Psychiatric Advance Nursing Practicum
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. Psychiatric Advance Nursing Practicum
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 Psychiatric Advance Nursing Practicum
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).
(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
J.S is an 8-year-old, African American/Caucasian, male. Psychiatric Advance Nursing Practicum
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. Psychiatric Advance Nursing Practicum
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
Mother reports none.
Substance use history
Mother reports none. Psychiatric Advance Nursing Practicum
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.
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. Psychiatric Advance Nursing Practicum
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. Psychiatric Advance Nursing Practicum
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.
47 Height: inches
Temp: 37 C.
Pulse: 82 BPM
Appearance: Slender bi-racial male, slightly tan, appearing younger than stated age in distress, no acute distress, neatly dressed and groomed. Psychiatric Advance Nursing Practicum
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.
Z63.5 Disruption of family by separation and divorce
Seperation and Anxiety Disorder
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). Psychiatric Advance Nursing Practicum
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. Psychiatric Advance Nursing Practicum
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
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. Psychiatric Advance Nursing Practicum
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
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. Psychiatric Advance Nursing Practicum
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 Psychiatric Advance Nursing Practicum
Also check: Psychiatric Evaluation