Comprehensive Psychiatric Evaluation Nursing Essay Sample

Comprehensive Psychiatric Evaluation Nursing Essay Sample

Patient Initials: Y.U

Gender: Female

CC (chief complaint): “My wife complains that my facial expression is changing these days, that I am frowning too much or sticking out my tongue. All I know is that I am no longer outgoing.”(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

HPI: Y.U is a 47-year-old white male referred for psychiatric evaluation by PCP. His wife reports unusual frowning and waddle-like walking behavior. I know my finders keep shaking.” Y.U report abusing alcohol, tobacco, opioids, and cocaine to keep “sane.” The client reports involuntary rapid blinking eyes and trembling fingers for some months, which affects his inability to write steadily. He lost his job four months ago as an accountant and has since lacked the motivation to move. He no longer enjoys going out with the “big boys.” The wife reports hygiene issues and difficulty thinking and focusing. He is always thinking of losing his house since he no longer earns. The client also reports stiff and painful muscles that affect his ability to walk long distances as he used to.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Past Psychiatric History:

• General Statement: Entered treatment age of 17 for management of PTSD following an accident that left his parents and elder sister dead.
• Caregivers (if applicable):(Comprehensive Psychiatric Evaluation Nursing Essay Sample)
• Hospitalizations: The client was first hospitalized at age 17 and underwent successful knee surgery after an accident. The client was hospitalized following a suicide attempt three years later. The client was treated for severe and recurrent MDD and managed using Prozac.
• Medication trials: No medication trial was reported.
• Psychotherapy or Previous Psychiatric Diagnosis: The client has a history of PTSD, MDD, and Schizophrenia diagnosis, managed with medication and counseling.  (Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Substance Current Use and History: The client reports abusing multiple drugs:

Alcohol, last used today

Tobacco, last used today

Opioids were last used two days ago

Cocaine was last used two weeks ago.  

Family Psychiatric/Substance Use History: Denies family history of psychiatric diagnosis of substance use.

Psychosocial History: The client is married with two sons, aged 25 and 25, and a daughter, aged 18. The wife and children are alive and well. He is unemployed and lost his job four months ago as an accountant. He enjoys adventure, although he has not gone on an adventure for the past two years.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Medical History:

• Current Medications: Rispiredal 2 mg/day once daily for the management of Schizophrenia, Prozac 20 mg P.O. qDay for MDD, and Sertraline 50 mg P.O. qDay for PTSD.
• Allergies:NKFA.
• Reproductive Hx:Sexually active.

ROS:

GENERAL: No weight loss, fever, or chills. Reports frequent weakness and fatigue.

HEENT: Eyes: No problem with vision. Ears, Nose, Throat: No hearing loss, nasal congestion, or difficulty swallowing.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, pressure, or discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain.

GENITOURINARY: Burning on urination, urgency, or hesitancy.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

NEUROLOGICAL: Reports numbness after prolonged sitting. No current headache or history of syncope or paralysis. No change in bowel or bladder control.

MUSCULOSKELETAL: Reports muscle stiffness and joint pain. Denies back pain.  

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Physical exam: N.A.

Diagnostic results:

Lab findings WNL

Tox screen: Positive for alcohol, opioid, and nicotine.

Assessment

Mental Status Examination: The client is a 47-year-old male who looks slightly older than the stated age. The client is well-groomed and appropriately dressed. The client is alert and oriented. Finger tremors and tongue sticking is noted throughout the examination. The client is cooperative, attentive, and conversant. The speech is slightly clear and coherent with low volume and tone. His thought process is logical and goal-directed. There of no flight of ideas. The mood is depressed, and his affect is congruent with the mood. Denies visual or auditory hallucinations. Denies delusional thought patterns. He denies present suicide or homicide ideation. His memory is recent and intact. His concentration and insight are good.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Differential Diagnoses:

1. 333.85 (G24.01), Tardive Dyskinesia – Tardive dyskinesia is characterized by the choreiform or involuntary athetoid movements of the lower face, tongue, and extremities, including the trunk, pharyngeal, or diaphragmatic muscles (American Psychiatric Association, 2019) These symptoms develop flowing medication use and persists more than 4 to 8 week.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)
2. 332.1 (G21.19), Other Medication-Induced Parkinsonism (709) – Medication-induced Parkinsonism is characterized by muscular rigidity, difficulty initiating movement/loss of movements (akinesia), slow motion (bradykinesia), or tremor that started following medications, including neuroleptics (APA, 2019). The symptoms may occur weeks after treatment initiation, tapering, or increasing dosage.
3. 333.99 (G25.71 ), Tardive Akathisia – Tardive akathisia is characterized by various involuntary movements, which can be akathisia (inability to sit still/restlessness affecting lower limb) or dystonia (involuntary contraction of muscles) (APA, 2019).(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Plan

Pharmacotherapy

Start Tetrabenazine 6 P.O. qDay. Tetrabenazine is indicated for tardive dyskinesia treatment (Niemann & Jimenez-Shahed, 2019). It is effective and well-tolerated (Niemann & Jimenez-Shahed, 2019). Antidepressants enhance the antipsychotic-like effect of risperidone and vice versa (Alhomrani et al., 2022).  This might increase the chances of developing medication-induced side effects (Ricciardi et al., 2019). Taper the current dosage for Risperdal and re-evaluate Schizophrenia symptoms after four weeks to avoid relapse.  (Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Psychotherapy

Starting cognitive behavioral therapy is recommended for this client. CBT effectively reduces tardive dyskinesia symptoms (Shou et al., 2022). In addition, the client would learn about symptoms and how to cope with them.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Patient Education

Educate the patient on the risk and benefits of medication. Educate the patient on the impact of drug and substance abuse on his mental health outcomes. Warn the patients of worsening symptoms with tapering of dosage. Talk to the patient and the wife about tardive dyskinesia and the symptoms(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Reflections

Tardive dyskinesia is the primary diagnosis based on the client’s symptoms. The client’s tremor affects his upper limbs and eyelids, and he reports facial frowning and tongue sticking, which are primary symptoms of tardive dyskinesia (Sadock et al., 2015). Parkinson’s disease is a secondary diagnosis since symptoms are well explained by tardive dyskinesia. Tardive akathisia is refuted and considered a secondary diagnosis due to its late onset during treatment and persistent nature (months or years) with or without dosage reduction or discontinuation. Besides, Tardive akathisia is associated with muscle restlessness in the lower limb, which the client does not show. However, comprehensive information is necessary to ascertain this diagnosis considering the potential symptoms have started way back when the client first entered treatment or during subsequent treatment. Therefore, a focused and comprehensive neurological evaluation and additional family history are crucial in diagnosing tardive dyskinesia (Sadock et al., 2015).(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

The prevalence of medication, including movement disorders, is associated with the dosage before discontinuation, the half-life of the medication, and other mediating genetic factors (APA, 2019). Although little is now of its course development, the impact decreases over time with dosage tapering. The role of mental health care practitioners is to demonstrate competency in diagnosis and treatment planning, which are crucial to positive health outcomes. Therefore, the ethical and legal concerns ins this case are primarily informed consent and nonmaleficence, to inform the client of his condition, available medication, risks and benefits, and obligation to avoid harm, respectively. The primary diagnosis results from the side effect of antipsychotic medication, and the mental health practitioner must adopt an appropriate way to minimize pharmacological interactions and side effects. Given a similar case, I would obtain additional family history and review medication interactions to ensure proper tapering and discontinuation and avoid further risks of symptom exacerbation. (Comprehensive Psychiatric Evaluation Nursing Essay Sample)

References

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Ricciardi, L., Pringsheim, T., Barnes, T. R., Martino, D., Gardner, D., Remington, G., … & Edwards, M. (2019). Treatment recommendations for tardive dyskinesia. The Canadian Journal of Psychiatry, 64(6), 388-399. (Comprehensive Psychiatric Evaluation Nursing Essay Sample)https://doi.org/10.1177%2F0706743719828968

Shou, S., Li, Y., Fan, G., Zhang, Q., Yan, Y., Lv, T., & Wang, J. (2022). The Efficacy of Cognitive Behavioral Therapy for Tic Disorder: A Meta-Analysis and a Literature Review. Frontiers in Psychology, 13, 851250-851250. (Comprehensive Psychiatric Evaluation Nursing Essay Sample)https://doi.org/10.3389/fpsyg.2022.851250

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral Sciences/Clinical Psychiatry (11th ed.). Wolters Kluwer.(Comprehensive Psychiatric Evaluation Nursing Essay Sample)

Alhomrani, M., Alsanie, W. F., Alamri, A. S., Alyami, H., Habeeballah, H., Alkhatabi, H. A., … & Gaber, A. (2022). Enhancing the Antipsychotic Effect of Risperidone by Increasing Its Binding Affinity to Serotonin Receptor via Picric Acid: A Molecular Dynamics Simulation. Pharmaceuticals, 15(3), 285. (Comprehensive Psychiatric Evaluation Nursing Essay Sample)https://doi.org/10.3390/ph15030285

Niemann, N., & Jimenez-Shahed, J. (2019). Deutetrabenazine in the treatment of tardive dyskinesia. Neurodegenerative Disease Management, 9(2), 59-71. https://doi.org/10.2217/nmt-2018-0042