1. Select a client or case that you have worked within either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.
2. Prepare a full mental health evaluation on your client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
a. A full psychiatric, physical, social, family, and work history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
b. The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
c. A full physical assessment in addition to the mental status exam and psychiatric history
3. Develop a DSM-5 diagnostic assessment:
a. Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.
4. Propose a practical, evidence-based plan of care:
a. Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has been chronically back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address those aspects of the client’s poor psychological functioning.
1) Support your assessment, diagnosis, and treatment and management plan with appropriate literature citations.
2) The paper should be no more than ten pages in length, not including a title page and references.
3) Use current APA formatting and citations minimal -4 reference in last 5 years
4) Acronyms should not be used.
5) The assessment must be well written and be of professional quality. It must be clear, and well developed, free of spelling, grammatical, and syntactical errors and in full sentences format.
Your writing Assignment should:
2. follow the conventions of Standard English (correct grammar, punctuation, etc.);
3. be well ordered, logical, and unified, as well as original and insightful;
4. be a minimum of 5 pages in length, not including cover or reference page;
5. display superior content, organization, style, and mechanics; and;
6. use APA formatting and citation style.
In this assignment you will analyze and synthesize the components of a complete psychiatric assessment with a formulated diagnosis and rationale, as well as clinical interventions for treatment, based on evidence-based clinical practice guidelines and theoretical knowledge you have covered in the PMHNP program thus far. This assignment allows you to demonstrate all course objectives in practice:
MN663-1: Prepare a consistent approach to the evaluation and management of mental health disorders and conditions for adult/geriatric clients and clients across the lifespan presenting in the acute and/or primary care setting.
MN663-2: Inspect diagnostic testing based on the history and mental health assessment for adult/geriatric clients presenting with acute, chronic, and complex mental health disorders in the acute and/or primary care setting.
MN663-3: Formulate evidence-based, therapeutic, patient-centered treatment plans that incorporate traditional and complementary pharmacological/non-pharmaceutical interventions for adult/geriatric clients in the acute and/or primary care setting.
MN663-4: Design age-appropriate mental health and physical health maintenance and screening plans for adult/geriatric clients with mental health disorders taking into consideration cultural, gender, ethnicity, spiritual, and social competencies.
MN663-5: Examine professional values and ethical/legal standards of the PMHNP role with relation to client safety, outcome improvement and collaborative relationships in the delivery of mental health care to the adult/geriatric client population.
Your writing Assignment should:
· follow the conventions of Standard English (correct grammar, punctuation, etc.);
· be well ordered, logical, and unified, as well as original and insightful;
· be a minimum of 5 pages in length, not including cover or reference page;
· display superior content, organization, style, and mechanics; and;
· use APA formatting and citation style.
To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of the Course Resources.
Submit your assignment to the unit Dropbox before midnight on the last day of the unit.
Please follow this Example
Mental Health Evaluation
Mr. R, a 45-year-old man, was recommended for a mental health evaluation by his primary care physician. Mr. R has struggled with mental health issues for quite some time, including depression, anxiety, and substance abuse. Hypertension and diabetes are among his medical conditions. Mr. R. says he cannot cope with his current circumstances, which include the loss of his employment and an uncertain financial future. He says he is feeling depressed and despondent. Many diagnostic instruments were used to measure Mr. R’s mental health during the evaluation, including the Beck Depression Inventory, the Hamilton Anxiety Rating Scale, and the Addiction Severity Index. The mental and physical health of Mr. R were both thoroughly evaluated. The evaluation revealed that Mr. R. meets the criteria for diagnosing Major Depressive Disorder, Generalized Anxiety Disorder, and substance use disorder. Psychotherapy, medication management, and other forms of support are all a part of the planned treatment strategy. The purpose of Mr. R’s treatment is to assist him in coping with his symptoms and enhancing his quality of life.
Psychiatric, Physical, Social, Family, and Work History:
Mr. R has a history of mental health issues, including depression, anxiety, and substance abuse. In addition, he mentions that he is feeling overwhelmed by his present life position, which includes the sudden loss of work and uncertain financial circumstances. He describes himself as having a sensation of hopelessness and a poor mood. He claims that he has been experiencing these emotions for the previous forty-eight days. Mr. R acknowledges that he experiences a variety of depressive symptoms, such as feelings of melancholy, poor energy, difficulties concentrating, diminished interest in activities, and a decreased appetite. He also mentions feeling anxious and on edge, increased irritability, and having trouble sleeping due to these feelings. Mr. R is reluctant to disclose his past substance abuse, but he is honest about the fact that he has an issue with alcohol.
Mr. R has been diagnosed with hypertension and diabetes based on his physical health. His blood sugar levels are within the usual range, and his blood pressure is currently at 140/90. He denies ever having smoked cigarettes and never having used illicit substances or alcoholic beverages. Mr. R’s medical history includes no episodes of head trauma or seizures. He claims that he is not experiencing any physical signs that cause concern. According to the medical examination results, Mr. R appears to be in good physical health and is well-nourished. He knows who is around him, where he is, and what time it is. His delivery is understandable, and the effect he uses is acceptable. His gait is normal, and he has not lost any coordination. He exhibits none of the symptoms of anxiety or cognitive impairment.
Currently, Mr. R has no job and is residing in temporary accommodation. He is no longer married to his ex-wife, and his children have moved in with their mother. He describes feeling alone and having trouble maintaining relationships with other people. According to him, drinking helps him deal with the challenges of his current living circumstances and his feelings of melancholy and worry (Klein et al., 2022). In addition to that, he admits to occasionally taking marijuana. Although Mr. R’s family believes that it is important for him to receive treatment for his mental illness, they are unable to help him in any way, including financially or in any other way. Due to financial constraints, Mr. R is only able to obtain limited access to medical treatment and is unable to obtain mental health therapies.
Mr. R is the youngest child out of a total of three. His mother is still alive, but she does not play a role in any aspect of his life. When he was a little boy, his father went suddenly unexpectedly. According to Mr. R, his father had a history of substance abuse and concerns related to his mental health (Klein et al., 2022). He claims that his siblings were encouraging to him when he was younger, but he does not have a very close relationship with any of them at this point in his life. According to Mr. R, his relationship with his ex-wife was tense, and he claims that she frequently did not support his efforts to seek treatment for his mental illness. According to him, his children currently reside with their mother, and he does not report having a particularly close relationship with any of them.
Mr. R’s professional background includes time spent working in the construction industry. He claims that the economic slump caused him to be terminated from his most recent position for no fault of his own. He states that he successfully located temporary work but could not land a position that required him to work full-time. Mr. R also mentions that, due to his mental health concerns, he has difficulty maintaining a job. He claims he has trouble managing his depression and anxiety at work and has been fired or laid off from several positions due to his sadness and anxiety. He also claims he has been dismissed or laid off from multiple positions due to his depression and anxiety.
Psychiatric Screening or Assessment Tool:
The Patient Health Questionnaire-9 (PHQ-9)
The Patient Health Questionnaire-9, or the PHQ-9, is a self-report questionnaire consisting of nine questions used to evaluate the severity of depressive symptoms in patients (Beswick et al., 2022). The Patient Health Questionnaire (PHQ-9) includes questions about the frequency of depressive symptoms in the past two weeks. These symptoms include sadness, lack of interest in activities, changes in appetite and sleep, difficulty concentrating, feelings of worthlessness, and thoughts of suicide. The PHQ-9 is a valuable instrument for determining the severity of one’s depression and tracking the progression of their symptoms over time (Mohamed et al., 2020). Throughout his evaluation, Mr. R was required to complete the PHQ-9, and the results revealed that he is currently suffering from severe depression. He admitted to experiencing various symptoms, such as despair, a loss of interest in activities, difficulties concentrating, low levels of energy, and even thoughts of ending his own life. These findings are in line with the information that was gathered during the mental status test as well as the data from the other diagnostic tools. He scored 23 on the PHQ-9. Mr R’s PHQ-9 score falls into severe depression.
In addition to the mental status test and psychiatric history, a comprehensive physical assessment of Mr. R was performed as part of the evaluation process. According to the medical examination results, Mr. R appears to be in good physical health and is well-nourished. He knows who is around him, where he is, and what time it is. His delivery is unmistakable, and his voice is appropriate (Mohamed et al., 2020). His gait is normal, and he has not lost any coordination. There are no indications of mental discomfort or cognitive deficiencies present in him. The patient underwent a comprehensive physical examination, which consisted of the following components: vital signs (blood pressure of 140/90, a pulse of 78, and respirations of 12), height and weight (5’10” and 175 lbs, respectively), head, neck, and lymph nodes (no abnormalities noted), chest and lungs (clear to auscultation bilaterally), heart (regular rate and rhythm, no murmur), abdomen (non-tender, no masses), extremities (normal range of motion (intact cranial nerves, normal muscle strength, and tone).
Mental Status Exam
A thorough evaluation of his mental health determined that Mr. R is awake and able to tell time, place, and people. He is appropriate for his age and averagely groomed. His tone and delivery are just right. He claims to be fully functional cognitively and to have never experienced any auditory or visual hallucinations. He can give detailed accounts of his present and recent history and recollect important occurrences. His perception or judgment has not deteriorated (Beswick et al., 2022). He denies suicidal and homicidal thoughts. He complains of anxiousness and irritation in addition to his melancholy and hopelessness. He has provided a list of all medications he is now using and claims to be abstaining from all drugs.
Major Depressive Disorder, Single Episode, Severe (F32.2)
According the DSM-5, the criterial for MDD should be based on presenting symptoms such as; persistent feelings of sadness, hopelessness, loss of interest in activities once pleasurable and enjoyable, depressed mood, weight gain/loss, hypersomnia/insomnia, fatigue, suicidal thoughts, poor concentration, and psychomotor retardation or agitation (Lyness, 2019).
Support for Diagnosis
The evaluation revealed that Mr. R. meets the criteria for diagnosing Major Depressive Disorder, Generalized Anxiety Disorder, and substance use disorder. His lengthy history of mood and anxiety disorders and substance abuse all meet DSM-5 criteria for the respective disorders. The evaluation data is consistent with the PHQ-9 results since Mr. R did endorse a variety of depressive symptomatology (Tolentino & Schmidt, 2018). His diagnosis is supported by the findings of a thorough physical examination, which turned up no anomalies.
Plan of Care:
Mr. R’S plan of care should focus on reducing and managing his symptoms of depression. The goal of treatment is to relieve his symptoms and improve his functioning. The treatment plan should include the following:
Psychiatric treatment is part of Mr. R’s planned treatment plan. To help Mr. R cope with his sadness and anxiety, cognitive behavioral therapy (CBT) is suggested. CBT’s purpose is to assist Mr. R in recognizing and disputing unhelpful thought patterns and adopting more constructive ways of dealing with them (Pinho et al., 2021). Mr. R can benefit from CBT to treat his depression and anxiety.
Medication management is a component of the overall care strategy. A course of antidepressant medication will be prescribed to Mr. R to alleviate his depression. We will adjust the antidepressant dose based on how well it works and is tolerated by the patient. It has been decided to begin Mr. R. on medication for anxiety (Pinho et al., 2021). The success and safety of the medication will be tracked. Mr. R will be prescribed 10 mg of Lexarpo PO QHS.
In addition, Mr. R will provide pain management as part of his overall treatment plan. This will include the use of interventions that do not involve the consumption of pharmaceuticals, such as relaxation methods, physical activity, and mindfulness practices. In addition, Mr. R may need medicine to help him manage the persistent pain he is experiencing. The specific requirements of Mr. R will direct both the choice of medication and the amount to be administered to him. Recommendation for pain management referral has been sent to Mr. R primary care provider.
In addition, the utilization of social services is a component of the care plan. Mr. R will be directed to a social worker who will assist him in securing and retaining employment and gaining access to medical treatment. In addition, the social worker will assist Mr. R in gaining access to community resources that will assist him in coping with his anxiety, despair, and substance abuse (Pinho et al., 2021). Mr. R will receive assistance in becoming more self-sufficient and managing his mental health difficulties from the social worker, who will offer support and counseling.
Mr. R will have follow-up appointments at predetermined intervals following his initial appointment. Mr. R’s progress will be tracked at each appointment, and any necessary changes will be made to his pharmaceutical regimen. In addition, Mr. R will participate in psychotherapy (2 times a week) and other forms of supportive services as required. Mr. R needs to keep all of his appointments and adhere to the treatment plan that has been devised for him in order for him to be successful in addressing his mental health concerns and enhancing his overall quality of life.
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