Development of a Practice Focused Framework Assignment Paper

NRNP 6645 Psychotherapy with Multiple Modalities

SUBJECTIVE DATA

Chief Complaint: “Referred for treatment due to impulsivity.”

History of Presented Illness

The client SG is a 19-year-old-female. The client is presented to the clinic for being impulsive. She uses her mother’s credit card to order gifts and other items for her friends. Consequently, the mother cut SG off from using the credit card. The mother has referred her for treatment due to impulsivity, which started when she was a young child. The mother reported that SG has an 8-month-old daughter. She was recently beaten up by the father to her daughter upon visiting him. The mother added that SG was going out with different men before becoming pregnant. Her mother also revealed that the client had once tried to jump out of a moving car. SG’s mother and mother’s boyfriend have been taking care of her baby. Development of a Practice Focused Framework Assignment Paper

Medications: Psychotropic and she was noncompliant

Psychotherapy or previous psychiatric diagnosis: No history of psychiatric diagnosis or psychotherapy.

Social History: The client lives with her mother, her biological siblings, her step father, three step siblings, and her 8-month-old baby girl. Her biological father died when SG was 13.

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Reproductive history: Before getting pregnant, the client had breast implants. She removed them during her pregnancy since they were causing some health issues. She has a 8-month-old daughter.

ROS

General: She denies weakness or fatigue.

Skin: She denies skin rashes.

HEENT: The client denies head injuries. She denies blurred vision. She denies hearing difficulty. She denies nasal congestion. She denies difficulty swallowing.

Respiratory: Denies wheezing sound.

Cardiovascular: Denies shortness of breath.

Gastrointestinal: Denies constipations.

Genitourinary: Denies blood in the urine.

Peripheral Vascular: Denies changes in temperature.

Musculoskeletal: Denies back pain.

Neurologic: Denies numbness.

Hematologic: Denies bleeding.

Endocrine: Denies increased hunger or thirst.

Psychiatric: Denies suicidal ideations. Reports impulsivity.

OBJECTIVE DATA

Physical exam

General: The client is a 19yo female. The client seems to be well-developed, nourished, and healthy. She is appropriately dressed for today’s weather. She seems to be easily distracted and her mother answers most interview questions on her behalf. She seem to be in mild distress. Development of a Practice Focused Framework Assignment Paper

Vitals: Temp-97.4*F, B/P-128/80, HR-96, RR-19, Pulse Ox-99%, Weight – 178 lbs, Height – 5′ 8″ and BMI score of 27.1

Skin: No rashes or swellings.

Head: Long, brown, and evenly distributed hair. Both eyes are sensitive to light. No drainage noted on both ears. No external lesions on her nose. No bleeding gums or mouth ulcers.

Neck: Trachea is midline

Breasts: No masses on both breasts.

Respiratory: Lungs clear to auscultation

Cardiovascular: Regular heart rhythm.

Gastrointestinal: Non-tender abdomen.

Genitourinary: No blood seen in the urine.

Musculoskeletal: Normal motor strength                                                                                                                                                                                          Neurological: Symmetrical movement present

Psych: Impulsive and mild distress.

Diagnostic results

ASSESSMENT

Possible Diagnosis

Three potential diagnoses for this client starting with the highest to lowest priority are as listed below.

1. Antisocial personality disorder
2. Borderline personality disorder
3. Dependent personality disorder Development of a Practice Focused Framework Assignment Paper

Primary Diagnosis

Antisocial personality disorder is the primary diagnosis for this client. According to DSM-5 diagnostic criteria, this personality disorder is characterized by antisocial behavior, hostility, deceitfulness, irresponsibility, manipulativeness, risk-taking behaviors, impulsivity, aggression, irritability (Van den Bosch et al., 2018). The client reported most of these symptoms, including impulsivity, which started when she was a young child. Additionally, the client depicts irresponsibility by using her mother’s credit card to buy gifts and other items to her friends. The client also demonstrates risk-taking behaviors by jumping out of a moving car and having unprotected sex with different men before getting pregnant. Therefore, the primary diagnosis for this client aligns with DSM-5 diagnostic criteria for antisocial personality disorder.

Differential Diagnosis

Borderline personality disorder is another potential diagnosis for this client. This personality disorder is characterized by fear of abandonment, unstable relationships, impulsive, self-destructive behaviors, self-harm, extreme emotional swings, or explosive anger (Bozzatello et al., 2021). The client might have this disorder since she reported impulsivity, unstable relationships, and self-destructive behaviors, which was depicted by jumping out of a moving car. However, this disorder is ruled out due to absence of fear of abandonment, which is the most significant symptom of borderline personality disorder.

Dependent personality disorder is another possible diagnosis for this client. The client also qualifies for this diagnosis, which is characterized by avoidance of personal responsibility, feeling helpless when relationships end, oversensitivity to criticism, and trouble making everyday decisions (Bornstein, 2020). The client might have this disorder due to avoidance of personal responsibility, which is depicted by failure to take care of her baby. The client also feels helpless when relationships end, thus following her baby’s dad who beats her up. However, this condition is ruled out since it is not characterized by impulsivity, which is client’s chief complaint. Development of a Practice Focused Framework Assignment Paper

TREATMENT PLAN

The treatment plan for this client involves referring her to a psychotherapist for a talk therapy. According to Pi and Zuo (2021), talk therapy is effective in treating people with antisocial personality disorder. During the talk therapy, a psychologist listens to the issues raised by the client and try to influence him or her to think positively. The client will be scheduled a follow-up clinic in every four weeks to allow the psychotherapist monitor her progress.

REFLECTION

Managing client’s condition focuses on providing her with holistic healthcare to improve her health status, quality of life, and life. Thus, treatment of this client should consider the HealthyPeople 2030 social health determinates. Gómez et al. (2021) indicated that conditions and environments in which individuals are born and live significantly impact their health. Thus, client’s health is influenced by social determinants of health.

References

Bornstein, R. F. (2020). Dependent personality disorder. The Wiley Encyclopedia of Personality and Individual Differences: Clinical, Applied, and Cross‐Cultural Research, 193-198.

Bozzatello, P., Garbarini, C., Rocca, P., & Bellino, S. (2021). Borderline Personality Disorder: Risk Factors and Early Detection. Diagnostics, 11(11), 2142.

Gómez, C. A., Kleinman, D. V., Pronk, N., Gordon, G. L. W., Ochiai, E., Blakey, C., … & Brewer, K. H. (2021). Practice Full Report: Addressing Health Equity and Social Determinants of Health through Healthy People 2030. Journal of Public Health Management and Practice, 27(6), S249.

Pi, M., & Zuo, Y. (2021, December). Responding to the Antisocial Personality Disorder and Narcissistic Personality Disorder: Etiology, Challenges, and Treatment. In 2021 4th International Conference on Humanities Education and Social Sciences (ICHESS 2021) (pp. 1899-1902). Atlantis Press.

Van den Bosch, L. M. C., Rijckmans, M. J. N., Decoene, S., & Chapman, A. L. (2018). Treatment of antisocial personality disorder: Development of a practice focused framework. International journal of law and psychiatry, 58, 72-78.

Week 7 – Assignment 2: Comprehensive Psychiatric Evaluation Note
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided.
To Prepare
• Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
• Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide.
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
RUBIC
Excellent
Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent histories and/or ROS Development of a Practice Focused Framework Assignment Paper
9 (9%) – 10 (10%)
The psychiatric evaluation accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.
Discuss Objective data:
• 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
9 (9%) – 10 (10%)
The psychiatric evaluation accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable
Discuss results of Assessment:
• Results of the mental status examination
• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
18 (18%) – 20 (20%)
The video accurately documents the results of the mental status exam.
Psychiatric evaluation presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.
Discuss treatment Plan:
• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals
18 (18%) – 20 (20%)
The psychiatric evaluation clearly and concisely outlines an evidence-based treatment plan for the patient that addresses treatment modality, psychotherapy choice with framework principles, and rationale.
Discussion includes a clear and concise follow-up plan and parameters.
The discussion includes a clear and concise referral plan.
Reflections on this case.
Points Range: 5 (5%) – 5 (5%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.

Reflections contain all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field. Development of a Practice Focused Framework Assignment Paper

Comprehensive Psychiatric Evaluation documentation
18 (18%) – 20 (20%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. Development of a Practice Focused Framework Assignment Paper

Resources

Document: Comprehensive Psychiatric Evaluation Note Template (Word document)

Document: Comprehensive Psychiatric Evaluation Note Exemplar (Word document)

Required Media (click to expand/reduce)

Classroom Productions. (Producer). (2016). Impulse and conduct disorders [Video]. Walden University.

Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinar [Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE

IDENTIFIED PATIENT

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SG IS A 19-YEAR-OLD-FEMALE WHO LIVES WITH HER MOTHER, STEPFATHER, THREE BIOLOGICAL SIBLINGS AND 3 STEPCHILDREN. SG HAS BEEN IMPULSIVE BY ORDERING MANY ITEMS, GIFTS FOR FRIENDS USING HER MOTHER’S CREDIT CARD. HER MOTHER CUT HER OFF FROM USING THE CREDIT CARD. MOTHER REFERRED HER FOR TREATMENT. MOTHER REPORTS SG HAS HAD PROBLEMS WITH IMPULSIVITY SINCE A YOUNG CHILD. SG’S FATHER DIED WHEN SHE WAS 13.

SG HAS AN 8-MONTH-OLD BABY GIRL. THE PATIENT WENT TO SEE THE FATHER OF THE BABY RECENTLY AND HE BEAT HER UP. MOTHER REPORTS SG WAS GOING OUT WITH DIFFERENT MEN AND THEN GOT PREGNANT. ADDITIONALLY, SG HAD BREAST IMPLANTS PRIOR TO GETTING PREGNANT. ONCE SHE WAS PREGNENT THEY CAUSED PROBLEMS AND THEY HAD TO BE REMOVED.
MOTHER REPORTS SG TRIED TO JUMP OUT OF A MOVING CAR ONCE. SG WAS ON PSYCHOTROPICS AT ONE TIME BUT DID NOT REMEMBER WHAT. SHE WAS NONCOMPLIANT. NO MEDICAL ISSUES WERE REPORTED.
SG’S MOTHER AND THE BOYFRIEND’S MOTHER ARE HELPING CARE FOR THE BABY. Development of a Practice Focused Framework Assignment Paper