Client Assessment And Treatment Plan ✓ Solved

Client Assessment And Treatment Plan

Provide a comprehensive client assessment including demographic information, presenting problem, history of present illness, past psychiatric and medical histories, substance use history, developmental history, family psychiatric history, psychosocial history, history of abuse/trauma, review of systems, physical assessment, mental status exam, differential diagnosis, case formulation, and treatment plan. Additionally, prepare a family genogram extending back three generations for the client.

Sample Paper For Above instruction

Introduction

The purpose of this paper is to conduct a thorough assessment and develop a treatment plan for a fictional client, Jack Pie, based on provided case details. The assessment covers demographic data, presenting concerns, history, review of systems, physical and mental status, differential diagnoses, and case formulation. It also includes creating a generational genogram to understand the client’s family dynamics. This comprehensive approach aims to facilitate an effective, personalized treatment plan grounded in evidence-based practices and professional standards in psychiatric nursing.

Demographic Information

Client Name: Jack Pie

Date of Birth: March 26, 1979

Age: 44 years

Gender: Male

Ethnicity: African American

Race: Black

Language: English

Cultural Background: American

Primary Phone Number: [not provided]

Emergency Contact: Big (Girlfriend)

Emergency Contact Phone Number: [not provided]

Address: [not provided]

Presenting Problem

Jack reports difficulty coping with his sister’s recent death from breast cancer. He states, “I don’t know how to handle her passing,” indicating emotional distress and possible symptoms of grief or depression.

History of Present Illness

Jack has been experiencing intense feelings of sadness, helplessness, and grief since his sister’s death. He reports difficulty sleeping, having frequent intrusive thoughts about her, and feelings of guilt over unresolved issues with her. He avoids social interactions and has expressed a lack of interest in daily activities. He endorses feelings of despair and occasional tearfulness but denies suicidal ideation. His symptoms have persisted for approximately two months.

Past Psychiatric History

Jack indicates no prior psychiatric diagnoses but reports occasional episodes of sadness during stressful life events. He denies any history of psychiatric medication use, hospitalizations, or psychotherapy.

Medical History

Medical history is unremarkable. No known chronic illnesses or surgeries are reported. Routine health checks have been normal.

Substance Use History

Jack reports occasional alcohol consumption, approximately 2-3 beers weekly. He denies use of illicit drugs or prescription misuse. No history of substance dependence is noted.

Developmental History

Born and raised in an urban setting, Jack reports stable childhood with supportive family, although he experienced the loss of his mother at age 15. He completed high school and attended some college but did not graduate due to financial difficulties. He is currently employed part-time and lives independently.

Family Psychiatric History

Family history includes a mother with depression and a father with alcohol dependence. No known history of schizophrenia, bipolar disorder, or other severe mental illnesses within the family. Jack's sister’s death is recent; no other familial deaths or diagnoses are documented.

Psychosocial History

Jack describes a generally stable psychosocial environment but indicates limited social support. He maintains a few close friends but reports feeling isolated lately. He is single, has no children, and spends substantial time alone. He reports a history of resilient coping but admits this recent loss has overwhelmed his usual strategies.

History of Abuse/Trauma

There is no indication of personal abuse or trauma in Jack’s history. However, the recent loss appears to be a significant stressor potentially triggering grief-related symptoms.

Review of Systems

General: No recent weight changes, fever, or chills. Feeling sad and fatigued.

Head: No headaches or dizziness.

Eyes: No visual disturbances.

Ears: No hearing loss or tinnitus.

Nose: No nasal congestion or bleeding.

Throat/Mouth: No sore throat or dental issues.

Neck: No pain or stiffness.

Cardiovascular: No chest pain or palpitations.

Respiratory: No shortness of breath or cough.

Gastrointestinal: No nausea, vomiting, or bowel changes.

Genitourinary: No urinary issues.

Musculoskeletal: No joint pain or muscle weakness.

Nervous System: No neurological deficits, but reports difficulty concentrating.

Skin: No rashes or lesions.

Physical Assessment

Vital signs: BP 130/80 mmHg, HR 72 bpm, R 16/min, Temp 98.6°F, O2 Sat 98%. Height 5'10", Weight 185 lbs, BMI 26.6.

General: Alert, cooperative, appears tired and somewhat withdrawn.

Head, Eyes, Ears, Nose, Throat (HEENT): Normocephalic, atraumatic. Pupils equal, reactive, no conjunctival pallor or erythema. Ears normal. No nasal or oral abnormalities.

Neck: Supple, no lymphadenopathy or thyroid enlargement.

Chest and Lungs: Clear auscultation, no wheezes or crackles.

Cardiovascular: Regular rhythm, no murmurs or gallops.

Abdomen: Soft, non-tender, normal bowel sounds.

Musculoskeletal: No deformities, full range of motion intact.

Neurological: Alert and oriented, cranial nerves intact, reflexes normal, no focal deficits.

Skin: No lesions, rashes, or scars.

Mental Status Exam

Appearance: Disheveled, appears fatigued.

Behavior: Cooperative, minimal eye contact.

Speech: Slow but coherent.

Mood: Sad.

Affect: Restricted.

Thought Process: Logical and goal-directed.

Thought Content: Preoccupied with grief, no evidence of delusions or hallucinations.

Perception: No perceptual disturbances.

Cognition: Alert, oriented to person, place, time, and situation. Memory intact.

Insight/Judgment: Fair.

Suicide Risk: No current suicidal ideation, but grief may increase risk; monitor accordingly.

Differential Diagnosis

• Major Depressive Disorder (MDD)
• Complicated Grief / Persistent Complex Bereavement Disorder
• Adjustment Disorder with Depressed Mood

Case Formulation

Jack presents with persistent grief symptoms that meet criteria for uncomplicated grief but are intense enough to suggest possible comorbid depression or factor into a diagnosis of Adjustment Disorder. His recent loss acts as a significant stressor, exacerbating underlying vulnerabilities such as previous depressive tendencies. His social isolation and limited support network may impede resolution, necessitating a targeted therapeutic approach. Close monitoring for potential suicidal ideation and addressing grief-related distress are essential.

Treatment Plan

1. Psychotherapy: Initiate grief counseling and cognitive-behavioral therapy (CBT) focusing on processing loss, restructuring maladaptive thoughts, and enhancing coping skills.
2. Pharmacotherapy: Consider prescribing antidepressants such as SSRIs (e.g., sertraline or paroxetine) to manage depressive symptoms after evaluating contraindications and patient preference.
3. Support Systems: Encourage participation in support groups for bereavement.
4. Follow-up: Schedule regular follow-up visits every 2-4 weeks to monitor progress, evaluate suicidality, and adjust treatment as needed.
5. Safety Planning: Develop a plan for crisis intervention if suicidal thoughts intensify.

Family Genogram

Due to limitations, a textual description of the genogram is provided:

• Great Grandparents: No documented psychiatric or hereditary issues.
• Grandparents:
  • Maternal Grandfather: No known illnesses.
  • Maternal Grandmother: Depression, deceased at 80.
  • Paternal Grandfather: Unknown.
  • Paternal Grandmother: No known psychiatric issues.
• Parents:
  • Mother: Depression, died recently from pneumonia.
  • Father: Cocaine and alcohol abuse, deceased 25 years ago.
• Sibling:
  • One sister: Passed away from breast cancer, recent death.

This genogram highlights familial mental health vulnerabilities and possible hereditary influences impacting Jack’s emotional health.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Braines, P. (2018). The importance of grief counseling in primary care. Journal of Mental Health Nursing, 12(2), 45-58.
• Holland, J. (2013). Grief counseling and grief therapy: A handbook for the mental health practitioner. Routledge.
• McGoldrick, M., Gerson, R., & Peterson, S. (2008). Genogram interpretation: Working with families. W. W. Norton & Company.
• Nancy, R. (2014). Evidence-based approaches to treat complicated grief. American Journal of Psychiatry, 171(11), 1152-1159.
• Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing.