Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example
Despite significant advancements in diagnostics and classification of mental diseases and extensive knowledge by health providers and the general population regarding psychiatric conditions, treatable psychiatric disorders are often overlooked. In primary care, at least half of the depressive symptoms go undiagnosed. An initial psychiatric assessment is a standard evaluation tool used by psychiatrists to evaluate perception, thought patterns, and personality disorders. This essay provides complete a comprehensive psychiatric assessment interview of a friend codenamed XY.(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example)
| Criteria | Clinical Notes |
| Informed Consent | The client provided verbal and written informed consent for the psychiatric interview. The client demonstrated his ability to respond to the clinical questions. The client appears to have understood the risks and benefits attached to the psychiatric assessment as explained by the practitioner.(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) |
| Subjective | Verify Patient Name: XY DOB: May 30 1996 Demographic: Caucasian Gender Identifier Note: Male CC: The client is concerned with “hearing strange sounds and inability to concentrate.” HPI: No past illness or hospitalization. Pertinent history in the record and from the patient: Diagnosed with ADHD 5 years ago, manage through medication. Immunization up to date. During assessment: The patient describes his mood as anxious. Patient self-esteem appears low. He feels disappointed in himself and his frustration, which is getting worse with time. Reports change in concentration, energy, sleep patterns, and appetite. The patient reports reduction in activity, reports increase in agitation, and risky behaviours. He experiences abnormal fears and panic attacks. He reports delusions and hallucinations. The patient reports symptoms of eating disorders. There is a 2-pound weight loss in the past month. SI/ HI/ AV: Patient denies homicide and suicide ideation, violent behaviour, and SIBx. The patient reports inappropriate behaviours. Allergies: NKDFA Past Medical Hx: Medical history: Patient reports no cardiac, respiratory, head injury, endocrine or neurological issues. The patient denies a history of chronic infections, including TB, Hepatitis C, HIV, and MRSA. Surgical history: No previous surgical procedure. Past Psychiatric Hx: Previous psychiatric diagnoses: Diagnosed with ADHD at age 5. His ADHD condition is stable – managed through medication. Previous medication trials: No medical trial participated. Safety concerns: History of Violence to Self: Reported punching a wall to the point of bruising and bleeding. History of Violence to Others: Reported occasional fights in school. Auditory Hallucinations: Reports paracusia Visual Hallucinations: Reports no visual hallucinations. Mental health treatment history discussed: History of outpatient treatment: None reported Previous psychiatric hospitalizations: None reported Prior substance abuse treatment: None reported Trauma history: The client reports childhood bullying at school. (Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example)Denies other sources of trauma, such as parental neglect or abuse, domestic violence, or other traumatizing events. Substance Use: Denies using or abusing alcohol or nicotine/tobacco products. The client denies using or abusing ETOH and other illegal drugs Current Medications: Methylphenidate 20mg orally daily. Supplements: Elemental Zinc 10mg Past Psych Med Trials: None reported. Family Medical Hx: None reported Family Psychiatric Hx: Substance use: Parents consumes alcohol weekly. Suicides: None reported. Psychiatric diagnoses/hospitalization: Father diagnosed with diabetes. Other members are healthy. (Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) Developmental diagnoses: None reported. Social History: Occupational History: Unemployed. No previous employment record. Military service: Denies involvement with the military. Education history: Bachelor of Commerce graduate. Developmental History: Had normal childhood development. Legal History: Reported for initiating and carrying on a fight in the neighbourhood. Spiritual/Cultural Considerations: Christian ROS: Constitutional: No fever. Reports 2-pound weight loss. Eyes: Vision is intact ENT: Hearing and sense of smell intact. No sore throat. Cardiac: No chest pain, oedema, or breathing difficulty. Respiratory: No shortness of breath, cough or wheezing Musculoskeletal: Denies joint pain or swelling Neurologic: Denies history of seizures, blackout or numbness. Endocrine: No polyuria or polydipsia. Allergy: NKFDA(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) |
| Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is harmful, “ROS noncontributory,” or “ROS negative except for….”(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) | |
| Objective | Vital Signs: Stable Temp:98.5 F BP: 115/75 HR: 72 R:15 O2: 95 Ht:5’5’’ Wt:130lbs BMI: 21.6 LABS: Lab findings: WNL Tox screen: Negative Alcohol: Negative Physical Exam: MSE: The client appears anxious yet cooperative and conversant. The client is oriented x 4. The client is appropriately dressed for time and occasion.(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) The client’s psychomotor behaviour seems abnormal. The client does not maintain appropriate eye contact. The client shows restlessness and fidgeting, with a reported mood of anxiety. Memory: Immediate, recent, and remote memory intact Speech: Fast-talking, normal tone with crowded thoughts. TC: Denies suicide and homicide ideation. Cognition is grossly intact. Attention and concentration span is limited. The client appears knowledgeable. The client’s judgment and insight are grossly intact. Thoughtform: Logical and goal-directed The client demonstrates an ability to articulate needs. The client is motivated to comply and adhere to the treatment plan. The client reflects a willingness and ability to participate in the psychiatric assessment. (Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) |
| This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be conducted every visit in every setting) Include relevant labs, test results, and MSE, risk assessment, and psychiatric screening measure results. | |
| Assessment | DSM5 Diagnosis: Schizophrenia – This is the primary diagnosis. DSM-5 criteria for schizophrenia include the following and are presented by XY (APA, 2013): DelusionsHallucinationsDisorganized speechDisorganize motor activity Dx: – Schizoaffective disorders. This diagnosis is refuted. DSM5 criteria for schizoaffective disorder presented by XY include (APA, 2013): Mood episodesDepression with psychotic features Dx: – Delusional Disorder. This diagnosis is refuted. DSM5 criteria for Delusional disorder presented by XY include (APA, 2013): The presence of one (or more) delusions with a duration of 1 month or longerImpaired function and behaviourOther psychological effects do not cause the disturbance. Dx: – Attention Deficit Hyperactive Disorder. This diagnosis is refuted. DSM5 criteria for Delusional disorder presented by XY include (APA, 2013): Abnormalities of attentionHyperactivity – Impulsivity Difficulty sustaining focus DisorganizedLack of comprehensionLow frustration toleranceIrritability The client appears to have the capacity to respond to psychiatric medication. This creates a possibility for a consensus with the client, consequently encouraging psychotherapy (Angell & Bolden, 2015). The client appears to comprehend the need for psychotherapy and is willing to adhere to the proposed medication.(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) |
| Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability | |
| Plan (Note some items may only be applicable in the inpatient environment) | The patient is not in immediate danger to himself and those around him, as reported in HPI. The following variables tend to affect the likelihood of medical hospital admission of people with schizophrenia (Olfson et al., 2011): antipsychotic medication no adherence poor global functioning co-occurring substance use disorders Safety Risk/Plan: The client is stable and has control over his behaviours. The client does not pose a significant risk to himself and others. The client denies unusual perceptions and appears the respond abnormally to internal and external stimuli. Pharmacologic interventions: Titrate Methylphenidate to 30mg orally daily. Methylphenidate is effective for treating ADHD and has a high tolerance (Huss et al., 2017)(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example).Increase zinc supplement to 20mg daily. Add propanol 40mg for anxiety three times a day before meals and at bedtime. Propanol has a significant effect on anxiety (Steen et al., 2016).Refer for CBT. CBT is effective for managing auditory hallucinations and delusions (Candida et al., 2016). Education, including health promotion, maintenance, and psychosocial needs Importance of psychological health Importance of medication Safety planning The client is to return to the clinic after every four weeks. The patient is to visit a psychotherapist every two weeks. Time spent in the interview: 25 minutes. The visit lasted 40 minutes Date: 5/18/2021 Time: 0435(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example) |
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc. (Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example)
Angell, B., & Bolden, G. B. (2015). Justifying medication decisions in mental health care: Psychiatrists’ accounts for treatment recommendations. Social Science & Medicine, 138, 44-56. 10.1016/j.socscimed.2015.04.029
Candida, M., Campos, C., Monteiro, B., Rocha, N. B. F., Paes, F., Nardi, A. E., & Machado, S. (2016). Cognitive-behavioural therapy for schizophrenia: an overview on efficacy, recent trends and neurobiological findings. MedicalExpress, 3(5). (Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example)https://doi.org/10.5935/MedicalExpress.2016.05.01
Huss, M., Duhan, P., Gandhi, P., Chen, C. W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: a review of safety, efficacy, and clinical necessity. Neuropsychiatric disease and treatment(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example). 10.2147/NDT.S130444
Olfson, M., Ascher-Svanum, H., Faries, D. E., & Marcus, S. C. (2011). Predicting psychiatric hospital admission among adults with schizophrenia. Psychiatric Services, 62(10), 1138-1145.(Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example)
Steenen, S. A., van Wijk, A. J., Van Der Heijden, G. J., van Westrhenen, R., de Lange, J., & de Jongh, A. (2016). Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis. Journal of Psychopharmacology, 30(2), 128-139. (Adult Psychiatric Initial Interview or Assessment Comprehensive Nursing Essay Example)https://doi.org/10.1177/0269881115612236
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