NURS 6660 Week 1: Comprehensive Integrated Psychiatric Assessment

NURS 6660 Week 1: Comprehensive Integrated Psychiatric Assessment

 The comprehensive integrated psychiatric assessment of a child or adolescent consists of gathering information from not only the child but from several sources, most notably the family members, caregivers, and the child’s teacher or school counselor. Because of this, the diagnostic assessment becomes more complicated. Issues of confidentiality, privacy, and consent must be addressed. Also, the PMHNP must take into consideration the impact of culture on the child.

In this Discussion, you review and critique the techniques and methods of a mental health professional as he or she completes a comprehensive integrated psychiatric assessment of an adolescent.

To Prepare for the Assignment:

• Review the Learning Resources concerning the comprehensive integrated psychiatric assessment.
• Watch the Mental Status Examination video.
• Watch the two YMH Bostonvideos.

Assignment

Based on the YMH Boston Vignette 4 video, post answers to the following questions:

• What did the practitioner do well?
• In what areas can the practitioner improve?
• At this point in the clinical interview, do you have any compelling concerns? If so, what are they?
• What would be your next question, and why?

PLEASE, INCLUDE INTRODUCTION, CONCLUSION, 3 OR MORE REFERENCES LESS THAN 5 YEARS OLD, AND ANSWER ALL THE QUESTIONS AS INSTRUCTED

Learning Resources

Required Readings

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Chapter 5, “Examination and      Diagnosis of the Psychiatric Patient” (pp. 192–289)

Chapter 31, “Child Psychiatry” (pp. 1082–1107)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Kaplan, C. (2017). Ethical dilemmas. Advanced Healthcare Network. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/Ethical-Dilemmas-2.aspx

Pumariega, A. J., Rothe, E., Mian, A., Carlisle, L., Toppelberg, C., Harris, T., . . .  Smith, J. (2013). Practice parameter for cultural competence in child and adolescent psychiatric practice. Journal of the American Academy of Child HYPERLINK “http://pumariega, a. j., rothe, e., mian, a., carlisle, l., toppelberg, c., harris, t., . . .  smith, j. (2013). practice parameter for cultural competence in child and adolescent psychiatric practice. journal of the american academy of child & adolescent psychiatry, 52(10), 1101–1115. retrieved from http://www.jaacap.com/article/S0890-8567(13)00479-6/pdf”&HYPERLINK “http://pumariega, a. j., rothe, e., mian, a., carlisle, l., toppelberg, c., harris, t., . . .  smith, j. (2013). practice parameter for cultural competence in child and adolescent psychiatric practice. journal of the american academy of child & adolescent psychiatry, 52(10), 1101–1115. retrieved from http://www.jaacap.com/article/S0890-8567(13)00479-6/pdf” Adolescent Psychiatry, 52(10), 1101–1115. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00479-6/pdf

American Academy of Child HYPERLINK “http://american academy of child & adolescent psychiatry (aacap). (2012a). practice parameter for psychodynamic psychotherapy with children. journal of the american academy of child & adolescent psychiatry, 51(5), 541–557. retrieved from http://www.jaacap.com/article/S0890-8567(12)00141-4/pdf”&HYPERLINK “http://american academy of child & adolescent psychiatry (aacap). (2012a). practice parameter for psychodynamic psychotherapy with children. journal of the american academy of child & adolescent psychiatry, 51(5), 541–557. retrieved from http://www.jaacap.com/article/S0890-8567(12)00141-4/pdf” Adolescent Psychiatry (AACAP). (2012a). Practice parameter for psychodynamic psychotherapy with children. Journal of the American Academy of Child HYPERLINK “http://american academy of child & adolescent psychiatry (aacap). (2012a). practice parameter for psychodynamic psychotherapy with children. journal of the american academy of child & adolescent psychiatry, 51(5), 541–557. retrieved from http://www.jaacap.com/article/S0890-8567(12)00141-4/pdf”&HYPERLINK “http://american academy of child & adolescent psychiatry (aacap). (2012a). practice parameter for psychodynamic psychotherapy with children. journal of the american academy of child & adolescent psychiatry, 51(5), 541–557. retrieved from http://www.jaacap.com/article/S0890-8567(12)00141-4/pdf” Adolescent Psychiatry, 51(5), 541–557. Retrieved from http://www.jaacap.com/article/S0890-8567(12)00141-4/pdf

American Psychological Association. (2017). Code of Ethics. Retrieved from http://www.apa.org/ethics/code/

Required Media

Gajbhare, P. (2014, March 8). Mental status examination [Video file]. Retrieved from https://www.youtube.com/watch?v=VjWVYgf2UcU

YMH Boston. (2013a, May 22). Vignette 1 – Introduction to a preventive services visit [Video file]. Retrieved from https://www.youtube.com/watch?v=pQy-jwiu7gM

YMH Boston. (2013c, May 22). Vignette 4 – Introduction to a mental health assessment [Video file]. Retrieved from https://www.youtube.com/watch?v=JCJOXQa9wcE

SEE SAMPLE ANSWER BELOW

NURS 6000N: PMH Nurse Practitioner Role I: Child and Adolescent

WEEK 1 INITIAL DISCUSSION POST

The YMH Boston Vignette 4 video, described a 16 year adolescent client who came into an outpatient clinic for a mental health assessment.  He was referred there by his mother and he reported he had no idea why he was there.  In the video, it was evident the client did not want to be at the appointment.  The provider used many techniques to engage the adolescent client.  Some techniques displayed in the vignette were helpful and some techniques should have been avoided.  The following post will answer four questions provided from the discussion board in relationship to the video.

What did the practitioner do well?

At the beginning of the session the provider informed the client about confidentiality.  Confidentiality is a cornerstone of healthy therapeutic relationships and effective treatment and is based upon the ethical principles of autonomy and fidelity (Wheeler, 2014).  Another positive is that the provider engaged the client by asking him about his views.  That indirectly communicates that the provider believes the client has his own thoughts and feelings. The client has a positive response to the engagement as he becomes more verbal and makes better eye contact.  Sadock, Sadock, and Ruiz (2014) reported once rapport has been established, many adolescents appreciate the opportunity to tell their side of the story (p. 1109).  Lastly, the provider asks about other people in the client’s life.  In doing this, the provider finds out that the client is more comfortable relating to his girlfriend and his coach. The client feels more comfortable talking about those relationships and becomes more genuine when talking about other relationships.

In what areas can the practitioner improve?

There were a few areas the provider could improve on.  When the patient states his mother thinks he has an “anger management” problem, the provider challenges him, saying that his mother must have a reason for thinking this. The provider’s tone of voice and facial expressions indicate that he is having some negative feelings about this patient. By taking the approach that challenges the client it alienates him.  In the vignette the client withdraws and looked down with his hands in his lap when the provider expressed that.  Learning to read a teen’s body language is an important skill.  A teen who is avoiding eye contact, mumbling words, or giving one word answers may be struggling with something, and providers can often help teens open up by acknowledging this discomfort (Tomescu and Ginsburg, 2012).

At this point in the clinical interview, any compelling concerns? If so, what are they?

At this point in the interview there are a few compelling concerns.  One being the provider doesn’t elicit strategies for the patient to communicate with his mother more effectively.  The patient says he doesn’t like it when his mother “keeps nagging him” to talk about his feelings. This can be viewed as a developmental issue as well as a family issue, as adolescent boys do not generally want to talk to their mothers about their feelings (Sadock, Sadock, and Ruiz, 2014). Although development does not occur in a linear stage, familiarity with the primary developmental themes and transitions of each age period provides an important context from which to view current symptoms (Sadock, Sadock, and Ruiz, 2014).  The provider should also recognize that the patient is saying that talking about his feelings is hard for him and he feels angry when he is pushed to try. The provider reflects and normalizes the patient’s aversion to talking to his mother by using humor. This resonates with the patient and helps him become more connected.

What would be your next question, and why?

The provider identified the client’s positive attributes, but the “at risk” behavior was not addressed.  I would assess substance use, abuse, and addiction.  I would start with a question from the CRAFFT screening tool “have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?”  Substance abuse or dependence can have a significant impact on psychiatric symptoms and treatment course (Sadock, Sadock, and Ruiz, 2014).  Substance use contributes sharply to the mortality related to injuries and violence, and to the morbidities of school failure, depression, and sexually transmitted disease acquisitions (Pollack, 2006).

References

Pollack, W. (2006). The “war” for boys: Hearing “real boys” voices, healing their pain.Professional Psychology-Research and Practice, 37(2), 190-195. Retrieved from Walden Library databases

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Tomescu, O. & Ginsburg, K. R. (2012). Interviewing the adolescent: strategies that promote communication and foster resilience. In Emans, Laufer, Goldstein’s Pediatric and Adolescent

Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

YMH Boston. (2013c, May 22). Vignette 4 – Introduction to a mental health assessment [Video file]. Retrieved from https://www.youtube.com/watch?v=JCJOXQa9wcE

Assignment 1: Practicum: Decision Tree

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting symptoms of a mental health disorder.

Learning Objectives

Students will:

• Evaluate clients for treatment of mental health disorders
• Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

The Assignment:

Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

• Decision #1: Differential Diagnosis
• Which Decision did you select?
• Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
• What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
• Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
• Decision #2: Treatment Plan for Psychotherapy
• Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
• What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
• Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
• Decision #3: Treatment Plan for Psychopharmacology
• Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
• What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
• Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients and their families.

BACKGROUND

Tyrel is an 8-year-old black male who is brought in by his mother for a variety of psychiatric complaints. Shaquana, Tyrel’s mother, reports that Tyrel has been exhibiting a lot of worry and “nervousness” over the past 2 months. She states that she notices that he has been quite “keyed up” and spends a great deal of time worrying about “germs.” She states that he is constantly washing his hands because he feels as though he is going to get sick like he did a few weeks ago, which kept him both out of school and off the playground. He was also not able to see his father for two weekends because of being sick. Shaquana explains that although she and her ex-husband Desmond divorced about 2 years ago, their divorce was amicable and they both endeavor to see that Tyrel is well cared for.

Shaquana reports that Tyrel is irritable at times and has also had some sleep disturbances (which she reports as “trouble staying asleep”). She reports that he has been more and more difficult to get to school as he has become nervous around his classmates. He has missed about 8 days over the course of the last 3 weeks. He has also stopped playing with his best friend from across the street.

His mother reports that she feels “responsible” for his current symptoms. She explains that after he was sick with strep throat a few weeks ago, she encouraged him to be more careful about washing his hands after playing with other children, handling things that did not belong to him, and especially before eating. She continues by saying “maybe if I didn’t make such a big deal about it, he would not be obsessed with germs.”

Per Shaquana, her pregnancy with Tyrel was uncomplicated, and Tyrel has met all developmental milestones on time. He has had an uneventful medical history and is current on all immunizations.

OBJECTIVE

During your assessment of Tyrel, he seems cautious being around you. He warms a bit as you discuss school, his friends at school, and what he likes to do. He admits that he has been feeling “nervous” lately, but when you question him as to why, he simply shrugs his shoulders.

When you discuss his handwashing with him, he tells you that “handwashing is the best way to keep from getting sick.” When you question him how many times a day he washes his hands, he again shrugs his shoulders. You can see that his bilateral hands are dry. Throughout your assessment, Tyrel reveals that he has been thinking of how dirty his hands are; and no matter how hard he tries to stop thinking about his “dirty” hands, he is unable to do so. He reports that he gets “really nervous” and “scared” that he will get sick, and that the only way to make himself feel better is to wash his hands. He reports that it does work for a while and that he feels “better” after he washes his hands, but then a little while later, he will begin thinking “did I wash my hands well enough? What if I missed an area?” He reports that he can feel himself getting more and more “scared” until he washes his hands again.

MENTAL STATUS EXAM

Tyrel is alert and oriented to all spheres. Eye contact varies throughout the clinical interview. He reports his mood as “good,” admits to anxiety. Affect consistent to self-reported mood. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes were apparent. He denies suicidal ideation.

Lab studies obtained from Tyrel’s pediatric nurse practitioner were all within normal parameters. An antistreptolysin O antibody titer was obtained for reasons you are unclear of, and this titer was shown to be above normal parameters.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Decision Point One

Obsessive Compulsive Disorder

Decision Point Two

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/05/mm/decision_tree/img/pill-blue.pngBegin Fluvoxamine immediate release 25 mg orally at bedtime

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.
• She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.

Decision Point Three

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/05/mm/decision_tree/img/pill-red.pngIncrease Fluvoxamine to 50 mg orally at bedtime

Guidance to Student

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well.

NURS 660 Week 4: Trauma and Stressor-Related Disorders in Childhood

“He was drunk again, so I should have known better. I should have stayed away from the house, but that would have made him madder. He has done this before, but not nearly this bad. He broke my wrist as I was protecting my mom. The neighbor heard the screaming and called the cops. They hauled him away, but I know he will be back. She always lets him come back.”

Avery, age 14

In August of 2005, thousands of children lost their homes in Hurricane Katrina. On December 14, 2012, the students at Sandy Hook Elementary School experienced the death of 20 of their classmates and six of their teachers. Every day, children experience physical and sexual abuse and neglect by their parents or caregivers. These types of trauma have a lifelong impact on the children involved and those witnessing the events. As much as we try to prevent unwanted childhood trauma and stressors, the phenomena are present in our culture. Childhood trauma is a significant contributor to both physical and mental health problems in children and adults.

This week, you examine several cases of child abuse and neglect, and you recommend strategies for assessing for abuse. You analyze influences of media and social media on mental health and evaluate the need for mandatory reporting of abuse. You also submit your Practicum Journal and Assignments.

Photo Credit: StaffordStudios / Getty Images

Learning Resources

Required Readings

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

• Chapter 31, “Child Psychiatry” (pp. 1216–1226)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

• “Trauma- and Stressor-related Disorders”

Note: You will access this book from the Walden Library databases.

Pfefferbaum, B., & Shaw, J. A. (2013). Practice parameter on disaster preparedness. Journal of the American Academy of Child & Adolescent Psychiatry, 52(11), 1224–1238. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00550-9/pdf

American Psychiatric Nurses Association. (2017). Childhood and adolescent trauma. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageID=4545

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

Optional Resources

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.

• Chapter 50, “Provision of Intensive Treatment: Intensive Outreach, Day Units, and In-Patient Units” (pp. 648–664)
• Chapter 58, “Disorders of Attachment and Social Engagement Related to Deprivation” (pp. 795–805)
• Chapter 59, “Post Traumatic Stress Disorder” (pp. 806–821)
• Chapter 64, “Suicidal Behavior and Self-Harm” (pp. 893–912)

Discussion: Treating Childhood Abuse

In 2012, statistics in the United States indicated that state CPS agencies received 3.4 million referrals for child abuse and neglect. Of these, nearly 700,000 children were found to be victims of maltreatment: 18% were victims of physical abuse and 78% were victims of neglect (CDC, 2014). Child sexual abuse makes up roughly 10% of child maltreatment cases in the United States (CDC, 2014). The CDC considers sexual abuse at any age a form of violence. Child abuse of any kind can lead to an increased state of inflammatory markers in adulthood, as well as multiple physical illnesses and high-risk behavior such as alcoholism and drug abuse. If a PMHNP identifies child abuse, there may be a need to report the abuse to authorities. Once able to provide treatment, the PMHNP can be instrumental in reducing the long-term effects of child abuse.

In this Discussion, you recommend strategies for assessing for abuse and analyze influences of media and social media on mental health. You also evaluate the need for mandatory reporting of abuse.

Learning Objectives

Students will:

• Recommend strategies for assessing for abuse
• Analyze influences of media and social media on mental health
• Evaluate the need for mandatory reporting of abuse

To Prepare for this Discussion:

• Read the Learning Resources concerning treating childhood abuse.
• Read the Child Abuse Case Study in the Learning Resources. See Child Abuse Case Study

Assignment Question to be addressed

• What strategies would you employ to assess the patient for abuse? Explain why you selected these strategies.
• How might exposure to the media and/or social media affect the patient?
• What type of mandatory reporting (if any) is required in this case? Why?