NURS6640 Assignment 2: Practicum – Assessing Client Progress

NURS6640 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

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
• 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.

Comprehensive Client Assessment

Walden University

NURS-6640 Psychotherapy Individual

June 16, 2019

Part A: Clinical Assessment

Demographic information.

1. 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

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
• 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.

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.
• 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).

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:

1. 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.
2. 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.

Family Genogram

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/diseases-conditions/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