Week 3: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Assessment
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Subjective: CC (chief complaint): I am worried and have nightmares. While I’m at school, I worry about my mother and younger brother. People at school dislike me and call me names.
HPI: D.C. is a 7-year-old male child who comes to the clinic for the first time to be evaluated because of previous abnormal behavior. He is accompanied by his mother, who is concerned about his deteriorating behavior. The patient is concerned and has nightmares. He can’t concentrate in school because he’s worried about his mother and younger brother. His mother complains that he can’t sleep because the lights are on and the door is open. He has never been in psychiatric care before. Teachers at school can hardly get him to concentrate or stop staring out the window. He has trouble sleeping. DDVAP was prescribed by a pediatrician, but it does not appear to be effective. Almost every day, she complains of a headache and a stomachache. He does not consume any food. In the last three weeks, he has lost three pounds. – PhD Dissertation Writing Services USA
Current Substance Use: No history of substance abuse.
Medical history: I’m taking DDVAP, but it’s not helping.
• Medications in Use: DDVAP
• Allergies: There are no known drug allergies.
• Reproductive Hx: Sexually inactive
ROS:
• GENERAL: 3 pound unintentional weight loss in the last three weeks. There is no appetite.
• HEENT: No loss of hearing, blurred vision, sore throat, or bleeding or discharge. Almost every day, she complains of a headache.
• SKIN: There are no skin lesions or itching.
• CARDIOVASCULAR: There is no chest pain, pressure, swelling, or palpitation.
• RESPIRATORY: No breathing difficulties.
• GASTROINTESTINAL: There is no stomach pain, reflux, nausea, vomiting, or diarrhea.
• GENITOURINARY: Inability to control bladder during the night. Despite his age and medication, he still wets his bed (DDVAP).
• NEUROLOGICAL: Has headaches almost every day.
• MUSCULOSKELETAL: There has been no history of itching muscles, joints, or gout.
• HEMATOLOGIC: There is no bleeding or bruising.
• LYMPHATICS: No enlargement of nodes.
• ENDOCRINOLOGIC: No endocrine disorder found.
Results of diagnostic tests:
A thorough medical Assessment will be required to determine the possible cause of the symptoms. The Child PTSD Symptom Scale (CPSS-5), which effectively assesses post-traumatic stress in children aged 8 to 18, is one of the likely diagnostic tools. Parts one and two each contain 24 questions. However, because the child is under the age of eight, the tool cannot be used. A psychiatrist would need more information to rule out conditions like separation anxiety disorder or generalized anxiety disorder. A structured interview will be required by a psychiatrist to evaluate the child’s feelings, thoughts, moods, and experiences. Separation anxiety can coexist with other disorders. To rule out the possibility of drug abuse, blood and urine tests may be required to assess the child for generalized anxiety disorder. Marijuana abuse can lead to worry or anxiety.
Assessment:
Examination of Mental Status:
D.C. is a 7-year-old male who appeared to be his stated age. During the psychiatric interview, the client remains calm and cooperative. His thought process is well-organized, and his memory is complete. He is aware that he has come to see a psychiatrist to help him with his depression. He denies having a drug problem. He is frequently concerned at home and at school. While at school, the student is concerned about the safety of his mother and baby brother. Throughout the conversation, the patient remains calm and maintains eye contact. He has been suffering from anxiety and mood swings.
F93. 0 Diagnostic Impression Anxiety about Separation (SAD)
SAD is characterized by excessive anxiety caused by separation from important people such as parents, close friends, or guardians. Separation from homes or schools where people have formed strong bonds can cause anxiety (Schneier et al., 2017). The condition indicates the possibility of mental and mood problems. According to statistics, at least 4% of the child population suffers from SAD. Life stressors such as divorce among parents, which affects children, or the death of a loved one are examples of possible causes (Schneier et al., 2017).
The child is most likely suffering from separation anxiety disorder. One of the reasons is that the child feels unsafe because of the father’s death. His mother never told him that his father died in the military. When the child is separated from his mother and baby brother, he may feel unsafe. He is also concerned about sleeping without turning on the lights.
Posttraumatic Stress Disorder (F43.12) (PTSD)
PTSD is a condition caused by traumatic experiences such as natural disasters. Psychologists define the condition as the inability to recover from a traumatic experience (Cloitre et al., 2019). Terrorist attacks, violence, child abuse, sexual abuse, and the loss of a loved one are some of the causes. Children’s moods can be affected by frightening memories from their past. Failure to treat the condition can have serious consequences for children (Cloitre et al., 2019).
1 GAD (Generalized Anxiety Disorder) (GAD)
Excessive worry and anxiety about life issues causes GAD. People with GAD are constantly afraid and anticipate disaster. GAD can be triggered by biological factors, life experiences, and background (Toussaint et al., 2020). The mere thought of getting through the day can cause anxiety.
10 Social Phobias (Social Anxiety Disorder)
A social phobia is an intense fear of social situations. Worry can be distressing and have an impact on one’s quality of life (Dobos et al., 2019). Although the condition usually manifests itself during adolescence, it can manifest itself earlier in some children depending on their genetic background and life stressors.
Reflections:
On the assessment and diagnostic impression, I agree with my preceptor.
The patient’s symptoms include mood swings and excessive worry. The patient is concerned about the mother and the baby brother’s well-being. He is occasionally concerned that his mother will not come to pick him up from school. He can barely concentrate in school because of his anxiety, and he denies using drugs, which is likely to cause worry and anxiety. His mother never told him that his father had died in battle. The most likely source of his concern is his fear that his mother and baby brother will vanish without a trace. He is concerned about being away from his family.
To confirm the diagnosis, a second psychiatric Assessment is required. For example, urine and blood tests will be required to rule out other causes of concern or anxiety, such as drug abuse. The mother should provide more information about the worry’s history. The additional information will Help a psychiatrist in determining the potential causes of the symptoms (Schneier et al., 2017). Additional information from the teacher is required to explain the child’s behavior. The information will help a psychiatrist to narrow down to one disorder and start treatment.
It will be critical to restore the ability to concentrate in school and eliminate worry during the delivery of care. Ethical considerations are important because they ensure professional and ethical care. For instance, the child is below the standard 18 years of consenting to treatment (McDermott-Levy et al., 2018). A psychiatrist will require the consent of the mother. Another ethical consideration is justice and fairness for the single mother. It will be essential to show respect and empathy despite what has happened before, such as failing to tell the son that his father died in the military. Veracity is another vital ethical issue that involves telling the truth (McDermott-Levy et al., 2018). For instance, it will be crucial to tell the mother to disclose the fate of the father. The disclosure combined with therapeutic interventions can lessen the worry of the child. Maleficence and beneficence are vital considerations since they involve using professional knowledge to provide the best care without the risk of medical errors (McDermott-Levy et al., 2018).
Case Formulation and Treatment Plan:
The patient’s condition requires further diagnostic tests such as urine and blood tests to rule out the impact of drug abuse on mood changes (Cloitre et al., 2019). Additional information will be required from the parent and the teacher on the history of the patient. The psychiatrist will require further medical review of the patient’s condition to ascertain the disorder the patient is suffering from (Cloitre et al., 2019).
The mother needs to learn the importance of creating rapport and a close relationship with the child. The boy requires assurance from the mother that she will always take care of his welfare. The assurance is vital to ensure the boy is not disturbed about whether the mother will come for him in school. It will be effective to educate the mother and the teachers in the schools on how to handle the boy bearing in mind his psychiatric condition. For instance, it will be crucial always to keep promises, leave with a goodbye and promise to come, and avoid exposing the child to new surroundings. The psychiatrist should educate the teacher to control the behavior of other children that bully the boy. He complains the classmates call him names which makes him feel bad.
The patient should begin treatment for at least 12 sessions using cognitive behavior therapy. The therapy will comprise sessions 45 minutes long at least for three months. After the treatment, the client should come back for follow up to prevent relapse (Schneier et al., 2017). Interventions from other healthcare workers and referrals can be made in case of co-occurring conditions. Family therapy is necessary to create trust and harmony in the family. Palliative care that involves assurance and watchful waiting are vital in the provision of care.
Treatment will involve a combination of medication and psychotherapeutic interventions to generate positive outcomes, such as selective serotonin reuptake inhibitors (SSRIs) to address anxiety (Schneier et al., 2017). Cognitive behavior therapy will change the thinking patterns and address the mood changes.
References
Schneier, F. R., Moskow, D. M., Choo, T. H., Galfalvy, H., Campeas, R., & Sanchez‐Lacay, A. (2017). A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder. Depression and Anxiety, 34(12), 1085-1095.
Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD‐11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population‐based study. Journal of Traumatic Stress, 32(6), 833-842.
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
Dobos, B., Piko, B. F., & Kenny, D. T. (2019). Music performance anxiety and its relationship with social phobia and dimensions of perfectionism. Research Studies in Music Education, 41(3), 310-326.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, d6(5), 473-481.
