Week 2 nrnp 6645 assign

NRNP/PRAC 6645 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:

(include psychiatric ROS rule out)

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:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

Case Formulation and Treatment Plan:

References

Page 1 of 3

NRNP/PRAC 6645 Comprehensive Psychiatric

Evaluation Note Template

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 assignments. After reviewing 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 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 illn

WEEK 2 NRNP 6645 ASSIGNMENT

Assignment: Family Assessment

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

Photo Credit: Getty Images

To prepare:

· Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.

· Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.

· View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.

The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

· Chief complaint

· History of present illness

· Past psychiatric history

· Substance use history

· Family psychiatric/substance use history

· Psychosocial history/Developmental history

· Medical history

· Review of systems (ROS)

· Physical assessment (if applicable)

· Mental status exam

· Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5 diagnostic criteria

· Case formulation and treatment plan

· Include a psychotherapy genogram for the family

Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.

Running head: PSYCHOTHERAPY 1

PSYCHOTHERAPY 5

0:00TRANSCRIPT OF VIDEO FILE:

00:00:00_____________________________________________________________________

00:00:00BEGIN TRANSCRIPT:

00:00:00[music]

00:00:35A MOTHER and A DAUGHTER:

00:00:35A CULTURAL TALE

00:00:35AN INTERVIEW WITH

00:00:35GONZALO BACIGALUPE, PhD

00:00:35Produced by

00:00:35Andrews & Clark

00:00:35Explorations, Inc.

00:00:35GONZALO BACIGALUPE When I’m asked to do a consultation, one of the first things I ask is, what will be the most benefit for the client and the therapist and in the case that you’re going to see I’m basically asked to have a reflecting team and what we did was first have an interview with the therapist and the family and ask them what they will find useful for the interview and basically to ask them about the history of the therapy and the history of what are the kinds of things that they have been working on. I ask the reflecting team to come in and I instructed them to think of themselves as so let the god mothers of the therapist, who in a way, put them, himself, or in this case herself at risk in front of her peers and another people. So, I wanted them, the reflecting team to address the therapeutic system as a whole not just to address the family, I wanted them to talk also about the therapist and to be protective of them. I also ask the reflecting team not to be too much of clinician, but to really react on a more personal level around the family. I sometimes reflected on what they were saying to clarify or to expand the idea or how I understood it to give voice to other possibilities, but respecting the personal peace, and then, I ask I ask the family to come back to, in a classical way, to respond to those comments what strike them. In the case that we watch, it seems that the family was dealing with sort of like two forms of trauma and/or three forms of trauma; one is, history of battering the domestic violence, child sexual abuse, a history of immigration that in some ways we lay it to that trauma getting away from it and basically the mother of five children deciding that they need to move out of the home, but in the process leaving one behind who is later on sexually, I mean, raped by the father. And then at the present moment mother dealing with a fairly traumatic illness that have her, very disable, unable to walk and to work. So, it’s sort of like the interview trying to address this different forms of trauma and the way in which the young adults are trying to make sense of their bicultural life and how the whole family is trying to make sense of

Family Assessment and Psychotherapeutic Approaches

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychotherapy with Multiple Modalities

June 13, 2021

Abstract

As providers, it is vital to be open-minded, if you are not aware or do not understand a person’s

culture, show your patients respect. Be engaged, respectful, and ask questions. Learn from your

patients, this helps develop a rapport. As providers we are obligated to provide optimal care, if

we feel a patient’s needs are out of our scope, the client should be referred to a provider that can

give them the help they need and deserve (Nichols & Davis, 2020).

The purpose of this paper is to provide documentation and a psychiatric comprehensive

assessment of a patient and family during a family therapy interview that highlights differences

in a multicultural family, respecting cultural norms and differences, and develop an

individualized treatment plan.

Keywords: Family therapy

Family Assessment and Psychotherapeutic Approaches

Subjective:

CC (chief complaint): “I like to learn to live on my own and not depend on the kids.”

HPI: A 40-year-old female (Patti) and her five children (Sheela age 24, Sharleen aged 23

and present today, Shireen age 21 recently reunited with family, Armin Jr. age 18, and Sam age

15), of Iranian descent, has been in individual and family therapy for the last 18 months. Patti

came to the clinic related to chaos in the home after her daughter was finally reunited with the

family after ten years. The family initially had rejoiced and celebrated, and after a few weeks,

Shireen began to tell her mother and siblings the emotional, physical, and sexual abuse at the

hands of her father. She blamed and felt abandoned by her mother. Patti needed necessary

surgery to both her feet after an injury, that has now left her disabled and with chronic pain. The

additional burden of surgery and disability has increased tension and stress in the home. Patti

lives with her two sons; her daughters live on their own. Shireen recently moved out, marrying

someone the family does not know, with little contact. Mother speaks and sees Sheela and

Sharleen daily. Patti has increasingly felt alone, depressed, hopeless, and helpless wanting her

daughters to stay and help her at her home. A psychiatric provider has been referred for a

medication evaluation.

Past Psychiatric History:

General Statement: Patti and her family began therapy 18 months ago after daughter

Shireen reunited with the family after 12 years of separation. Shireen shared significant abuse

she expe