{"id":265256,"date":"2024-01-12T07:38:25","date_gmt":"2024-01-12T07:38:25","guid":{"rendered":"https:\/\/nursingstudy.org\/?p=265256"},"modified":"2024-05-09T19:16:50","modified_gmt":"2024-05-09T19:16:50","slug":"initial-psychiatric-interview-comprehensive-nursing-essay-example","status":"publish","type":"post","link":"https:\/\/nursingstudy.org\/examples\/initial-psychiatric-interview-comprehensive-nursing-essay-example\/","title":{"rendered":"Initial Psychiatric Interview Comprehensive Nursing Essay Example"},"content":{"rendered":"\n

Initial Psychiatric Interview Comprehensive Nursing Essay Example<\/strong><\/h2>\n\n\n\n
Criteria<\/strong><\/td>Clinical Notes<\/strong><\/td><\/tr>
 <\/strong><\/td> <\/td><\/tr>
Informed Consent<\/strong><\/td>The patient provided verbal and written consent on psychiatric assessment process and the selected therapeutic interventions. The patient exhibits the ability to respond and comprehend the intervention\u2019s risks and benefits.(Initial Psychiatric Interview Comprehensive Nursing Essay Example) The psychiatrist and the patient will review any additional and necessary informed consent during the treatment plan development. (Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/td><\/tr>
Subjective<\/strong><\/td>Verify Patient \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Name: Aaron Boyne \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 DOB: April 17 , 1947 \u00a0 Minor: X Accompanied by\/A \u00a0 Demographic: Non-Hispanic White \u00a0 Gender Identifier Note: Male \u00a0 CC: The patient reports challenges remembering things and feeling confused for past one week. \u00a0 HPI: Boyne is a 74 year old Non-Hispanic White that visited the clinic accompanied by his older daughter complaining of memory loss and confusion in the past one week. The daughter provides that his father has lost concentration considerably and exhibits significant behavioral changes. She states that Boyne seems depressed since memory loss symptoms appeared and no longer socialize with people. The daughter notes that Boyne has diminished ability to perform activities of daily living such as bathing and feeding in the last one week.(Initial Psychiatric Interview Comprehensive Nursing Essay Example) The daughter reports not additional symptoms and that the patient has attempted medications to control the symptoms.\u00a0\u00a0 \u00a0 Pertinent history in record and from patient: He has a past medical history of osteoporosis, pneumonia, respiratory problems, T2DM, and HTN. \u00a0 \u00a0 \u00a0 During assessment: Patient described mood changes since the symptoms commenced. The patient stated difficulty concentrating, following a conversation, and being confused about time and place. The patient reported agitation due to inability to perform familiar tasks and misplacing things. He can start a conversation but he reported challenges following through to the end and the daughter had to intervene from time to time to help Boyne converse and construct meaningful sentences.\u00a0 \u00a0\u00a0 . \u00a0 Patient self-esteem appears fair although the patient reports slight loss of confidence and feeling insecure. The patient no longer feels in control of his activities and does not trust his judgement. The patient denied any feelings of excessive guilt, anhedonia, libido changes or energy changes. However, the patient reported sleep disturbances and reduced appetite. He reported changes in memory and concentration. There is no indication of an eating disorder despite lower appetite and he reported no significant recent weight loss or gain.\u00a0\u00a0 \u00a0 SI\/ HI\/ AV: Patient currently denies suicidal ideation, homicidal ideations, but confirms irritation and agitation from time to time. Patient denies violent behavior and inappropriate or illegal behavior. (Initial Psychiatric Interview Comprehensive Nursing Essay Example)\u00a0 Allergies: NKDA \u00a0 Past Medical Hx: Medical history: Positive for cardiac and respiratory issues but negative for endocrine and neurological issues, including history of head injury. Patient confirms struggling with pneumonia but reports negative for history of MRSA, TB, HIV and Hep C. Surgical history None \u00a0 Past Psychiatric Hx: Patient denies any previous mental health disorder but confirms negative diagnoses for depression. \u00a0<\/strong> Safety concerns:<\/strong> History of Violence to Self:\u00a0 none reported History of Violence to Others: none\u00a0 reported\u00a0\u00a0\u00a0\u00a0 Auditory Hallucinations: None Visual Hallucinations: None \u00a0 Mental health treatment history<\/strong> discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment : Reports history of marijuana and alcohol abuse \u00a0 Trauma history:<\/strong> Client confirms a history of few domestic violence incidences but does not report any history of abuse or witnessing disturbing events apart from a one-time road accident \u00a0 Substance Use:<\/strong> Client denies use or dependence on nicotine but confirms use of tobacco products in his youthful years. Client \u00a0reports abuse of or dependence on alcohol and marijuana in his younger years. \u00a0 Current Medications: Metformin and Lisinopril for T2DM and HTN. (Initial Psychiatric Interview Comprehensive Nursing Essay Example)\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 (Contraceptives): Vasectomy in 1997 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Supplements: Vitamin C, multivitamin, and calcium supplements \u00a0 Past Psych Med Trials: None reported \u00a0 Family Medical Hx: None reported \u00a0 Family Psychiatric Hx: None reported \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Substance use: Father \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Suicides None reported \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Psychiatric diagnoses\/hospitalization: Mother diagnosed for delirium drug intoxication \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Developmental diagnoses Normal development curve reported \u00a0 Social History: Occupational History: Currently Retired accountant Military service History: Denies military service hx. Education history:\u00a0 Completed HS and vocational certificate Developmental History: No significant details reported. \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 (Childhood History include in utero if available) Legal History: Reports involvement in a customer fraud case as a witness, no reported\/known conservator or guardian. Spiritual\/Cultural Considerations: Reports he is a Catholic \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 ROS: Constitutional:\u00a0 No report of fever or weight loss.\u00a0 Eyes:\u00a0 No report of acute vision changes but confirms eye pain.\u00a0 ENT:\u00a0 No report of hearing changes or difficulty swallowing.\u00a0 Cardiac:\u00a0 Positive.\u00a0 Respiratory:\u00a0 Reports struggling with pneumonia.\u00a0 GI:\u00a0 No report of abdominal pain.\u00a0 GU:\u00a0 No report of dysuria or hematuria.\u00a0 Musculoskeletal:\u00a0 Reports joint pain or swelling from a history of osteoporosis.\u00a0 Skin:\u00a0 No report of rash, lesion, abrasions.\u00a0 Neurologic:\u00a0 No report of seizures, blackout, numbness or focal weakness. \u00a0 Endocrine:\u00a0 No report of polyuria or polydipsia.\u00a0 Hematologic:\u00a0 No report of blood clots or easy bleeding.\u00a0 Allergy:\u00a0 No report of hives or allergic reaction. Reproductive: No report of significant issues. (Females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc\u2026) (Initial Psychiatric Interview Comprehensive Nursing Essay Example)\u00a0<\/td><\/tr>
Verify Patient: <\/em>Name, Assigned\u00a0identification<\/strong>\u00a0number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. \u00a0<\/em> Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.<\/em> \u00a0<\/em> HPI:<\/em> \u00a0<\/em> \u00a0<\/em> \u00a0<\/em> \u00a0<\/em> \u00a0<\/em> , Past Medical and Psychiatric History,<\/em> Current Medications, Previous Psych Med trials,<\/em> Allergies.<\/em> \u00a0Social History, Family History.<\/em> Review of Systems (ROS) \u2013 if ROS is negative, \u201cROS noncontributory,\u201d or \u201cROS negative with the exception of\u2026\u201d<\/em> (Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/td><\/tr>
Objective                 <\/strong><\/td>Vital Signs: <\/strong>Stable Temp: 97.5 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 BP: 123\/78 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 HR:81 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 R:19 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 O2: Room Air Pulse Ox 97 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Pain:3\/10 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Ht:72 inches \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Wt:175.2 pounds \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 BMI: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 BMI Range: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 LABS: Lab findings WNL Tox screen: Negative Alcohol: Positive HCG: N\/A \u00a0 Physical Exam: MSE: Musculoskeletal:\u00a0 (Initial Psychiatric Interview Comprehensive Nursing Essay Example) Pain in joints from history of osteoporosis Appearance:\u00a0 Appears withdrawn and depressed but alert, calm, and cooperative. Patient maintains minimal eye contact Psychomotor activity appears within normal Orientation<\/a>: Self and situation aware but impaired awareness of time and place Mood:\u00a0 Depressed and anxious Gait:\u00a0 Unsteady AIMS Done?:\u00a0 No Speech:\u00a0 Clear volume but troubled rhythm, rate, and problem expressing self. TC: No abnormal content elicited. (Initial Psychiatric Interview Comprehensive Nursing Essay Example) Process appears linear, coherent, and goal oriented. Thought process\/Associations:\u00a0 Loose concentration and confused thought process Abnormal\/Psychotic Thoughts:\u00a0 No Hallucination\/Delusion Attention: Slightly Impaired Concentration:\u00a0 Inconsistent Insight\/ judgement comment:\u00a0 Impaired but patient is able to articulate need. Insights appear fair. Cognition is impaired Fund of knowledge:\u00a0 Average Slightly impaired short-term memory and impaired long-term memory Language:\u00a0 Challenging word finding and sentence construction \u00a0(Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/td><\/tr>
This is where the \u201cfacts\u201d are located.<\/em> Vitals,<\/em> **Physical Exam (if performed, will not be performed every visit in every setting)<\/em><\/strong> Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.<\/em>(Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/td><\/tr>
Assessment<\/strong><\/td>DSM5 Diagnosis: with ICD-10 codes \u00a0 Dx: – Dementia F02.81 (confirmed) \u00a0 F02.81 indicate a diagnosis for reimbursement purposes and is dementia classified with behavioral disturbance in other diseases. Assessed memory loss, language, problem-solving, and other thought processes that are significant to interfere with the patient\u2019s daily life. Assessed difficulty speaking, difficulty complex tasks, challenging planning and organizing, confusion and orientation, common dementia signs and symptoms according to Kales et al. (2015).(Initial Psychiatric Interview Comprehensive Nursing Essay Example) Evaluated risk factors include heavy alcohol use, smoking, diabetes, physical exercise, age, and genetic history of dementia. Most clinical manifestations, confusion, difficulty in speech, memory loss, planning and organizing, disorientation, alcohol use, diabetes, and smoking, met the etiology of dementia hence it was confirmed. \u00a0 Dx: – Alzheimer\u2019s Disease ICD10: G30.9 ( refuted) \u00a0 Alzheimer\u2019s severity increases progressively through gradual development of dementia symptoms for a number of years (Weller & Budson, 2018). Its signs and symptoms may overlap with dementia. Assessed memory loss<\/a>, impaired behavior and thinking, judgement, loss of spontaneity, increased aggression and anxiety, disorientation, and mood and personality changes. Assessed risk factors, including age, gender, and family history. It was disapproved as the patient did not exhibit vascular vitamin deficiency\u00a0 Autoimmune, swallowing problems, infection like prion disease substance abuse, hormone hypothyroidism, electrolyte disturbance and depression \u00a0 Dx: – \u00a0Parkinson\u2019s Disease ICD10: G20 \u00a0 Parkinson\u2019s disease is also progressive and affects the brain\u2019s nerve cells that condition body movement. Assessed increased memory loss and confusion. (Initial Psychiatric Interview Comprehensive Nursing Essay Example)I assessed insomnia, thinking problems, anxiety, poor balance, tremors, and depression. Evaluate risk factors, including smoking, age, trauma, and genetic factors. Ruled out as the patient did not exhibit tremors, poor balance, insomnia, or depression.\u00a0 \u00a0 Dx: – Manic Depressive Disorder (refuted) \u00a0 The patient appeared depressed and withdrawn but the assessment ruled it out. The patient did not report any sustained mood swings, sadness, emptiness, hopelessness, frustration, and angry outbursts. The patient did not indicate loss of interest or pleasure to normal activities like sports and hobbies but confirmed reducing socialization. The sleep disturbances emerged in the last one week and did not confirm depression. Ruled out as the patient did not exhbit tremors. \u00a0 Patient has capacity to respond to psychiatric medications and psychotherapy and comprehends the benefits and risks for medications\/psychotherapy and is willing to adhere. Reviewed potential risks and benefits, boxed warnings, alternative being stopping treatment. .(Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/td><\/tr>
Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes<\/u>, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.<\/em>  <\/em> Informed Consent Ability<\/em><\/td><\/tr>
Plan<\/strong>  <\/strong> (Note some items may only be applicable in the inpatient environment)  <\/strong><\/td>\u00a0 Inpatient: Psychiatric.\u00a0 Dementia as per HPI. Estimated stay 2-6 days Patients need hospital stay to begin medications and monitoring of effectiveness and vital signs. Patient needs close supervision to assess changes and necessary alteration to the treatment plan. \u00a0 Safety Risk\/Plan:\u00a0 The patient is found to be stable and has control of behavior. Patient poses minimal to no risk to self and others. \u00a0 \u00a0 Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: Medication prescribed based on assessment outcomes Medication to calm dementia symptoms: Administer Aripiprazole 30 mg to affect receptors and calm dementia symptoms. (Initial Psychiatric Interview Comprehensive Nursing Essay Example) Administer Galantamine 4mg to restore the brain\u2019s neurotransmitters\u2019 balance and improve memory and ability to conduct activities of daily living and treat moderate confusion.\u00a0 Continue prescription for Metformin 250 mg for the patient\u2019s T2DM and HTN \u00a0\u00a0\u00a0\u00a0 Education, including health promotion, maintenance, and psychosocial needs: Educate the patient to: Ensure medication and treatment compliance to attain positive outcomes.Increase knowledge of risk factors and interventions like exercising regularly, controlled alcohol use, and promote sleep.Understand healthy dieting to promote memory, orientation, and healing and limit foods with high-cholesterol and saturated fats Safety planning including falls preventionEducate patient and family to monitor worsening vital sign and when to report to ED Referrals: Rehabilitation to address additional dementia symptoms<\/a> if they do not diminish or improve after 7 days of treatment. (Initial Psychiatric Interview Comprehensive Nursing Essay Example) Refer the patient to a geriatrician for a comprehensive assessment Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit one week Follow up set in 7 days \u00a0 \u00a0 \u2612 > 50% time spent counseling\/coordination of care. \u00a0 Time spent in Psychotherapy\u00a0 20 minutes \u00a0<\/strong> Visit lasted 75 minutes \u00a0 Billing Codes for visit:\u00a0\u00a0 XX XX XX \u00a0 \u00a0 ____________________________________________ NAME, TITLE \u00a0 \u00a0 \u00a0 Date: Click here to enter a date.\u00a0\u00a0\u00a0 Time: X \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n
\"Initial<\/figure>\n\n\n\n

References<\/h2>\n\n\n\n

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. Bmj, 350.(Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/p>\n\n\n\n

Weller, J., & Budson, A. (2018). Current understanding of Alzheimer\u2019s disease diagnosis and<\/p>\n\n\n\n

Treatment. F1000Research, 7.(Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/p>\n\n\n\n

Foley, T., & Swanwick, G. (2014). Dementia: diagnosis and management in general practice.\u00a0Irish College of General Practitioners Quality in Practice Committee: Dublin<\/em>.(Initial Psychiatric Interview Comprehensive Nursing Essay Example)<\/p>\n\n\n\n

National Center for Biotechnology Information (nih.gov)<\/p>\n","protected":false},"excerpt":{"rendered":"

Initial Psychiatric Interview Comprehensive Nursing Essay Example Criteria Clinical Notes     Informed Consent The patient provided verbal and written consent on psychiatric assessment process and the selected therapeutic interventions.…<\/p>\n","protected":false},"author":16,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_wpscppro_dont_share_socialmedia":false,"_wpscppro_custom_social_share_image":0,"_facebook_share_type":"","_twitter_share_type":"","_linkedin_share_type":"","_pinterest_share_type":"","_linkedin_share_type_page":"","_instagram_share_type":"","_medium_share_type":"","_threads_share_type":"","_google_business_share_type":"","_selected_social_profile":[],"_wpsp_enable_custom_social_template":false,"_wpsp_social_scheduling":{"enabled":false,"datetime":null,"platforms":[],"status":"template_only","dateOption":"today","timeOption":"now","customDays":"","customHours":"","customDate":"","customTime":"","schedulingType":"absolute"},"_wpsp_active_default_template":true},"categories":[1061],"tags":[1185,2025],"class_list":["post-265256","post","type-post","status-publish","format-standard","hentry","category-nursing-essays","tag-initial-psychiatric-interview-soap-note","tag-nursing-essay-examples"],"_links":{"self":[{"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/posts\/265256","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/users\/16"}],"replies":[{"embeddable":true,"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/comments?post=265256"}],"version-history":[{"count":2,"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/posts\/265256\/revisions"}],"predecessor-version":[{"id":278082,"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/posts\/265256\/revisions\/278082"}],"wp:attachment":[{"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/media?parent=265256"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/categories?post=265256"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/nursingstudy.org\/examples\/wp-json\/wp\/v2\/tags?post=265256"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}