Assessing Client Progress Discussion

Assessing Client Progress Discussion Assessing Client Progress Discussion Assignment 2: Practicum – Assessing Client Progress LEARNING OBJECTIVES Students will: Assess progress for clients receiving psychotherapy Differentiate progress notes from privileged notes Analyze preceptor’s use of privileged notes. NURS6640 Walden Practicum Assessing Client Progress Discussion To prepare: Reflect on the client you selected for the Week 3 Practicum Assignment. Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format. The Assignment Part 1: Progress Note Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations): Treatment modality used and efficacy of approach. NURS6640 Walden Practicum Assessing Client Progress Discussion Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals) Modification(s) of the treatment plan that were made based on progress/lack of progress Clinical impressions regarding diagnosis and/or symptoms Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.) Safety issues Clinical emergencies/actions taken Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them) Treatment compliance/lack of compliance Clinical consultations Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.) Therapist’s recommendations, including whether the client agreed to the recommendations Referrals made/reasons for making referrals Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions) Issues related to consent and/or informed consent for treatment Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported Information reflecting the therapist’s exercise of clinical judgment Note: Be sure to exclude any information that should not be found in a discoverable progress note. Part 2: Privileged Note Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment. The privileged note should include items that you would not typically include in a note as part of the clinical record. Explain why the items you included in the privileged note would not be included in the client’s progress note. Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why. wk3assign2__6640.docx ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Running Head: Comprehensive Client Assessment Comprehensive Client Assessment Walden University NURS-6640 Psychotherapy Individual June 16, 2019 1 Comprehensive Client Assessment 2 Part A: Clinical Assessment Demographic information. A. S is a 27 years old African American woman who came to the clinic today seeking help. She lives in Baltimore, single no child. Presenting problem/ Present illness: This patient presents today with a feeling of sadness, guilt, loss of social activities, poor appetite, loss of a job, and no source of income. Patient stated, “I am tired of living like this, I do not want to do this again, get a job and have my own family. It started six months ago when my boyfriend of 10 years forced me to have an abortion, abandoned me, and got married to another woman. Past Psychiatric History: no history with mental illness until now. She also denies any suicidal plans. Medical history- None Substance Abuse History- illicit drug use Developmental History- The client was born full term with no complications. Graduated high school, four years of university completed. Middle school teacher. Family Psychiatric History- Maternal. Mother deceased 7years, grandmother dementia, and depression. Paternal- no history of mental illness. Sibling, 5year old stepbrother no problem Comprehensive Client Assessment 3 Psychosocial history- Raised in a loving home, has been a happy single woman until now, Live in a townhome where her boyfriend abandoned her and got married to another woman. She is friendly, has friends, and enjoy traveling. Due to her recent symptoms, She has lost her job and almost losing her townhouse. Presently, associates mostly with drug users. Abuse/trauma History. Death of her mother, abortion 2years ago, and the abandonment by her boyfriend. Review of System & Assessment • HEENT: denies any • Respiratory: Breathing is normal, and no signs of abnormal sounds. • Cardiovascular: no dyspnea, or heart mummers. • Gastrointestinal: report loss of appetite, nausea, and vomiting. • Genitourinary: Denies Hep C, HIV, no sexually transmitted disease • Musculoskeletal: normal range and motion • Integumentary: No rashes, positive for lesions • Psychiatric: opioid addiction, spend $100 a day. no suicidal ideation Physical Assessment • General: AOX4, anxious and depressed, appears well groomed, moderately nourished, good historian, and answers all questions appropriately. • Vital signs: BP 127/69, p 77, R 20, T 98.3 orally, H 5.6, WT 150lb, BMI 24.2 Comprehensive Client Assessment • HEENT: nose pale, boggy nasal mucosa, clear thin secretions, enlarged nasal turbinates • Cardiovascular: Good S1 and S2, no murmur, no JVD • Abdomen: soft non distended, positive BS X4 • Musculoskeletal: symmetrical muscle movement, muscle strength 5/5 • Neurological: Alert, oriented, and cooperative. • Skin/lymph nodes: no edema, rashes, lesions, no palpations of lymph nodes. 4 Mental Status Examination: • Appearance/Behavior: Good hygiene, flat affect, and dressed neatly and appropriate for the current climate. Answers questions appropriately. • Speech/ Language: Appropriate and fluent. • Motor Activity: normal gait but slow movement • Affect and mood: Depressed mood and flat affect. • Perception: No reports of hallucinations or dissociation. • Thought process: Normal, no disorganization • Thought content: no delusions, suicidal, thoughts. NURS6640 Walden Practicum Assessing Client Progress Discussion • Sensorium and Cognition: Awake, oriented to the time and place. • Memory: No deficits. • Insight: Aware of situation • Differential Diagnosis Major Depressive Disorder: This is a mood disorder that involves a persistent feeling of sadness and loss of interest in activities (anhedonia) and causing a deficiency in daily activities (MayoClinc 2018). Comprehensive Client Assessment 5 Adjustment disorder: reaction to some identifiable stressors or adverse life situation (Casey & Casey, 2014). Dysthymia: This is a chronic depressive disorder that lasts over two years. The symptoms are usually milder but last longer than major depressive disorder (Adler, et al., 2004) Final Diagnosis DSM-V Diagnosis: Major Depressive Disorder Case Formulation: A. S is a 27 years old African American single woman. She has been depressed for the past six months because her high school sweetheart of ten years convinced her to have abortion two years ago, and six months ago, abandoned her and got married to another woman. She reports loss of appetite, weakness, illicit drug use, apathy, hopelessness, loss of interest in activities that she loves, such as traveling, and socializing with friends. She has recently lost her job as a middle school teacher, and she is in the process of losing her townhome. She is ready for a change. She wants to be clean to get a job and have her own family. B. Treatment Plan: The #1goal for the client to get back to be free from depression, stop illicit drug use, resumed social life, client to apply for a job and keep busy. Pt needs to start on an antidepressant and a low dose methadone 30mg PO daily for 30days. Pt will report to the clinic for a daily dose with no sign of relapse or depression. Comprehensive Client Assessment 6 Family Genogram Great Grandfather grandfather GreatGreat grandfather grandfather Great Greatgrandmother grandmothe Great Grandmother grandmother r# Depression # # GreatGreat grandmother grandmother # Great Greatgrandmother grandmother GreatGreat grandfather grandfather Depression Grandmother Grandmother # Grandmother Grandmother Grandfather Grandfather Great grandfather # Grandfather Grandfather Grandfather # Depression Mo Mother ther # Mother # Father Client, A. # S Client Depression Comprehensive Client Assessment 7 References Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Depression (major depressive disorder). Retrieved from https://www.mayoclinic.org/diseasesconditions/depression/symptoms-causes/syc-20356007 Adler, D. A., Adler, D. A., Irish, J. T., McLaughlin, T. J., Perissinotto, C., Chang, H., . . . Lerner, D. (2004). The work impact of dysthymia in a primary care population. General Hospital Psychiatry, 26(4), 269-276. Retrieved 6 16, 2019, from https://ncbi.nlm.nih.gov/pubmed/15234821 Casey, P., & Casey, P. (2014). Adjustment Disorder: New Developments. Current Psychiatry Reports, 16(6), 451. Retrieved 6 16, 2019, from https://link.springer.com/article/10.1007/s11920-014-0451-2 Comprehensive Client Assessment 8 … Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service . 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