD-9 and 10 codes, when we mention a disorder from one of the other chapters of DSM-5. 

For example, to use one of the bipolar and related disorders mentioned earlier in this program, Bipolar I disorder, with the current or most recent episode manic and mild, is coded as F31.11 (296.41), part of the F30 to F39 section of the ICD-10 on mood affective disorders. Organizationally, there are few differences between the layouts of the DSM-5 and the ICD-10. The ICD-10 puts depressive disorders into their larger section on mood affective disorders in their F30 to F39 block. And many of the depressive and bipolar disorders that are separate in DSM-5 are mixed together in the ICD-10. For example, dysthymia, referred to as persistent depressive disorder (Dysthymia) in DSM-5, and cyclothymia, a bipolar related disorder in DSM-5, are both placed in the F34 section of the ICD-10 for persistent mood affective disorders.

While the ICD-10 grouping of all mood disorders into a larger section may seem like a minor organizational difference. It does further illuminate the underlying similarities between depressive and bipolar disorders, which we will highlight throughout this program and in that on bipolar disorders. Two other major differences are with substance or medication-induced depressive disorder. And depressive disorder due to another medical condition. The ICD-10 puts what they call mental and behavioral disorders due to psychoactive substance abuse in the F10 block. And organic, including symptomatic disorders in the F00 to F09, specifically F06, or other mental disorders due to brain damage and dysfunction and to physical disease. In this case, the code is for FO6.3 for organic mood affective disorder. 

00:06:55MAJOR DEPRESSIVE DISORDER 

00:07:00JIM HARRIGAN Major depressive disorder is the most prevalent of the depressive disorders affecting 7 percent of the population. This can be even higher in females, since they experience a 2:1 preponderance to males. However, despite the high prevalence, only one out of three individuals experiencing major depressive disorder seek treatment. An individual with major depressive disorder may experience a depressed mood, loss of pleasure, fatigue, problems with sleeping, weight loss, and more, happening for the majority of time during a specific time period lasting at least two weeks. This is categorized as a major depressive episode, one of three mood episodes, because this episode is such a significant aspect of the diagnosis for major depressive disorder. We will first take a closer look at mood episodes, then major depressive episodes, before further exploring how these episodes tie into a diagnosis of major depressive disorder.

00:08:15SCHIZOPHRENIA 

00:08:15FUNDAMENTAL CHARACTERISTICS 

00:08:20JIM HARRIGAN A mood episode is a specific period of time where an individual feels abnormally energized and elevated, or alternatively depressed. The presence and repetition or lack there of, of these episodes affects the coding of the disorder. But even beyond that, these mood episodes can be considered the basis of some disorders, as they are for major depressive disorder. In addition to depressive episodes, there are manic episodes in which the individual experiences at least a week of increased energy or activity and the less severe hypomanic episodes which feature the same symptoms, but to a less debilitating extent.

For both of these episodes, the individual may experience racing thoughts, a need for less sleep, overly increased self-esteem, distractibility, or excessive poor judgment regarding dangerous activities among other symptoms. While these are worth mentioning to contrast them against a major depressive episode, the presence of a manic or hypomanic episode will change the patient’s diagnosis to a bipolar or a related disorder. And so we will explore them in greater detail in our program on bipolar disorders. 

00:09:50MAJOR DEPRESSIVE EPISODE 

00:09:55JIM HARRIGAN A major depressive episode has a number of characteristic features, which take place most of the day, nearly every day, where relevant. The two main characteristics are a depressed mood, and a noticeably decreased interest in most activities. Other characteristics include trouble sleeping, diminished hunger or pronounced weight loss, trouble concentrating or making decisions, fatigue or loss of energy, recurring suicidal thoughts with or without intent to act on these thoughts, feelings of worthlessness or excessive or inappropriate guilt, psychomotor agitation or retardation, and feelings of low self-worth or pronounced guilt. These symptoms must cause marked distress in the patient’s work or social life. For all of these episodes the clinician should ensure that the symptoms are not better explained by another medical condition or by the affects of a substance. 

00:11:00HANNAH HUFF No, I know, I don’t think that there is a normal response. How are you supposed to get over something like this? He was here and now he’s gone. He’s just not around anymore. This… he was a person who’s, who’s life is just gone. 

00:11:20JIM HARRIGAN For a major depressive episode, the clinician should carefully consider its part in the diagnosis, if the patient has recently experienced a significant loss. While the DSM-4 allowed for a bereavement exclusion, this is absent in the DSM-5. Some clinicians claim this is because depression linked to the death or a loss of a loved one, doesn’t greatly differ from other causes of depression. Still, in these cases, the clinician should factor in cultural norms, the patients history, the severity of the symptoms, and whether or not the patient seems to improve before making their diagnosis. There are ways for the clinician to distinguish between grief and a major depressive episode. Grief decreases over time, and may become more present when thinking of the deceased. A major depressive episode on the other hand, is more constant and persistent, and does not include the ability to experience joy, which is still present throughout the grieving process. 

00:12:30MAJOR DEPRESSIVE DISORDER 

00:12:30FUNDAMENTAL CHARACTERISTICS 

00:12:35JIM HARRIGAN Major depressive disorder involves experiencing a major depressive episode, which causes significant impairment for the individual’s work and social life. These episodes last on average from six to nine months but can go for as long as years in some individuals. A major depressive episode can be quoted as a single episode or recurrent. A single episode means that only one episode occurs during the patient’s lifetime. As always, it is important that the clinician rule out that the condition is not better explained by other disorders. The physiological affects of the substance or another medical condition. If a depressive disorder is induced by another medication, a diagnosis of substance/medication-induced depressive disorder maybe given. And if it is caused by a medical condition, the clinician can give the diagnosis of depressive disorder due to another medical condition. The clinician is also able to specify the presence of psychotic features, the state of remission, and severity, as mentioned previously. 

00:13:45MAJOR DEPRESSIVE DISORDER 

00:13:45SPECIFIERS 

00:13:50JIM HARRIGAN There are numerous specifiers the clinician can add to the diagnosis. These will allow the clinician to include extra detail and information to the diagnosis, which can potentially help future clinicians in understanding the patient. For example, the specifier with anxious distress can indicate that the patient has experienced feelings of foreboding, agitation, or tension, intense worry leading to trouble concentrating, or the feeling that they may lose control of themselves during the majority of their most recent episode. In addition to with anxious distress, other potential specifiers include but are not limited to, with mixed features, with catatonia, with peripartum onset, and with seasonal pattern. 

00:14:45PERSISTENT DEPRESSIVE DISORDER 

00:14:45(DYSTHYMIA) 

00:14:50JIM HARRIGAN Persistent depressive disorder, also referred to as dysthymia, is characterized as a depressed mood that lasts for at least two years. This occurs during the majority of days during this time period. While the possible symptomatology of persistent depressive disorder isn’t quite as extensive as it is for major depressive disorder, patients with dysthymia can experience a range of severity. Many of the characteristics are similar to that of major depressive disorder, difficulty concentrating, problems with sleep, poor self-esteem, poor appetite, low energy, and feeling hopeless. 

00:15:35PERSISTENT DEPRESSIVE DISORDER 

00:15:35SPECIFIERS 

00:15:40JIM HARRIGAN A patient with persistent depressive disorder may or may not have a major depressive episode for all or some of the period of symptoms. In addition to the specifiers available for major depressive disorder, allowing the clinician to indicate severity, the state of remission, and other features, there are also specifiers to signify the role of major depressive episodes in the disorder. A patient who for two years, has not experienced any major episodes can be said to have persistent depressive disorder with pure dysthymic syndrome. If, in the last two years, a patient has met the characteristics for a major depressive episode, then the specifier with persistent major depressive episode can be applied. 

If the patient is currently experiencing a major depressive episode, but has had periods of around two months, without qualifying for a full episode, the clinician should use the specifier with intermittent major depressive episodes, with current episode. And if they aren’t currently experiencing a major depressive episode, but have had one or more in the last two years, the clinician should use with intermittent major depressive episodes, without current episode. The clinician can also indicate if the onset of dysthymia happened early onset or before the age of 21, or late onset if the symptoms happened later than age 21. 

00:17:15DIFFERENTIAL DIAGNOSIS AND COMORBIDITY 

00:17:20JIM HARRIGAN Some alternatives to consider with persistent depressive disorder ar

NRNP-6640-14 Psychotherapy Individuals Week 1-2

Week 1: Foundations of Psychotherapy

While working with a patient in the late 1800s, Sigmund Freud discovered the health benefits of talking about emotions and illnesses. When Sigmund Freud introduced his “talking cure” (fundamental psychotherapy), his efforts were met with considerable skepticism. However, as more and more psychiatrists learned that Freud’s methods brought about change in patients who suffered from a variety of mental health issues, his methods were adopted and refined. Today, psychotherapy is recognized as a viable treatment for a wide variety of mental health issues, many of which are examined throughout this course.

This week, as you explore the foundations of psychotherapy, you consider its biological basis. You also examine the influence of culture, religion, and socioeconomics on psychotherapy treatments.

NRNP-6640-14 Psychotherapy Individuals Week 1-2 Learning Resources

Required Readings

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

• Standard 1 “Assessment” (pages 44 & 45)

Note: Throughout the program you will be reading excerpts from the ANA’s Scope & Standards of Practice for Psychiatric-Mental Health Nursing. It is essential to your success on the ANCC board certification exam for Psychiatric/Mental Health Nurse Practitioners that you know the scope of practice of the advanced practice psychiatric/mental health nurse. You should also be able to differentiate between the generalist RN role in psychiatric/mental health nursing and the advanced practice nurse role.

Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

• Chapter 1, “The Nurse Psychotherapist and a Framework for Practice” (pp. 3–52)

Fournier, J. C., & Price, R. B. (2014). Psychotherapy and neuroimaging. Psychotherapy: New Evidence and New Approaches, 12(3), 290–298. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207360/

Holttum, S. (2014). When bad things happen our brains change but psychotherapy and support can help the recovery of our brains and our lives. Mental Health and Social Inclusion, 18(2), 52–58. doi:10.1108/MHSI-02-2014-0006 

Petiprin, A. (2016). Psychiatric and mental health nursing. Nursing Theory. Retrieved from http://www.nursing-theory.org/theories-and-models/psychiatric-and-mental-health-nursing.php

Fisher, M. A. (2016). Introduction. In Confidentiality limits in psychotherapy: Ethics checklists for mental health professionals (pp. 3–12). Washington, DC: American Psychological Association. doi:10.1037/14860-001

Document: Midterm Exam Study Guide (Word document)

Document: Final Exam Study Guide (Word document)

Required Media

Laureate Education (Producer). (2016). Introduction to psychotherapy with individuals [Video file]. Baltimore, MD: Author.

Note: The approximate length of this media piece is 2 minutes.

Accessible player

Laureate Education (Producer). (2015e). Therapies are helpful: Dodo bird conjecture [Video file]. Baltimore, MD: Author.

Provided courtesy of the Laureate International Network of Universities.

Note: The approximate length of this media piece is 2 minutes.

Accessible player

Credit: Provided courtesy of the Laureate International Network of Universities.

Laureate Education (Producer). (2015f). Therapies change and integrate different approaches over time [Video file]. Baltimore, MD: Author.

Provided courtesy of the Laureate International Network of Universities.

Note: The approximate length of this media piece is 1 minute.

Accessible player

Credit: Provided courtesy of the Laureate International Network of Universities.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Clinical interview: Intake, assessment, & therapeutic alliance [Video file]. Mill Valley, CA: Psychotherapy.net.

Sommer-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

Discussion: Does Psychotherapy Have a Biological Basis?

Many studies have found that psychotherapy is as effective as psychopharmacology in terms of influencing changes in behaviors, symptoms of anxiety, and changes in mental state. Changes influenced by psychopharmacology can be explained by the biological basis of treatments. But how does psychotherapy achieve these changes? Does psychotherapy share common neuronal pathways with psychopharmacology? For this Discussion, consider whether psychotherapy also has a biological basis.

Learning Objectives

Students will:

• Evaluate biological basis of psychotherapy treatments
• Analyze influences of culture, religion, and socioeconomics on personal perspectives of psychotherapy treatments

To prepare:

• Review this week’s Learning Resources.
• Reflect on foundational concepts of psychotherapy.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click Submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before clicking Submit!

By Day 3

Post an explanation of whether psychotherapy has a biological basis. Explain how culture, religion, and socioeconomics might influence one’s perspective of the value of psychotherapy treatments. Support your rationale with evidence-based literature.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues by providing an additional scholarly resource that supports or challenges their position along with a brief explanation of the resource.

Biological Basis and Ethical/Legal Considerations of Psychotherapy Example

Psychotherapy is a commonly used intervention in the management of mental health issues. It is often recommended as the first-line treatment before other options, such as psycho-pharmacotherapy in some conditions, such as anxiety. It is a collaborative treatment intervention that relies heavily on the care provider-patient relationship. Various types of psychotherapy include cognitive behavioral therapy and family therapy. Debates on the effectiveness of psychotherapy and the biological basis of psychotherapy exist. This essay evaluates the biological basis of psychotherapy and evaluates individual, group, and family therapy.

Psychotherapy has a biological basis, like psychopharmacological interventions, due to its therapeutic ability. Research affirms that psychotherapy changes brain connectivity and activity. Deits-Lebehn et al. (2020) state that well-perched psychotherapy provides adequate psychological stimulation, promoting new growth, neuron connectivity, and better blood supply. Research also shows that psychotherapy stimulates hormone release, which can be successful in offsetting negative emotions and moderating these emotions, such as over-excitation (arousal) and stress (depression) (Deits-Lebehn et al., 2020). Repeated cycles of psychotherapy assist in many instances, such as depression and anxiety, and anger management. 

Researchers argue that erasing unhelpful schemas and beliefs helps showcase transformational change in psychotherapy (Kramer et al., 2020). For example, psychotherapy has successfully managed bullying behavior in children and adolescents, leading to complete transformation, indicating that psychotherapy could have a biological basis. Cultural, social-economic, and religious practices also affect an individual’s view of the effectiveness of psychotherapy. Some cultures do not encourage speaking up or discussing personal problems, which may limit their perception and acceptance of psychotherapy (Wheeler, 2020). Thus, individual perspectives may embrace or disregard practices, hence the need to be culturally sensitive as a care provider.

Legal and ethical considerations differ in the individual, family, and group therapy settings. Like all other care interventions, individual therapy follows all ethical and legal principles. Informed consent, justice, veracity, fidelity, self-respect, autonomy, beneficence, and non-maleficence are all vital individual therapy (Sanghvi & Pandley, 2019). Despite sharing personal information, group therapy sessions maintain confidentiality in that patients only share the information they are comfortable with (Hahn et al., 2022). 

The group participants voluntarily participate hence altruism and other ethical issues such as justice and confidentiality. Information shared restricts deep-message sharing and entails what is significant to others. In addition, these groups are led by competent professionals who ensure that legal and ethical considerations are duly followed. They help handle group differences and ensure objective achievement despite the differences among group members.  

In family therapy, confidentiality is also vital, and unlike individual therapy, only the information the patient is willing to share is discussed. Family therapy often entails how the family members can promote quality outcomes for the patient or problem (Barnett & Jacobson, 2019). In family therapy, the intervention conceptualizes the origin of a problem as a dysfunctional process. Barnett and Jacobson (2019) note that the focus of family therapy is thus addressing these dysfunctional patterns, especially relationships between family members. Cultural awareness, informed consent, and confidentiality (except when concealed information can lead to family harm) are essential considerations in family therapy.

Conclusion

All these articles used were sourced from current and reputable journals in psychiatry, and most were pulled from the American Psychological Association website. The APA website is a reliable database for sourcing peer-reviewed work. The articles are peer-reviewed and current (produced within the last five years). From the evidence presented above, psychotherapy has a biological basis due to the changes in areas such as memory and behavior and physical brain changes observed after psychotherapy. Understanding the biological basis of psychotherapy helps care providers plan and utilize psychotherapy to achieve the desired outcomes. Ethical and legal issues differ in individual, family, and group therapy. Understanding their differences and similarities can help professionals implement psychotherapy with minimal ethical and legal problems in these groups.

References

Barnett, J. E., & Jacobson, C. H. (2019). Ethical and legal issues in family and couple therapy. In APA handbook of contemporary family psychology: Family therapy and training, Vol. 3 (pp. 53–68). American Psychological Association. https://doi.org/10.1037/0000101-004

Deits-Lebehn, C., Baucom, K. J., Crenshaw, A. O., Smith, T. W., & Baucom, B. R. (2020). Incorporating physiology into the study of the psychotherapy process. Journal of Counseling Psychology, 67(4), 488. https://doi.org/10.1037/cou0000391

Hahn, A., Paquin, J. D., Glean, E., McQuillan, K., & Hamilton, D. (2022). Developing into a group therapist: An empirical investigation of expert group therapists’ training experiences. American Psychologist, 77(5), 691–709. https://doi.org/10.1037/amp0000956

Kramer, U., Beuchat, H., Grandjean, L., & Pascual-Leone, A. (2020). How personality disorders change in psychotherapy: A concise review of process. Current Psychiatry Reports, 22, 1-9. https://doi.org/10.1007/s11920-020-01162-3

Sanghvi, P., & Pandey, S. (2019). Ethical and Legal Constraints in Psychotherapy. Journal of Psychosocial Research, 14(1). https://doi.org/10.32381/JPR.2019.14.01.2

Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

Week 2: Assessment and Diagnosis in Psychotherapy

“A sensitively crafted intake assessment can be a powerful therapeutic tool. It can establish rapport between patient and therapist, further the therapeutic alliance, alleviate anxiety, provide reassurance, and facilitate the flow of information necessary for an accurate diagnosis and appropriate treatment plan.”

—Pamela Bjorklund, clinical psychologist

Whether you are treating patients for physical ailments or clients for mental health issues, the assessment process is an inextricable part of health care. To properly diagnose clients and develop treatment plans, you must have a strong foundation in assessment. This includes a working knowledge of assessments that are available to aid in diagnosis, how to use these assessments, and how to select the most appropriate assessment based on a client’s presentation.

This week, as you explore assessment and diagnosis in psychotherapy, you examine assessment tools, including their psychometric properties and appropriate use.

Photo Credit: [Wavebreakmedia Ltd]/[Wavebreak Media / Getty Images Plus]/Getty Images

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

• Chapter 3, “Assessment and Diagnosis” (pp. 95–168)
• Chapter 4, “The Initial Contact and Maintaining the Frame” (pp. 169–224)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

American Academy of Child and Adolescent Psychiatry. (1995). Practice parameters for the psychiatric assessment of children and adolescents. Washington, DC: Author. Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/psychiatric_assessment_practice_parameter.pdf

American Psychiatric Association. (2016). Practice guidelines for the psychiatric evaluation of adults (3rd ed.). Arlington, VA: Author. Retrieved from http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426760

Walden Library. (2017). NURS 6640 week 2 discussion guide. Retrieved from http://academicguides.waldenu.edu/nurs6640week2discussion

Walden University. (n.d.). Tests & measures: Home. Retrieved February 6, 2017, from http://academicguides.waldenu.edu/library/testsmeasures

Note: This database may be helpful in obtaining assessment tool information for this week’s Discussion.

Required Media

Laureate Education (Producer). (2015a). Counseling competencies—The application of ethical guides and laws to record keeping [Video file]. Baltimore, MD: Author.

Provided courtesy of the Laureate International Network of Universities.

Note: The approximate length of this media piece is 23 minutes.

Accessible player

Discussion: Assessment Tools

Assessment tools have two primary purposes: 1) to measure illness and diagnose clients, and 2) to measure a client’s response to treatment. Often, you will find that multiple assessment tools are designed to measure the same condition or response. Not all tools, however, are appropriate for use in all clinical situations. You must consider the strengths and weaknesses of each tool to select the appropriate assessment tool for your client. For this Discussion, as you examine the assessment tool assigned to you by the Course Instructor, consider its use in psychotherapy.

Learning Objectives

Students will:

• Analyze psychometric properties of assessment tools
• Evaluate appropriate use of assessment tools in psychotherapy
• Compare assessment tools used in psychotherapy

Note: By Day 1 of this week, the Course Instructor will assign you to an assessment tool that is used in psychotherapy.

To prepare:

• Review this week’s Learning Resources and reflect on the insights they provide.
• Consider the assessment tool assigned to you by the Course Instructor.
• Review the Library Course Guide in your Learning Resources for assistance in locating information on the assessment tool you were assigned.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click Submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before clicking Submit!

By Day 3

Post an explanation of the psychometric properties of the assessment tool you were assigned. Explain when it is appropriate to use this assessment tool with clients, including whether the tool can be used to evaluate the efficacy of psychopharmacologic medications. Support your approach with evidence-based literature.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues by comparing your assessment tool to theirs.

Also Read: NRNP 6650 Psychotherapy With Groups and Families

NRNP 6645 Week 4 Exploring Psychodynamic Theories

NRNP 6645 Week 4 Exploring Psychodynamic Theories

Contemporary psychodynamic psychotherapy, also referred to as psychoanalytic therapy, is rooted in Dr. Sigmund Freud’s proposal that unconscious thought processes, or thoughts and feelings outside of our conscious awareness, are responsible for mental health issues. This therapeutic approach is unique because its goal is to help patients achieve changes in personality and emotional development.

Like most therapeutic approaches, however, psychodynamic psychotherapy is not appropriate for every patient. In your role as a psychiatric-mental health nurse practitioner, you must be able to properly assess patients to determine whether this therapeutic approach would improve their clinical outcomes.

This week, you explore psychodynamic psychotherapy and examine the application of current literature to clinical practice.

ORDER THROUGH BOUTESSAY

Learning Resources – NRNP 6645 Week 4 Exploring Psychodynamic Theories

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

• For reference as needed

Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.

• Chapter 8, “Psychoanalytic Family Therapy”

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

• Chapter 5, “Supportive and Psychodynamic Psychotherapy”
  • Review the sections on psychodynamic therapy only.
• Chapter 21, “Psychotherapeutic Approaches with Children and Adolescents”
  • pp. 790–791 only

Required Media (click to expand/reduce)

Alexander Street. (2014, February 24). Jungian play therapy and sandplay with children: Myth, mandala, and meaning [Video]. YouTube. https://www.youtube.com/watch?v=qOj4MPCFiDU

Grande, T. (2016, January 29). Adlerian therapy role-play – “Acting as if” technique [Video]. YouTube. https://www.youtube.com/watch?v=nsp3JZ4uYF4

Grande, T. (2016, February 23). Psychodynamic therapy role-play – Defense mechanisms and free association [Video]. YouTube. https://www.youtube.com/watch?v=z9fF9F5w1cI

PsychotherapyNet. (2018, December 7). Youtube Kernberg psychoanalytic psychotherapy [Video]. YouTube. https://www.youtube.com/watch?v=xkYIdEO4jQg

Optional Resources

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice [Video]. https://waldenu.kanopy.com/video/counseling-and-psychotherapy-theories-contex

• Psychodynamic Therapy (starts at 3 minutes)

Exploring Psychodynamic Theories

When thinking of classic Freudian techniques, what images come to mind? Perhaps the omniscient Freud smoking a pipe, sitting behind a client, passively taking notes—or troubled clients lying sprawled on a couch, speaking about their sexuality or early experiences in dealing with aggression or angst.

Though many associate all psychodynamic theories with well-known images of Freudian psychoanalysis, the works of Jung, Adler, and other prominent psychodynamic theorists took strides to significantly depart from Freud’s theory of personality and therapy. Modern psychodynamic approaches place the therapist across from the patient, actively engaging the patient in the psychotherapeutic process.

During this process, however, therapists place much focus on the unconscious mind and past relationships of the patient—a focus unique to psychodynamic theories.

This week there is no assessment, but you will explore unique interventions and strategies derived from the psychodynamic theoretical approach through the Learning Resources.

NRNP 6645 Week 5 Discussion – Cognitive Behavioral Therapy: Comparing Group, Family, And Individual Settings

There are significant differences in the applications of cognitive behavior therapy (CBT) for families and individuals. The same is true for CBT in group settings and CBT in family settings. In your role, it is essential to understand these differences to appropriately apply this therapeutic approach across multiple settings. For this Discussion, as you compare the use of CBT in individual, group, and family settings, consider challenges of using this approach with groups you may lead, as well as strategies for overcoming those challenges.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

To prepare:

•   Review the videos in this week’s Learning Resources and consider the insights provided on CBT in various settings. 

By Day 3

Post an explanation of how the use of CBT in groups compares to its use in family or individual settings. Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings. Support your response with specific examples from this week’s media and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly and attach the PDFs of your sources.

Read a selection of your colleagues’ responses.

Respond to at least two of your colleagues by recommending strategies to overcome the challenges your colleagues have identified. Support your recommendation with evidence-based literature and/or your own experiences with clients.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply! 

 LEARNING RESOURCES

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

• Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.

• Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

Required Media

• Beck Institute for Cognitive Behavior Therapy. (2018, June 7). CBT for couples. [Video]. YouTube. https://www.youtube.com/watch?v=JZH196rOGsc
• MedCircle. (2019, December 13). What a cognitive behavioral therapy (CBT) session looks like. [Video]. YouTube. https://www.youtube.com/watch?v=8-2WQF3SWwo
• PsychExamReview. (2019, April 30). Cognitive therapy, CBT, & group approaches (intro psych tutorial #241). [Video]. YouTube. https://www.youtube.com/watch?v=A2_NN1Q7Rfg

NRNP 6645 Week 4 Exploring Psychodynamic Theories Optional Resources

• Beck, A. (1994). Aaron Beck on cognitive therapy. [Video file]. Mill Valley, CA: Psychotherapy.net.
• Eysenck, H. (n.d.). Hans Eysenck on behavior therapy. [Video file]. Mill Valley, CA: Psychotherapy.net.
• Psychotherapy.net. (Producer). (2009). Rational emotive behavior therapy for addictions. [Video file]. Psychotherapy.net: Author.
• Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice. [Video]. https://waldenu.kanopy.com/video/counseling-and-psychotherapy-theories-contex
• CBT (starts at 2 hours 27 minutes)

NRNP 6645 Week 4 Exploring Psychodynamic Theories Example 1 – Amanda 

Cognitive Behavioral Therapy (CBT) is a type of psychotherapy in which the therapist utilizes techniques to help to change the mindset and thinking pattern of the client or patient to reduce psychological symptoms of conditions such as anxiety, depression, addictions and other types of mental illness.  The underlying principle is that psychological problems are at least in part due to thought processes which are maladaptive or otherwise unhealthy and that these thought patterns are learned behaviors which can subsequently be unlearned through therapy.  

Once these faulty thought processes are unlearned, they can be replaced with new skills, thought processes and more effective coping mechanisms to use instead (Society of Clinical Psychology, 2017).  Some challenges that present in this type of therapy are the ability to change someone’s mindset from a negative one to a positive one.  When attempting to use the techniques in a group setting the level of difficulty is increased dramatically.  Even when you have a group of people who share a common diagnosis, such as anxiety, there are still many unique contributing factors to each person’s specific symptoms and manifestations of those symptoms. 

Most group CBT success has been seen in the treatment of depression and anxiety as group participants can practice empathy towards others and provide their own personal experiences with symptoms which others in the group can relate (Thimm, 2014).  Some difficulty does lie in the fact that there are differing cultural, religious and socioeconomic views and beliefs that further impact each person’s cognition, outlook and overall emotional functioning and will impact the therapeutic processes.  Understanding how these things can impact the therapeutic processes for each person will help improve the outcome of therapy, but in a group setting it will be harder to modify therapy in a way to fit every participant in the group.  

Nothing in psychotherapy is a one size fits all that works equally for every patient and attempting to gain the same results with multiple people with one standard technique is not a realistic expectation.  Each person in a group therapy session will also have different perspectives and interpretation of their thoughts, emotions and the ramifications of those things on their current symptoms.  Group therapy participants may also drop out of their sessions if they feel they are not effective and the change in group dynamics when someone stops coming to group can negatively impact the remaining participants (Thimm & Liss, 2014). 

There are some benefits to group CBT sessions such as the ability to role play these newly learned CBT techniques and being able to practice things such as empathy (Beck Institute for Cognitive Behavior Therapy, 2018).  Due to these challenges, it may be more effective to utilize individual CBT sessions over group CBT settings to reduce potential setbacks in the therapeutic processes and have the most positive impact on the thought of the patient (Guo, et al, 2021). 

References

Beck Institute for Cognitive Behavior Therapy. (2018, June 7). CBT for couples. [Video]. YouTube. https://www.youtube.com/watch?v=JZH196rOGscLinks to an external site.

Guo, T., Su, J., Hu, J., Aalberg, M., Zhu, Y., Teng, T., and Zhou, X. (2021). Individual      vs. Group Cognitive Behavior Therapy for Anxiety Disorder in Children and    Adolescents: A meta-analysis of Randomized Controlled Trials. Retrieved from: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.674267/full.

Society of Clinical Psychology. (2017). What is Cognitive Behavioral Therapy?         Retrieved from: https://www.apa.org/ptsd-guideline/patients-and-          families/cognitive-behavioral.

Thimm J & Liss A. (2014). Effectiveness of cognitive behavioral group therapy for depression in routine practice. BMC Psychiatry. 14(292). Retrieved from: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-014-0292-x.

Also Read: Case Study: An Elderly Iranian Man with Alzheimers Disease – NURS 6521