Comprehensive Psychiatric Evaluation-Nursing Paper Sample

Comprehensive Psychiatric Evaluation-Nursing Paper Sample

Patient Initials: K.W.

Gender: Male

SUBJECTIVE:

CC: ‘“My anxiety is getting worse every day. I have had anxiety before, and lately I have struggled to concentrate on one activity. How can you help reduce my anxiety and maintaining my focus?”’(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

HPI: 26 years old male Mr. K.W. formerly struggled with anxiety and ADHD. According to the patient, he has had ADHD since he was a little child. When he was younger, his mother claimed that he was “everywhere, jumping objects,” but his illness was not discovered until 2021. The patient said he attended the facility to “maintain his sobriety,” that he is currently “trying to deal with things” on his own, and that he would like to take medication to help him focus. The patient, who is a resident of a drug rehab center, states that he is undergoing treatment since it is a prerequisite for him to go back to his mother’s house.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Social Hx: Wyatt, a US-born Hispanic man, 26 years old and unmarried. He spent his youth and adolescent years living with his mother because his parents were never married. The patient stated that although he just graduated from high school, he would like to finish his education by obtaining a college degree. He currently resides in a rehab center for drug abuse. He enjoys reading, talking to people, and fishing.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Legal Hx: The patient reports breaking into his friend’s home and stealing his father’s cannabis when he was 14 years old. He was detained but not taken to jail.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Medical Hx: Denied

Surgical Hx: Appendectomy in 2017

Psychiatric Hx: Patient reports Anxiety and ADHD hx. Patient denied family history of mental illness.

Psychiatric medication use: Adderall 30 mg daily, Xanax 1 mg daily, Clonidine 0.1 mg daily (at night).

Substance Abuse hx: Patient confessed taking multiple recreational drugs, for example:(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Marijuana, last used one month ago.

Cocaine, last used a two ago

Heroine, last used 3 years ago

Xanax, last used one week ago (Patient was not prescribed Xanax and he is getting it from a friend).

MSE: Mr. Wyatt arrived for a mental assessment. The patient was dressed appropriately for the environment and the time of year. Despite being highly talkative, he sat for the rest of the interview and was obedient. He also displayed no signs of discomfort. The patient denied having hallucinations, suicidal or homicidal thoughts, paranoia, insomnia, appetite loss, or auditory or visual hallucinations.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

ROS:

General: Denies weight loss, 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 Psychiatric Evaluation-Nursing Paper Sample)

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.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, 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 and paying attention.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

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

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

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

OBJECTIVE:

Vital Signs

Temp: 98.3 F

            BP: 117/59

            HR:71

             R: 18; non-labored

             O2: 96% room air

             Pain: Negative

             Ht:5ft, 2 inches

             Wt.: 162 pounds.

             BMI:29.6

             BMI Range: Overweight      

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

HCG: N/A

Physical Exam:

General appearance: The patient appears well-fed and healthy. He routinely engages in discussion with the medical personnel, although he often interrupts the conversation or changes the topic to a subject he is interested in.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

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.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Cardiovascular: Although the patient’s heartbeat and rhythm are regular, there are murmurs and other sounds coming from his chest. The patient’s heart rate is constant and capillaries refill in two seconds.  (Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

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 clear.

Psychiatric: The patient’s fast switching from one discussion or topic to another indicates inattentiveness. Patient is easily distracted, yet occasionally appears to pay attention to the caregiver.

Neuropsychological testing: Patient has difficulties executing functions where he is required to prioritize, plan, inhibit behavior, and attend to processing speed.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Diagnostic results:

ASSESSMENT:

Mental Status Examination:

Patient appears aware and alert of place, situation, and self. The patient converses normally with the medical staff, but is more focused on conversations he is interested in. The patient is easily distracted and cannot maintain attention for elongated periods of time. Patient appears irritated about some questions, but answers well and appears well-informed of his condition. Patient is anxious and taps his hand on the chair. (Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Differential Diagnoses:

1. F90.9. Attention-Deficit hyperactivity disorder (Confirmed): Attention-deficit/hyperactivity disorder (ADHD), a chronic mental health condition that frequently becomes worse as people age, affects millions of children. ADHD’s enduring symptoms include hyperactivity, impulsive behavior, and difficulties paying focus. For those with ADHD, especially children, common issues include low self-esteem, troubled relationships, and lack of involvement (Magnus et al., 2017). The signs of adult ADHD include impulsivity, disorganization, poor time management, problems setting priorities, difficulty focusing, difficulties multitasking, excessive activity and restlessness, poor planning, and a low tolerance for annoyance.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

The patient reported feeling worried and asked for medication to help him focus. The DSM-5 diagnostic criteria for adults with ADHD entail five or more inattentional symptoms, a number of which must have appeared before 12 years, several of which must have appeared in two settings, evidence that the symptoms impair or negatively affect social, academic, or occupational functioning, and symptoms that do not only coexist with another psychotic disorder (Magnus et al., 2017). The patient demonstrates continuous loss of focus and attention and has previously been diagnosed with ADHD. The primary diagnosis, according to the examination, is ADHD.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

2. F41.9. Generalized Anxiety Disorder: Excessive, exacerbated anxiety and worry about things without a clear reason are characteristics of generalized anxiety disorder (GAD) (Munir et al., 2021). 3.1 percent of the population, or more than 6.8 million adults, are affected. Even while it can begin at any age and progress gradually, the risk is most between the ages of five and middle age. Biological variables, family history, life events, and other stressors all contribute to GAD, despite the fact that the exact cause is unknown (Toussaint et al., 2020). Looking for symptoms like excessive, persistent worry and tension, unrealistic views of problems, restlessness or a feeling of being “edgy,” difficulty focusing, easily becoming exhausted, increased crankiness or irritability, trouble sleeping, and muscle tension can help diagnose general anxiety disorder. People with GAD frequently see calamity coming and worry excessively about everyday occurrences like going to work. GAD is identified when a person has uncontrollable worrying.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)
3. F19. 20. Psychotic substance dependence: Addiction to psychoactive substances causes abnormal brain activity that interferes with normal emotional, motivational, and perceptual brain functions, which is what is known as substance dependency (de Matos et al., 2018). Dependencies on substances like alcohol, opioids, sedatives or anxiolytics, cocaine, cannabis, and amphetamines are a few examples. A diagnosis of psychotic substance dependence requires at least three of the following: a substance that is regularly consumed in large doses over an extended period of time; a persistent desire to stop using it; one or more unsuccessful attempts to do so; a period of time needed to obtain, use, or recover from its effects; frequent intoxication or withdrawal symptoms; and giving up or reducing significant social, professional, or recreational activities in order to use substances. The patient may develop dependent syndrome after a prolonged period. Because the patient does not exhibit heavy drug usage and dependence, this diagnosis was ruled out.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

PLAN:

Pharmacologic Interventions:

For patients with ADHD, pharmacological medication continues to be the primary form of treatment. It is separated into two main groups that can be either stimulants or non-stimulants (Magnus et al., 2017). Both classes of stimulants prevent dopamine from reabsorbing at the postsynaptic and presynaptic membranes. (Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

• Start Buspar 10 mg 1 tab PO BID.
• Venlafaxine 18.75-75 mg/day; increasing to 150 mg/day after 4 weeks
• Bupropion Initial: 150 mg/day PO(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)
• Imipramine 75 PO qDay initially; increasing to 150 mg/day gradually
• Metadate CD: Initial, 20 mg PO qAM before breakfast
• Atomoxetine 40 mg PO once daily initially; increasing after ≥3 days to 80 mg PO once daily or divided q12hr

Psychotherapy

The patient requires behavioral therapy to enhance executive function, reduce anxiety, and improve ADHD symptoms. Psychosocial interventions such short-term psychodynamic psychotherapy, applied relaxation interpersonal psychotherapy, and social skills training will help reduce ADHD and anxiety symptoms. Cognitive-behavioral therapy will helps reduce anxiety and restlessness sensations that arise when performing tasks, improve focus and time management, and improve mood (Lopez et al., 2018). The treatment plan will also include coaching.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Patient education

• Educate patient and family regardingt risks and benefits of medication, including non-treatment, possible side effects.
• Talk to patient and familu when to stop medication, how to identify and when to report adverse events.
• Educate patient and family concerning the dangers of combining prescription pharmaceuticals with OTC, illicit, or natural substances.
• Educate patient the importance of structured daily routines, daily schedule, and minimize changes and how to develop them.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)
• Engage patient in skills training.
• Encourage patient to exercise daily..
• Educate the patient to accept himself and his limitations and socialize with people.

Follow-up: Patient should follow-up after one week.

Reflections:

ADHD has symptoms that overlap those of anxiety disorders. ADHD begins in childhood and can progress into adulthood. Diagnosing ADHD in adulthood is challenging and requires a comprehensive patient history to determine whether the patient was diagnosed or experienced ADHD during childhood to meet the DSM-5 criteria. The patient admits to using substances, including cocaine and marijuana, that increase the risk of worsening ADHD and developing other mental disorders like depression. The healthcare plan should include strategies to address substance abuse and ADHD together. This case is an interesting one and a learning opportunity because most ADHD patient encounters involve children and adolescents. This case offers a chance to learn how ADHD affects adults and strategies to address it in adults. It is also an intriguing case because co-occurring substance abuse and mental health disorders pose unique challenges for mental health practitioners. It also enhances the understanding that the social, economic, and cultural environments significantly affect substance use and mental health. Given another chance with the patient, I would inquire more about substance abuse and the treatment progress at the facility because I understand that substance abuse can worsen ADHD symptoms. (Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

References

de Matos, M. B., de Mola, C. L., Trettim, J. P., Jansen, K., da Silva, R. A., Souza, L., Ores, L., Molina, M. L., Coelho, F. T., Pinheiro, R. T., & Quevedo, L. A. (2018). Psychoactive substance abuse and dependence and its association with anxiety disorders: a population-based study of young adults in Brazil. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999), 40(4), 349–353. https://doi.org/10.1590/1516-4446-2017-2258(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich-Bakmas, M., Rojas, J. I., Romano, M., & Manes, F. F. (2018). Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane database of systematic reviews, 3(3), CD010840. https://doi.org/10.1002/14651858.CD010840.pub2(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention deficit hyperactivity disorder (ADHD).

Munir, S., Takov, V., & Coletti, V. A. (2021). Generalized Anxiety Disorder (Nursing). StatPearls [Internet].

Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.(Comprehensive Psychiatric Evaluation-Nursing Paper Sample)

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