Nrnpprac 6635 Comprehensive Psychiatric Evaluation Template

Nrnpprac 6635 Comprehensive Psychiatric Evaluation Templateweek Ente

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date Subjective: CC (chief complaint): HPI : Past Psychiatric History : · G eneral Statement: · C aregivers (if applicable): · H ospitalizations: · M edication trials: · P sychotherapy or P revious Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: · Current Medications : · Allergies : · Reproductive Hx : ROS : · GENERAL: · HEENT: · SKIN: · CARDIOVASCULAR: · RESPIRATORY: · GASTROINTESTINAL: · GENITOURINARY: · NEUROLOGICAL: · MUSCULOSKELETAL: · HEMATOLOGIC: · LYMPHATICS: · ENDOCRINOLOGIC: Objective: Physical exam: if applicable Diagnostic results : Assessment: Mental Status Examination: Differential Diagnoses: Reflections: References © 2021 Walden University Page 1 of 3 An important consideration when working with patients is their cultural background. Understanding an individual's culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations. For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background. To Prepare: Review this week’s Learning Resources and consider the insights they provide. Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment. 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 . Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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 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.).

Paper For Above instruction

The comprehensive psychiatric evaluation outlined by Walden University's assignment provides a structured approach to assessing a patient with potential substance-related or addictive disorders. This evaluation begins with a detailed subjective history, capturing the chief complaint, history of present illness, past psychiatric history, current substances used, family and psychosocial background, and medical history. An essential aspect of this narrative is to understand the patient's cultural background, as it influences both the presentation of symptoms and potential diagnostic considerations (Kleinman, 1988).

The case study patient, Katarina Bykov, a 41-year-old woman of Russian descent, presents with a complex history of substance use and mental health considerations. Her self-reported use of pain medications, including oxycodone for elbow pain, alcohol consumption, marijuana use, and past engagement with illicit substances like cocaine and LSD, necessitates a comprehensive assessment of her substance use pattern, motives, and the potential for substance dependence or misuse (Volkow & Morales, 2015). Analyzing her presentation in conjunction with her medical and psychosocial background aids in establishing differential diagnoses.

The subjective portion of the evaluation involves meticulously capturing the patient's chief complaints, which in this case relate to chronic pain management and substance use behaviors. Katarina reports using medication primarily for pain relief, expressing resistance to pharmaceuticals on personal and value-based grounds, yet admits to using substances like marijuana for headaches and occasional prescription medications like Xanax for anxiety. Her alcohol consumption occurs weekly, sometimes leading to legal issues, and her marijuana use, although infrequent, is significant due to prior legal entanglements and interference with her custody of her son. Her history also includes past illicit drug use, including cocaine and LSD, with the last use being a few months prior.

The objective assessment involves observations of her affect, appearance, and behavior, which may include signs of intoxication, withdrawal, or psychological distress. Her concern about legal issues, her expressed values regarding health, and her social interactions provide further insights.

The mental status examination evaluates her appearance, speech, mood, thought processes, and cognitive functioning. Based on her reported experiences and interviews, her mood might reflect anxiety or depression; thought processes appear logical but may include elaborations related to her legal and personal struggles. Notably, screening for suicidal ideation, homicidal thoughts, and insight into her substance use is critical (American Psychiatric Association, 2013).

The differential diagnosis process compares her case against DSM-5 criteria for substance use disorder, other mood or anxiety disorders, and possible trauma-related conditions. For substance use disorder, her pattern of polysubstance use, legal issues, and unsuccessful attempts at cessation support a high index of suspicion (APA, 2013). Alternatively, her symptoms could overlap with generalized anxiety disorder or dysthymia, especially given her stressors related to custody, legal troubles, and family dynamics.

The critical-thinking process involves weighing the influences of her cultural background—Russian cultural norms regarding substance use and mental health, her personal values, and her social environment—while applying DSM-5 diagnostic criteria systematically. For example, her frequent marijuana use with some legal consequences and her use of prescription medications without explicit prescriptions are pertinent positives supporting substance use disorder.

In conclusion, the primary diagnosis for Katarina is most consistent with stimulant and cannabis use disorder, complicated by legal issues and underlying anxiety. This diagnosis aligns with her reported use patterns, legal history, and potential impairment in functioning (American Psychiatric Association, 2013). Ethical and legal considerations include respecting her autonomy while providing education on substance use risks, potential harm reduction strategies, and culturally sensitive treatment approaches. Addressing her mental health comprehensively involves integrating health promotion and disease prevention strategies tailored to her socio-cultural context and personal history. For example, culturally competent counseling that respects her value system and addresses her chronic pain and anxiety holistically could enhance treatment outcomes.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
  • Kleinman, A. (1988). Rethinking psychiatry: From cultural categories to personal experience. Free Press.
  • Volkow, N. D., & Morales, M. (2015). The brain on drugs: From reward to addiction. Cell, 162(4), 712-725.
  • Hasin, D. S., O'Brien, C. P., & Aharonovich, E. (2017). Substance use disorders. In J. F. LeDoux (Ed.), Principles of addiction medicine (pp. 23-38).
  • Heitzeg, M. M., et al. (2014). Substance use and the developing brain: A review of neuroimaging findings. Human Brain Mapping, 35(12), 5854-5869.
  • Hoge, C. W., et al. (2014). Trauma, PTSD, and behavioral health risks: Consequences and strategies. American Journal of Psychiatry, 171(4), 366-377.
  • SAMHSA. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health.
  • McLellan, A. T., et al. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13), 1689-1695.
  • Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Treatment improvement protocol (TIP) Series, No. 63: Medications for opioid use disorder. HHS Publication No. PEP20-02-01-001.
  • Schuckit, M. A. (2016). Treatment of substance use disorders. Psychiatry, 13(1), 16-20.

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