FOCUSED SOAP NOTE FOR ANXIETY, PTSD, AND OCD

Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. (Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches. 

RESOURCES

Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

TO PREPARE

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  • Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
  • Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
  • Consider what history would be necessary to collect from this patient.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  • Consider what interview questions you would need to ask this patient.

THE ASSIGNMENT

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  • Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

BY DAY 7 OF WEEK 3

Submit your Focused SOAP Note.

SUBMISSION INFORMATION

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  1. To submit your completed assignment, save your Assignment as WK3Assgn_LastName_Firstinitial
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  3. Next, click on Upload File and select Submit Assignment for review.
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Rubric

NRNP_6675_Week3_Assignment_Rubric

NRNP_6675_Week3_Assignment_Rubric

CriteriaRatingsPts

This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about your assigned patient.In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

15 to >13.0 pts

Excellent 90%–100%

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

13 to >11.0 pts

Good 80%–89%

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

11 to >10.0 pts

Fair 70%–79%

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

10 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

15 pts

This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

15 to >13.0 pts

Excellent 90%–100%

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

13 to >11.0 pts

Good 80%–89%

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

11 to >10.0 pts

Fair 70%–79%

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

10 to >0 pts

Poor 0%–69%

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

15 pts

This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

20 to >17.0 pts

Excellent 90%–100%

The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

17 to >15.0 pts

Good 80%–89%

The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

15 to >13.0 pts

Fair 70%–79%

The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

13 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

20 pts

This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Incorporate one health promotion activity and one patient education strategy.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

25 to >22.0 pts

Excellent 90%–100%

The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding…. The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

22 to >19.0 pts

Good 80%–89%

The response provides an evidence-based and appropriate plan for psychotherapy for the patient…. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided…. The response includes at least one health promotion activity and one patient education strategy.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

19 to >17.0 pts

Fair 70%–79%

The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient…. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general…. The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

17 to >0 pts

Poor 0%–69%

The response provides an incomplete or inaccurate plan for psychotherapy for the patient…. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing…. The health promotion and patient education strategies are incomplete or missing.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

25 pts

This criterion is linked to a Learning Outcome• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

5 to >4.0 pts

Excellent 90%–100%

Reflections are thorough, thoughtful, and demonstrate critical thinking. Reflections contain a discussion of all elements described within assignment directions.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

4 to >3.5 pts

Good 80%–89%

Reflections demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) with consideration of patient factors and risk factors.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

3.5 to >3.0 pts

Fair 70%–79%

Reflections are somewhat general or do not demonstrate critical thinking. Reflections contain 2 out of 3 (legal/ethical considerations, social determinate of health, health promotion) without consideration of patient factors and risk factors.

3 to >0 pts

Poor 0%–69%

Reflections are incomplete, inaccurate, or missing.

5 pts

This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

10 to >8.0 pts

Excellent 90%–100%

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

8 to >7.0 pts

Good 80%–89%

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

7 to >6.0 pts

Fair 70%–79%

Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

6 to >0 pts

Poor 0%–69%

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

10 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

5 to >4.0 pts

Excellent 90%–100%

Uses correct APA format with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 APA format for parenthetical/in-text citations and reference list errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 APA format for parenthetical/in-text citations and reference list errors

3 to >0 pts

Poor 0%–69%

Contains five or more APA format for parenthetical/in-text citations and reference list errors

5 pts

This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation

5 to >4.0 pts

Excellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors

4 to >3.5 pts

Good 80%–89%

Contains 1-2 grammar, spelling, and punctuation format errors

3.5 to >3.0 pts

Fair 70%–79%

Contains 3-4 grammar, spelling, and punctuation format errors

3 to >0 pts

Poor 0%–69%

Contains five or more grammar, spelling, and punctuation format errors that interfere with the reader’s understanding

5 pts

Total Points: 100

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Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay

Focused SOAP Note for Anxiety Disorder

Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay

Anxiety disorder in children is common, affecting an eighth of the population. According to the National Institute of Mental Health, children and adolescents aged 13-18 are the most affected, with a prevalence of 25.1% and a 5.9% lifetime prevalence for severe anxiety disorder (Wang et al., 2019). Anxiety disorders among children typically impair other psychopathologies and affect social, emotional, and academic functioning and development. This paper intends to offer a comprehensive pediatric patient assessment per the case video.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Identifying Data:

Name: Dev. Cordoba (D.C.)  DOB: November 29, 2016, Minor: Yes Age: 7 Years Gender: Male

Accompanied by: Mother

SUBJECTIVE:

CC: “My mum told me you will make me better.”

HPI: The patient, a seven years old boy, presents at the clinic in the company of his mother. The patient reports that the mother told him that visiting the practitioner would make him better. The patient states being worried about everything. The mother reports that the patient experiences a lot of bad dreams. The patient admits to dreaming a lot and getting lost, such that he cannot find his mom and little brother. These dreams appear almost every night. The patient also reports he cannot sleep without the lights and an open door to ensure his mom is around. He states that he worries about his mom and baby brother and whether they are okay while at school, and it is everything he can think about. The patient reports that fellow students do not like him and call him Mr Smelly. His mom said he does not take baths and has night accidents (he wets the bed). The patient feels sad and bad because his dad never comes home, and he fears his mom will one day not come home too. The patient struggles at school, having difficulties sitting still and focusing according to what the teacher tells him. He finds himself in trouble for looking out the window. The teacher moved closer to the patient’s sitting area to control his behavior. The patient reports that he threw a book at a fellow student. According to the mother, the patient is always anxious and worried about things like whether she will die or not pick him up at school. The mother also states that the patient feels she loves his brother more than him. According to the mother, the patient struggles to fall asleep and wakes up frequently. He claims to experience stomach aches and headaches almost daily as an excuse to get away from school. The mother reports unexplained weight loss, with the patient losing three pounds in the last three weeks. The patient is currently on DDVAP, but it is no longer working.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Past Psychiatric History:

General statement: The patient has not received any psychiatric evaluation or diagnosis before and is not under any psychiatric treatment or medication. It is the first time the patient is seeing a psychiatrist.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Caregiver: The mother is the caregiver.

            Hospitalization: Denied previous hospitalization

Medication trials: No previous medical trails

Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric diagnosis

Substance Current Use: Denies usage or exposure to any substance.

Medical History: Denies medical history.

  • Current Medications: DDVAP for bed wetting.
  • Allergies:
  • Reproductive Hx:

Development Milestones:

Development milestones met on time

Health Promotion:

Vaccination up to date

Sleeps 4-6 hrs./night

Has proper nutrition per PCP.

Family Psychiatric/Substance Use History: No history of mental illnesses in the family. The mother is alive and well. The father died on military duty, but the patient believes he went on vacation and left them.

Psychosocial History: The patient lives with his mother, baby brother, and Sparky, his pet dog. The patient says his mum spends more time with his baby brother. The patient likes petting and playing with the dog and building Lego.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

ROS:  

General: Reports unexplained weight loss, 3 pounds in the last three weeks. Denies fever, chills, weakness, or fatigue.

HEENT: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, and odd color.

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports difficulties concentrating, paying attention, or staying still in class.  (Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies Sweating, No reports of cold or heat intolerance. No polyuria or polydipsia.

Psychiatric: Reports a worried and anxious mood, worrying every time and about everything. The patient has bad dreams that keep him awake. The patient has difficulty falling and staying asleep. Denies self-harm.    (Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

OBJECTIVE:

Vital signs: Stable

Temp: 97.4F

            B.P.: 100/80

            P: 58

             R.R.: 14

             O2: Room air

             Pain: 0/10

             Ht: 4’5 feet

             Wt: 65 lbs

             BMI: 16.3

             BMI Range: Healthy weight

Physical Exam:

General appearance: The patient is alert and oriented to self, date, and place. The patient looks well-fed and in good health. His conversation and engagement with the interviewer are regular, and he responds well to the questions, requiring no intervention from the mother to help answer the questions or ask the patient to answer. The patient was fully attentive during the interview.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: Although the patient’s heartbeat and rhythm are regular, murmurs and other sounds are coming from his chest. The patient’s heart rate is constant, and capillaries refill in two seconds.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is regular. His concentration and attention are impaired, and she struggles with school.    

Psychiatric: The patient has an anxious, worried, and sad mood. The patient indicates aggressive behavior.

Neuropsychological testing: The patient has difficulties executing schoolwork. (Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Labs:

Urinalysis: The patient needs a test to diagnose the bed-wetting problem further.

Diagnostic Results:

Hamilton Anxiety Rating Scale (HAM-A):

HAM-A is used to determine generalized anxiety symptoms with a rating scale ranging from 0 = not present to 1 = mild, 2 = moderate, and 3 = severe (Baker et al., 2019). The patient was asked questions on anxious mood, tension, fears, insomnia, intellectual, depressed mood, somatic muscular, somatic sensory, cardiovascular symptoms, respiratory symptoms, gastrointestinal symptoms, genitourinary symptoms, autonomic symptoms, and behavior at the interview was observed. The total score was 25, indicating severe anxiety.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Adjustment Disorder – New Module 20:

             ADNM–20 scale helps measure adjustments by inquiring about symptoms like preoccupation with the stressor and failure to adapt and additional symptoms like avoidance, depressed mood, anxiety, and impulsive disturbance. It also inquires about the frequency and longevity of these symptoms to determine severity (Lorenz et al., 2019). The mother was involved in helping the patient complete the assessment. The patient scored a total of 36.4. The results indicate that the patient did not reach the cut-off score 47.5, implying moderate symptoms.    (Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay) 

ASSESSMENT:

Mental Status Examination:

The patient is a 7-year-old male presenting with a worried and sad mood. The patient is worried all the time and about everything. The patient worries while at school about his mother and baby brother and what they are doing. The patient is sad about the dad leaving them and worries the mother will leave him too. The patient was cooperative during the interview, answering questions appropriately. The patient was alert and oriented to self, date, and place. The patient denies self-harm.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Diagnostic Impression:

  1. 9. Anxiety Disorder (Confirmed Diagnosis)
  2. 9. Attention-Deficit Hyperactivity Disorder
  3. 23. Adjustment Disorder
  4. F41.9. Anxiety Disorder (Confirmed Diagnosis): The patient indicates signs of anxiety disorder. The patient is worried all the time and about everything. The patient worries while in school about his mother and baby brother, and it is everything he can think about. He worries that his mother might die or she will not pick him up at school one day. The patient feels sad and bad about his father leaving them and worries that his mother will leave him too. He is struggling at school, and according to the teacher, he struggles with concentration and cannot stay still, always looking outside the window. He has difficulties sleeping, experiences bad dreams, and sleeps with the lights on. The patient also sleeps with the door open to feel his mother’s presence. The patient feels unwanted at school and gets bullied, nicknamed Mr Smelly because, according to the mother, he does not bathe and still wets his bed. People with anxiety disorder frequently anticipate disaster and are overly concerned with everyday events such as work (Bhatia & Goyal, 2019). Anxiety disorder is diagnosed when a person cannot control their worrying; the diagnosis was confirmed.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  5. F90.9. Attention-Deficit Hyperactivity Disorder: The patient also indicates signs of attention-deficit hyperactivity disorder. The patient’s concentration and attention are impaired, and he cannot stay still at school. He also struggles at school and is bullied for smelling unpleasant. The patient appears to have impaired functioning because, according to the mother, he rarely takes baths. DSM-5 diagnostic criteria for children with ADHD include a pervasive inattention and/or hyperactivity-impulsivity pattern interfering with functioning or development as indicated by inattention, with six or more symptoms persisting for a minimum of six weeks to a point it is inconsistent with developmental level and adverse affects directly social and academic activities, including often failing to offer close attention to details and committing careless mistakes in assignments and homework or during other activities, difficulty maintaining attention in tasks or play, seeming not listening when spoken to directly, failing to follow through instructions or finishing schoolwork, problems with task an activities organization, avoiding or being reluctant to engage in issues calling for sustained mental effort, losing things needed for particular tasks, being easily distracted by external stimuli, and indicating forgetfulness in daily activities (Abuse & Administration, 2019). This diagnosis was refuted because the patient does not meet the DMS-5 criteria for ADHD.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  6. F43.23. Adjustment Disorder: The patient also shows signs and symptoms of adjustment disorder. The patient experienced a stressful event; his father left them and never returned. Most of the worries the patient experiences are connected to this event, and he fears the mother will also leave him one day. Adjustment disorder occurs when a person has trouble adjusting after a stressful event at a degree disproportionate to the severity or intensity of the stressor. It is also a maladaptive emotional and/or behavioral reaction to a recognized psychosocial stressor. Stress responses that are inconsistent with socially or culturally expected responses to the stressor and/or that significantly affect everyday functioning are characteristics of A.D. symptoms (O’Donnell et al., 2019). Per the DSM-5 criteria, a diagnosis is established when an individual indicates emotional or behavioral symptoms development to respond to stressor(s) occurring within three months of the stressor(s) onset. The second criterion requires the symptoms to be clinically significant, as indicated by considerable stress that is unproportional to the stressor(s) severity or intensity, considering external context and cultural aspects that would influence symptom severity and presentation and the patient to indicate severe impairment in social, occupation, and other fundamental functioning areas (Abuse & Administration, 2022). The patient failed in all criteria; hence the diagnosis was refuted.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Case Formulation and Treatment Plan:

D.C. experiences pervasive worrying and reports a sad mood because the father left them and has never returned home. The patient worries about everything, especially her mother leaving or dying. D.C. struggles in school because he thinks about his mother and baby brother and their actions. He pretends to be sick to go home while at school, and he cannot stay still or concentrate, always looking outside the window. This symptomology indicates potential anxiety disorder. The patient would benefit from combining pharmacological interventions, psychotherapy, and patient education.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Pharmacological Intervention

Although not recommended as a first-line treatment in children, medication can also address anxiety disorders in children. The patient can be prescribed low doses of anti-depressants, Zoloft specifically, to reduce anxiety symptoms. 

Psychotherapy

Psychotherapy should be the first-line treatment for anxiety disorder in children because rarely is medication recommended. Behavioral psychotherapy is needed to enhance executive function and improve anxiety symptoms. Anxiety symptoms can be reduced with the help of psychosocial interventions, such as short-term psychodynamic psychotherapy, applied relaxation interpersonal psychotherapy, and social skills training. Cognitive-behavioural therapy will help reduce restlessness sensations that arise when performing tasks and at school and improve concentration and attention (Lopez et al., 2018).(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Patient Education

  • Talk to the patient and parent about the risks and benefits of medication, including non-treatment and probable side effects.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)
  • Discuss with the patient and parent when to stop the medication, how to recognize it, and when to report adverse events.
  • Talk to the patient and parent about the dangers of combining prescription pharmaceuticals with other substances.
  • Educate patient and parent to develop structured daily routines and schedules and minimize changes.
  • Engage the patient in skills training.
  • Encourage parent to make time for physical activities daily.
  • Advice parent to spend more time with the patient(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Follow-up: The patient should follow up after one week.

Referral: The patient should see a pediatric urologist with expertise in bed-wetting.

Reflection:

Lessons Learned and What I would do Differently

The interview was successful, and the data collected was comprehensive enough to make a diagnosis and create a treatment plan. The patient was cooperative and answered every question appropriately. The mother also provided valuable insights into the patient’s current condition and state. The patient indicates signs of anxiety disorder. Anxiety in children is a problematic condition that can affect functioning, academic performance, social relationships, and self-care. The patient exhibits constant worrying, anxiety, and sadness. He feels unloved and unwanted, detrimental to a child’s development and normal functioning. The patient is 7, and addressing this problem early would allow him to grow and develop normally and improve his mood. This case shows parental presence and communication can impact a child’s mental health. Most parents do not know how to communicate complex issues like death with their children, and their delivery or disclosure can affect how the child perceives and reacts to the message. In this case, the patient’s worries and anxiety are associated with thinking the father left them when the reality is that he died in the war. It also offers insights into the impact of anxiety and stress on a child, even as young as seven years, considering that prevalence is high between 13-15 years. If given another chance with the patient, I would inquire about more information from the school teacher to gain in-depth insights into the patient’s behavior and attitude at school and academic performance.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Ethical/Legal Considerations

Working with children can be challenging because of the ethical and legal considerations that require the practitioner to obtain informed consent from the parent, promote patient autonomy, ensure no harm, maintain veracity, and treat the patient with dignity and respect. Children cannot consent; hence it is ethical to be accompanied by a consenting adult, and the parent approves every decision. Maintaining veracity and objectivity is critical to establish patient trust, even when the truth might lead to distress (Varkey, 2021). The practitioner should also ensure privacy and confidentiality and obtain consent when sharing the patient’s medical data. (Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Health Promotion and Disease Prevention

           The mother needs to develop meal plans, physical activity routines, family activities and plans, and communication strategies to help address D.C.’s psychological and functional impairment. Meal plans would help address the weight loss experienced in the last three weeks. The patient needs physical activities linked to improved mood and a focused mind (Singh et al., 2023). The patient thinks the mother loves his brother more. Therefore, organizing family activities like playing together, going to fun packs, watching, and doing school work together can help improve relationships and demonstrate love. The mother needs to learn how to communicate with the patient and remain honest and sensitive while disclosing issues like his father’s death because he will continue to worry about his mother leaving until the patient knows the truth about what happened.(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

References

Baker, A., Simon, N., Keshaviah, A., Farabaugh, A., Deckersbach, T., Worthington, J. J., Hoge, E., Fava, M., & Pollack, M. P. (2019). Anxiety Symptoms Questionnaire (ASQ): development and validation. General psychiatry32(6), e100144. https://doi.org/10.1136/gpsych-2019-100144(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Bhatia, M. S., & Goyal, A. (2019). Anxiety disorders in children and adolescents: Need for early detection. Journal of postgraduate medicine64(2), 75–76. https://doi.org/10.4103/jpgm.JPGM_65_18

Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2019). Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database of systematic reviews3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2

Lorenz, L., Bachem, R. C., & Maercker, A. (2019). The Adjustment Disorder–New Module 20 as a Screening Instrument: Cluster Analysis and Cut-off Values. The international journal of Occupational and environmental medicine7(4), 215–220. https://doi.org/10.15171/ijoem.2019.775(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2022). Attention deficit hyperactivity disorder (ADHD).

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International journal of environmental research and public health16(14), 2537. https://doi.org/10.3390/ijerph16142537

Singh, B., Olds, T., Curtis, R., Dumuid, D., Virgara, R., Watson, A., Szeto, K., O’Connor, E., Ferguson, T., Eglitis, E., Miatke, A., Simpson, C. E., & Maher, C. (2023). Effectiveness of physical activity interventions for improving depression, anxiety and distress: An overview of systematic reviews. British Journal of Sports Medicine, by sports-2022-106195. https://doi.org/10.1136/bjsports-2022-106195

Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice: international journal of the Kuwait University, Health Science Centre30(1), 17–28. https://doi.org/10.1159/000509119(Comprehensive Focused SOAP Note for Anxiety Disorder Nursing Essay)

Wang, Z., Whiteside, S., & Sim, L. (2019). Anxiety in Children. Rockville (M.D.): Agency for Healthcare Research and Quality (U.S.). https://www.ncbi.nlm.nih.gov/books/NBK476265/

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