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.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template
AND
the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
In 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.
· Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least 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
.
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. 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.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrat
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NRNP_6635_Week8_Assignment_Rubric
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Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide: |
Points: Points Range: The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Feedback: |
Points: Points Range: The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Feedback: |
Points: Points Range: The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. Feedback: |
Points: Points Range: The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history o BEGIN TRANSCRIPT: Training Title 82 LISA: Well, I had to be here in this hospital if that answers your question. CAMERA: Yes, thank you. Can I get you a drink of water or something else to drink? Anything? LISA: A drink isn’t going to convince me, right? You’re going to have to convince me. OFF CAMERA: What is you want me to persuade you to do? LISA: Going to rehab. OFF CAMERA: What worries you about going to rehab? LISA: Everything. OFF CAMERA: Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today. LISA: Scared. OFF CAMERA: Can you tell me more about that feeling of being scared? LISA: Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t. OFF CAMERA: What do people say you are? LISA: And I’m not. OFF CAMERA: What don’t you want to be? LISA: An addict. OFF CAMERA: Do you use drugs and alcohol? LISA: Yeah, sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control. OFF CAMERA: Do you feel in control now? LISA: Maybe I could just get that drink [inaudible]. OFF CAMERA: Sure. Sure. Here you go. LISA: Thank you. LISA: you know what I just think I should leave. OFF CAMERA: You keep saying you should leave. You said that earlier but do you really want to leave? LISA: No. OFF CAMERA: Okay. Tell me why you are here. LISA: Because I’m scared. OFF CAMERA: You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear. LISA:No not these fears [inaudible] because it’s over. OFF CAMERA: What’s over? LISA: Everything. The business. OFF CAMERA What do you mean? LISA: Jeremy. OFF CAMERA: Who is Jeremy? LISA: He’s, my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk. OFF CAMERA: So you’re the one who caught Jeremy cheating? LISA: Yeah. Cheating? Yeah, that’s a clever word shrinks use. OFF CAMERA: So you and Jeremy share an office? LISA: Yeah, we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me. 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-alexanderstreetcom.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-alexanderstreetcom.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-alexanderstreetcom.ezp.waldenulibrary ASSIGNMENT QUESTIONS 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. · 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. 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 PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW: 1). ZERO (0) PLAGIARISM. 2). AT LEAST 5 REFERENCES, NO MORE THAN 5 YEARS (WITHIN 5YRS, OR LESS THAN 5YRS) 3). PLEASE SEE THE ATTACHED RUBRIC DETAILS, Comprehensive Psychiatric Evaluation Exemplar, Comprehensive Psychiatric Evaluation Template, Patient History Report, and transcripts. Assignment question. 4). Please review and follow the grading rubric details, and include each component in the assignment as required. Also, follow the APA 7 writing rules and style/Format. Thank you. 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: · General Statement: · Caregivers (if applicable): · Hospitalizations: · Medication trials: · Psychotherapy or Previous 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 
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