Comprehensive Psychiatric Evaluation and Patient Case Presentation

To Prepare

• Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
• Select a patient that you examined during the last 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.
• Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed, and each page must be initialed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document, as well as a PDF/images of each page that is initialed and signed by your Preceptor. You must submit your document using SafeAssign.Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
• Develop a video case presentation, based on your evaluation of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
• Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

Assignment

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. (The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

• Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
• Objective: What observations did you make during the interview and review of systems? 
• Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why? 
• Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

By Day 7

Submit your Video and Comprehensive Psychiatric Evaluation. You must submit two (2) files for the evaluation, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “Wk7Assgn2+last name+first initial.(extension)” as the name.
• Click the Week 7 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 7 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “Wk7Assgn2+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 7 Assignment 2 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 7 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7

To participate in this Assignment:

Week 7 Assignment 2

The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education

Introduction

Within the healthcare landscape, nursing students hold a crucial responsibility in tending to patients grappling with psychiatric issues. An in-depth psychiatric assessment and the adept presentation of patient cases stand out as indispensable tools in furnishing patient-centered care. These practices not only empower nurses to gauge a patient’s mental well-being but also foster seamless communication within the healthcare team, ultimately yielding a comprehensive and personalized treatment approach. This essay delves into the importance of comprehensive psychiatric assessments, outlines the core elements of these evaluations, and underscores the significance of proficiently presenting patient cases to aspiring nursing professionals.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

Significance of Thorough Psychiatric Evaluation

A comprehensive psychiatric assessment forms the bedrock of comprehending a patient’s mental health status. It entails a meticulous compilation of insights from diverse sources, including patients, families, medical records, and observations, to construct a precise evaluation. This assessment serves several pivotal purposes:(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

1. Precise Diagnosis: Achieving a precise diagnosis lies at the heart of efficacious psychiatric care. Through a comprehensive evaluation, nurses can pinpoint underlying psychiatric disorders, distinguish akin symptoms, and demarcate primary from secondary conditions.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
2. Tailored Treatment Planning: Comprehensive assessments provide a holistic panorama of a patient’s mental health, equipping nurses to collaboratively draft a personalized treatment plan with fellow healthcare professionals. This plan may span medication, therapy, lifestyle adjustments, and support strategies.
3. Risk Evaluation: Assessments assist in gauging a patient’s vulnerability to self-harm or endangering others. This intel steers interventions that safeguard patient well-being.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
4. Baseline for Progress Tracking: A detailed assessment establishes a baseline against which a patient’s progress can be gauged. This proves pivotal in charting changes over time and adapting the treatment plan as required.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

Core Components of a Comprehensive Psychiatric Assessment

A comprehensive psychiatric assessment enwraps a spectrum of components that together offer an all-encompassing view of the patient’s mental well-being:

1. Holistic Biopsychosocial Scrutiny: This entails collating insights on a patient’s biological, psychological, and social dimensions. It encompasses medical history, family records of mental health issues, existing medications, history of substance use, education background, vocational status, and interpersonal relationships.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
2. Mental State Examination (MSE): The MSE involves a systematic observation of a patient’s demeanor, conduct, emotional state, thought processes, cognitive acuity, and awareness. This aids in uncovering irregularities or incongruences.
3. Chief Complaint and Present Illness History: Comprehending the impetus for seeking care and the evolution of symptoms extends insight into the patient’s viewpoint, thereby aiding in the diagnostic process.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
4. Past Psychiatric Chronology: This entails previous psychiatric diagnoses, treatments, hospitalizations, and responses to interventions. This historical context is invaluable in spotting patterns and determining fitting treatments.
5. Developmental and Psychosocial Background: Delving into the patient’s life occurrences, traumas, and psychosocial stressors fosters recognition of triggers and tailoring of interventions.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
6. Cultural and Spiritual Appraisal: Cultural tenets and spiritual practices can shape a patient’s interpretation of illness and treatment. An assessment attuned to cultural nuances cements rapport and ensures care aligned with patient values.

The Skill of Presenting Patient Cases

Proficiently articulating a patient’s case represents an art form that nursing students must master. A well-structured case presentation guarantees lucid communication amid healthcare team members and propels collaborative decision-making:

1. Introduction: Embark with a concise introduction, encompassing patient demographics, cause for admission, and a succinct overview of their psychiatric history.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
2. Chief Complaint and Present Illness History: Present the patient’s main grievance and the trajectory of symptom development. Encompass pertinent details concerning inception, duration, severity, and potential triggers.
3. Mental State Examination: Summarize the patient’s outward appearance, demeanor, emotional state, thought content, thought processes, perceptual experiences, cognitive capacity, and self-awareness. Highlight noteworthy findings indicative of the patient’s mental state.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
4. Past Psychiatric Past: Succinctly outline previous psychiatric diagnoses, treatments, and responses to interventions. Any pertinent family history of mental health ailments should also be mentioned.
5. Holistic Biopsychosocial Context: Convey crucial facts about medical history, substance use, educational journey, employment, relationships, and recent life occurrences.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
6. Diagnosis and Assessment: Grounded in the amassed data, furnish a preliminary diagnosis and the rationale underlying it. If applicable, present alternative diagnoses, and deliberate on the patient’s insight into their condition.
7. Treatment Blueprint: Lay out the present treatment plan, spanning medications, therapeutic practices, and psychoeducational endeavors. Address safety concerns or risk evaluations as necessary.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)
8. Progress and Forecast: Sum up the patient’s journey since admission, underscoring any advancements or hurdles. Provide a succinct analysis of the anticipated prognosis and conceivable obstacles in the treatment trajectory.
9. Collective Discourse: Engage the healthcare team in a collective discussion pertaining to the patient’s case. Solicit input from diverse disciplines to mold a multifaceted approach to treatment.(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

Conclusion

In the domain of psychiatric nursing, mastering the art of a comprehensive assessment and skillfully presenting patient cases is quintessential for nursing students. These competencies not only pave the way for accurate assessments and diagnoses but also foster effective interaction and cooperation within the healthcare team. By honing the knack for exhaustive assessments and astute patient case presentations, nursing students make momentous contributions to delivering well-rounded, patient-centric care for those grappling with psychiatric disorders(The Vital Role of In-Depth Psychiatric Assessment and Patient Case Presentation in Nursing Education)

Reference

https://www.ncbi.nlm.nih.gov/