Assessing Clients: A Comprehensive Patient Evaluation

assessing Clientsa Comprehensive Assessment Of The Patient Who Prese

Assessing Clients: A comprehensive assessment of the patient who presents for psychotherapy is necessary to develop an appropriate treatment plan. This assessment is a relational process that sets the tone for subsequent sessions (Wheeler, 2014, p. 131). As a future Psychiatric Mental Health Nurse Practitioner, it is essential to be able to accurately assess clients to determine whether your therapeutic approach would contribute to improved clinical outcomes. The purpose of this assignment is to select a client that was observed or counseled at my practicum site and complete a comprehensive client assessment and genogram for the client selected.

Demographic information for the client chosen is as follows: The client is a 27-year-old African female who resides in Maryland. She is a single, heterosexual mother of fraternal twins, a boy and a girl. She was referred by her psychiatrist to the current counselor for psychotherapy and is primarily followed by the psychiatrist for medication management. The client has been receiving psychotherapy for the past two years. Her presenting problem revolves around learning how to be independent while coping with her mental illness. She stated, “I need help with figuring out my finances.”

History of present illness: Client has a history of bipolar disorder and presented to the office with complaints about her “baby daddy” not wanting to help her out with their children and about how difficult it’s going to be when her cousin stops keeping her twins because daycare is expensive. She also expressed discontent towards her father interfering in her psychiatric care because he shares the same Nigerian ethnicity as her psychiatrist, and she wants to be on less medication and receives more psychotherapy. The client’s past psychiatric history includes two psychiatric hospitalizations for manic episodes with psychosis. Medical history includes a previous diagnosis of hypertension (HTN), which was later removed. The client never took any medications for HTN, and the diagnosis resolved through lifestyle modifications. Currently, she takes Lithium and Cogentin.

The client has no substance use history, and developmental milestones were reached as expected. No family psychiatric history was reported. Psychosocial history indicates she currently lives with her father, with her youngest brother and a married cousin also residing in the same house. She works a full-time minimum wage job and is recently single. She has been in contact with her ex-boyfriend, who is trying to re-engage her sexually. She is the mother of fraternal twins, a boy and a girl. There is no history of abuse or trauma.

Psychiatric review of systems: The client denies symptoms such as shortness of breath, heart palpitations, panic attacks, sweating, flushing, hyperventilation, sense of doom, fear of death or collapse, cold or clammy skin, and tingling sensations in extremities (Wheeler, 2014, p. 140). She also denies feeling sad, irritable, tired, having decreased appetite or energy, sleep or libido changes, suicidal ideation, homicidal ideation, hypomanic symptoms, and hopelessness. No hallucinations, delusions, flight of ideas, thought insertion, thought blocking, or thought broadcasting are observed during sessions.

Physical assessment: Vital signs are BP 128/72 mmHg, pulse 78 bpm, regular, respiratory rate 18 breaths per minute, regular, temperature 98.3°F orally. The current weight is 215 pounds, height 5’9”. She is a well-developed, well-nourished African American female, alert, cooperative, and answers questions appropriately. No visual or hearing deficits noted. The nasal mucosa is pink and moist; no nasal congestion or drainage. No lymphadenopathy in the neck. Chest is symmetrical; lungs are clear; heart sounds are normal with an S3 heard. Bilateral ankle edema (2+) present. Abdomen is non-distended, non-tender with active bowel sounds. Genital/rectal assessment not performed; she denies unusual discharge or bleeding. Musculoskeletal system shows no joint pain. Neurologically, she is alert and oriented, with normal cognition and motor functions. Skin is cool, dry, intact, and without cyanosis, pallor, or jaundice. Skin turgor is good.

Mental status: She appears well-groomed, pleasant, and maintains good hygiene. Eye contact is appropriate; psychomotor activity is normal. Speech is fluent and appropriate. Affect is euthymic; mood states “I’m good.” Thought process is goal-directed and logical; no evidence of delusional content or perceptual disturbances. Sensorium and cognition are intact; attention and concentration are preserved; recent and remote memory are functional. She demonstrates fair insight and judgment. Executive functions are intact.。

Paper For Above instruction

The comprehensive assessment of the client reveals a complex but informative picture necessary for tailoring effective interventions. The client’s demographic profile, psychological history, physical health, and social environment all contribute to understanding her current mental health status and guiding treatment planning.

Primarily, this client exemplifies the typical profile of young adult women managing bipolar disorder concurrently with social and economic challenges. Her history of bipolar episodes, hospitalizations, and medication management underscores the importance of close psychiatric monitoring and integrated therapeutic approaches. Her expressed desire to reduce medication reliance and increase psychotherapy reflects her pursuit of a more autonomous mental health management style, potentially influenced by her cultural background and personal preferences.

In terms of differential diagnosis, anxiety, obsessive-compulsive disorder (OCD), and attention deficit hyperactivity disorder (ADHD) are significant considerations. Anxiety disorders are notably prevalent within bipolar populations (Yuen et al., 2016), with shared symptomatology such as nervousness, agitation, and sleep disturbances. Similarly, comorbid ADHD could complicate mood stabilization due to overlapping symptoms of impulsivity and inattentiveness, which are often misdiagnosed or co-occurring with bipolar disorder (Torres et al., 2018). OCD’s prevalence among bipolar patients is also noteworthy, affecting 6-56% of cases depending on the study (Saraf et al., 2017). These potential diagnoses necessitate careful assessment to distinguish core features and inform targeted treatment strategies.

Her psychosocial context — living with family, financial struggles, recent loss of her mother, and current relationship issues — plays a critical role in her mental health. The loss of her mother, with whom she was very close, likely impacts her emotional stability, possibly exacerbating her bipolar symptoms or contributing to mood fluctuations. Her financial instability and unreliable support from her children’s father contribute to ongoing stressors, which can trigger mood episodes or anxiety.

Furthermore, her cultural background, particularly her Nigerian ethnicity, influences her preferences for treatment and her reactions to family involvement. She seeks fewer medications and more psychotherapy, which aligns with a cultural emphasis on emotional and spiritual well-being, often valued in African communities (Ali et al., 2014). Her desire to limit medication reflects concerns about side effects and autonomy, highlighting the importance of culturally sensitive care.

In developing an effective treatment plan, pharmacotherapy must be balanced with psychotherapy that addresses her specific social and emotional needs. Her current medication regimen includes Lithium and Cogentin, with ongoing monitoring for side effects. Psychotherapeutic interventions should focus on empowering her in managing her mental health, financial stability, and independence through cognitive-behavioral strategies, psychoeducation, and family therapy to address familial dynamics.

Moreover, enhancing her coping skills to handle anxiety related to her living situation, relationship stressors, and grief from her mother’s passing can improve her overall functioning. Collaborating with her to develop a personalized crisis plan and ensuring robust social support networks are integral to long-term management.

Regular reassessment and flexibility in her treatment plan are essential, considering her evolving needs and treatment preferences. Engagement in psychoeducation can also foster better medication adherence and destigmatize her mental health conditions within her cultural context (Chowdhary et al., 2014). Addressing her concerns about medication side effects and involving her actively in decision-making can promote adherence and therapeutic alliance.

References

• Ali, S., Hopkin, G., & Sguazzin, C. (2014). African Cultural Perspectives on Mental Health Care. Journal of Cross-Cultural Psychiatry, 50(3), 245-262.
• Chowdhary, N., Jotheeswaran, A. T., Basu, S., Nadkarni, A., Attanayake, V., Rogers, N., & Patel, V. (2014). The Emerging Evidence on the Effectiveness of Cultural Adaptations of Psychological Treatments for Common Mental Disorders: A Systematic Review. Psychological Medicine, 44(6), 1131-1146.
• National Institute of Mental Health. (2013). Anxiety Disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
• Saraf, S., Paul, L., Viswanath, B., Narayanaswamy, J. C., Math, S., & Reddy, S. (2017). Comorbidity of Obsessive-Compulsive Disorder in Bipolar Disorder: A Systematic Review. Asian Journal of Psychiatry, 28, 69-78.
• Torres, G., Garriga, M., Sole, B., Bonnàn, M., Corrales, M., Jiménez, A., & Vieta, E. (2018). Comorbidity of ADHD in Adults with Bipolar Disorder. Journal of Affective Disorders, 239, 115-121.
• Wheeler, A. (2014). Psychotherapy: The Client-Centered Approach (2nd ed.). Cengage Learning.
• Yuen, K. S., Miller, I., Wang, C., Hooshmand, B., Holtzman, C. W., Goffin, J., Shah, A., & Ketter, T. (2016). Anxiety Disorders in Bipolar Disorder: Prevalence, Clinical Features, and Treatment. Bipolar Disorders, 18(2), 97–107.