Assessing Clients (Psychiatric Advance Nursing Practicum)

Learning Objectives Students will: •Assess clients presenting for psychotherapy • Develop genograms for clients presenting for psychotherapy

To prepare: • Select a client whom you have observed or counseled at your practicum site. • Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.

The Assignment

Part 1: Comprehensive Client Family Assessment With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations): •Demographic information •Presenting problem •History or present illness •Past psychiatric history •Medical history • Substance use history •Developmental history •Family psychiatric history •Psychosocial history •History of abuse/trauma •Review of systems •Physical assessment •Mental status exam •Differential diagnosis •Case formulation •Treatment plan

Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Required Readings:

(1) 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.

Part 1: Comprehensive Client Family Assessment

Demographic information

J.S is an 8-year-old, African American/Caucasian, male.

Presenting problem

Mother reports that she and J.S’s father separated in October of 2015. She reports J.S wishes for her and his father to reunite and get back together. She believes that he could benefit from additional support with understanding the separation of his parents. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room). Mother reports J.S talks to her, but is uncertain if he has any suppressed thoughts or feelings. She shared that J.S’s father was recently on the phone with a women while he was visiting. Mother reports since this J.S has been having a lot of questions about whether his parents will be together again and whether they have other significant relationships. She shared that she wants J.S to understand the concept of his parents being apart.

History or present illness

Mother reports onset of Jayden’s behavior occurred in 2015 when her and Jayden’s father separated.

Past psychiatric history

Mother reports none

Medical history

Mother reports none.

Substance use history

Mother reports none.

Developmental history

Mother reports no delays.

Family psychiatric history

Mother reports anxiety and depression on both J. S’s paternal and maternal side of family. Father is struggling with addiction.

Psychosocial history

J.S reports having a lot of friends. He reports getting along with his friends.

History of abuse/trauma

Mother reports none.

Review of systems

Gen:  Denies weakness, fatigue, fever, chills, night sweats, heat intolerance.

Head: normocephalic; denies migraine headaches.

ENT: Denies visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes. Cardiopulmonary: Denies cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.

GI: Negative for decreased appetite. Neg for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

GU: No dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

MS: Denies backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin: Denies bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro: Denies seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

Physical assessment

Vital Signs:

47 Height: inches

Weight: 115lbs

Temp: 37 C.

RR: 16

BP: 110/62

Pulse: 82 BPM

Appearance: Slender bi-racial male, slightly tan, appearing younger than stated age in   distress, no acute distress, neatly dressed and groomed.

Mental status exam

J.S presents to the appointment with his mother. He alert and oriented x4. Neurologically intact. J.S. is neatly dressed. Polite mannerism and very social. Mood and affect is euthymic and appropriate. J.S. is comfortable interviewing with therapist while mother steps out. He seems to like talking to therapist and asks many questions about games, books, etc. that are present in the room. J.S. denies any SI/HI or A/V/H. Speech is coherent and clear. J.S. fidgets with his hands during interview and processed better after therapist offered Play-Dough to figet with instead.

Differential diagnosis

Z63.5 Disruption of family by separation and divorce

Diagnosis

Seperation and Anxiety Disorder

Case formulation

Mother reports that her and J.S’s father separated in October of 2015. Mother reports since separation J.S is “clingy” as evidenced by wanting to be with mother all the time (e.g., wanting to sleep with mother, wanting to be with mother in the house and not alone in his room).

J.S attended session with his mother. He completed a Basic Emotion Assessment indicating mixed emotions (sad, angry, happy, excited). J.S rated sadness as a 4 on a scale from 0-5 with 5 indicating very sad. Jayden explained, “I am sad that my dad does not live with me anymore.” He reported that he is happy and excited because he will be going to his grandmother’s home for the summer.

According to the American Psychological Association (2013), diagnosis assigned to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to. The diagnosis is given only when the distress associated with the separation is unusual for an individual developmental level, is prolonged and severe. In accordance with J.S.’s intake assessment and individual therapy session, he fits the criteria for this diagnosis.

Treatment plan

Treatment Goals

J.S will acknowledge and accept the separation of his parents. He will begin a healthy grieving process and manage reactions experienced due to disruption of family by separation.

Estimated Completion: 3 Months

Objective #1

J.S will bring awareness to thoughts and feelings related to his parents’ separation as evidenced by (a) identifying and listing emotions surrounding two parents and two homes, (b) clarifying his relationship patterns with his custodial (mother) and noncustodial (father) parent, and (c) participating in expressive art activities or psychotherapy exercises to help express thoughts and feelings about parents’ separation. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.

Treatment Strategy / Interventions: Supportive psychotherapy, integrating psychodynamic, cognitive-behavioral, and interpersonal conceptual models and techniques will be used to address and respond to J.S’s thoughts and feelings related to his parents’ separation.

Therapist will educate J.S on how relationships may begin and end. Therapist will elicit J.S’s exploration, description, and ventilation surrounding the disruption of family by separation. Therapist will assist him in developing vocabulary to express emotions. Psychoeducation, Psychotherapy Homework, Psychotherapy Worksheet, Expressive Arts Therapy will be used to help him identify, list, and bring awareness to his emotions and thoughts. Therapist will help Jayden learn how to rate his emotions using basic emotion assessments each session. Supportive Reflection, Interactive Feedback, Symptom Management, Relaxation/Deep Breathing will be used to foster a therapeutic environment and alliance where J.S is comfortable in sharing.

Estimated Completion: 3 Months

Objective #2

J.S will accept parents’ separation with consequent understanding and control of feelings and behavior as evidenced by (a) practicing emotion regulation skills (e.g., opposite actions, checking the facts, focusing on positive events, etc.), (b) developing and using relaxation techniques (e.g., deep breathing, mindfulness, drawing, coloring, etc.), and (c) learning and verbalizing the stages of loss and grief for children whose parents have separated. Progress will be measured per J.S’s report, parent report, and Therapist direct observation.

Treatment Strategy / Interventions: Therapist will gently explore, confront, and address J.S’s reactions to his parent’s separation. Using DBT and CBT approaches, J.S will be educated, taught, and modeled skills he can use to cope with strong negative emotions. Therapist will help J.S understand the stages of loss and grief experienced by children. Therapist will determine what stage of loss and grief he is in and help him move towards acceptance. J.S will be asked to identify and list the advantages and disadvantages of his parent’s separation. He will be encouraged to focus on positive experiences he has had since his parents’ separation to help him accept and embrace changes. Role-Play/Behavioral Rehearsal, Psycho-Education, Psychotherapy Worksheet, Supportive Reflection, Symptom Management, Interactive Feedback, Exploration of Coping Patterns, Exploration of Coping Patterns, Exploration of Emotions will be used.

Estimated Completion: 3 Months

Social Support system:

Mother, maternal grandmother.

Part 2: Family Genogram

Genogram includes J.S. maternal side of family. Mom reports no knowledge of paternal family members by name.

Grand

Father Ed

Grand

mother Judy

Jade

Father

Greg

Mother

Ashley

Great

grandfather

Tom

Great

grandmother

Ann

Running head: THE HERNANDEZ CASE STUDY 1

THE HERNANDEZ CASE STUDY 9

The Hernandez Case Study

Name

Academic Institution

Author Note

Class

Professor

September 22, 2017

The Hernandez Case Study

Part 1: Comprehensive Client Family Assessment

Demographic information

Juan Hernandez Junior is an 8-year-old, Latino, male.

Presenting problem

Juan Hernandez Junior described a punishment at school that led to them calling the ACS. The school social worker was told of how the Hernandez parents made him kneel on his knees for hours while holding two heavy encyclopedias in each hand as a form of punishment. He reiterated that this punishment had been used on them on several occasions and this led to the ACS sending a worker to their home. The ACS worker thought that the concern was credible since this form of punishment was abusive and suggested that they start attending family sessions and visit the local community mental agency to complete a parenting group.

History or present illness

Past psychiatric history

Parents report that Juan Jr. has been of sound psychiatric health.

Medical history

Parents report that Juan Jr has been healthy. However, his mother has been diagnosed with diabetes recently.

Substance use history

Both parents have no history of substance abuse nor does Juan Jr.

Developmental history

Parents reports no delays.

Family psychiatric history

Parents report no psychiatric problems in their family history.

Psychosocial history

Juan Jr is quite sociable. He and his parents go to the beach and the park near their home on weekends to socialize and play.

History of abuse/trauma

Prior to the current problem that involves the form of punishment that the Hernandez are using on their children, there are no other abuse incidents that Juan Jr. has experienced.

Review of systems

Gen:  Has no fever, night sweats, heat intolerance, weakness or fatigue.

Head: No migraine headaches reported.

ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.

Cardiopulmonary: Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.

GI: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

GU: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

MS: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

Physical assessment

Vital Signs:

47 Height: inches

Weight: 129lbs

Temp: 37 0C.

RR: 16

BP: 120/59

Pulse: 79 BPM

Appearance:  Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.

Mental status exam

The whole family comes to the appointment since they have to do both family sessions and a positive parenting program for the parents. Juan Senior comes on with a lot of anger and resentment towards the counselor a she sees no point in attending the classes.

Differential diagnosis

The parents grew up too fast and are projecting their feelings on their children.

Diagnosis

Anger Management issues

Case formulation

The Hernandez parents, Juan Senior and Elena are brought for sessions by the ACS as a result of their son’s abuse allegations. Juan Hernandez is a 27 year old Latino man who works as a casual worker at the airport with back problems due to the amount of heavy lifting he has to do on a daily basis. He has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged. Additionally, he takes approximately six to eight beers every weekend. On the other hand, Elena is a 25 year old Latino woman born in Puerto Rico but raised in New York who was recently diagnosed with diabetes. She has no drug abuse problem nor a criminal history. She drinks 1 or 2 drinks a month.

Treatment plan

Treatment Goals

The weekly parenting classes and family sessions will teach the parents effective and safe discipline skills, the importance of recognizing age-appropriate behavior, managing one’s frustrations, and the child development techniques that boosts child’s self-esteem and their sense of confidence. It will also help the family as a whole come to terms with the situation at hand.

Estimated Completion: 3 Months

Objective #1

The parents will be able to discipline their children effectively and using safe options.

Treatment Strategy / Interventions: This will be done through teaching the parents the most effective and safe discipline skills they can use. These may include techniques such as setting limits like taking away their privileges and using time-out. This can only be successful if the parents fully understand the age appropriate behavior of each stage s they do not cross boundaries and punish them unnecessarily.

Estimated Completion: 3 Months

Objective #2

In the end, the parents should be able to find child development techniques that will boost their children’s self-esteem and ensure they have a strong sense of confidence. They should also be able to manage their frustrations as a family.

Treatment Strategy / Interventions: Through role playing, both the parents and the children are able to find a way to understand the feelings of the other so they can rectify any issues they might have had. This will help ensure order at home is maintained without the need for discipline and that the parents do not put unrealistic expectations on their children.

Estimated Completion: 3 Months

Social Support system:

Friends and family

Part 2: Family Genogram

Genogram includes Juan Hernandez Junior’s family.

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.

Hernandez Family Genogram

Juan Hernandez Senior (Father)

Juan Hernandez Junior (8 years old) (Son)

Alberto Hernandez (6 years old)(Son)

Elena Hernandez (Mother)

 
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