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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. The patient exhibits the ability to respond and comprehend the intervention’s 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) |
| Subjective | Verify Patient Name: Aaron Boyne DOB: April 17 , 1947 Minor: X Accompanied by/A Demographic: Non-Hispanic White Gender Identifier Note: Male CC: The patient reports challenges remembering things and feeling confused for past one week. 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. Pertinent history in record and from patient: He has a past medical history of osteoporosis, pneumonia, respiratory problems, T2DM, and HTN. 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. . 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. 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) Allergies: NKDA 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 Past Psychiatric Hx: Patient denies any previous mental health disorder but confirms negative diagnoses for depression. Safety concerns: History of Violence to Self: none reported History of Violence to Others: none reported Auditory Hallucinations: None Visual Hallucinations: None Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment : Reports history of marijuana and alcohol abuse Trauma history: 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 Substance Use: Client denies use or dependence on nicotine but confirms use of tobacco products in his youthful years. Client reports abuse of or dependence on alcohol and marijuana in his younger years. Current Medications: Metformin and Lisinopril for T2DM and HTN. (Initial Psychiatric Interview Comprehensive Nursing Essay Example) (Contraceptives): Vasectomy in 1997 Supplements: Vitamin C, multivitamin, and calcium supplements Past Psych Med Trials: None reported Family Medical Hx: None reported Family Psychiatric Hx: None reported Substance use: Father Suicides None reported Psychiatric diagnoses/hospitalization: Mother diagnosed for delirium drug intoxication Developmental diagnoses Normal development curve reported Social History: Occupational History: Currently Retired accountant Military service History: Denies military service hx. Education history: Completed HS and vocational certificate Developmental History: No significant details reported. (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 ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes but confirms eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: Positive. Respiratory: Reports struggling with pneumonia. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: Reports joint pain or swelling from a history of osteoporosis. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (Females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…) (Initial Psychiatric Interview Comprehensive Nursing Essay Example) |
| Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” (Initial Psychiatric Interview Comprehensive Nursing Essay Example) | |
| Objective | Vital Signs: Stable Temp: 97.5 BP: 123/78 HR:81 R:19 O2: Room Air Pulse Ox 97 Pain:3/10 Ht:72 inches Wt:175.2 pounds BMI: BMI Range: LABS: Lab findings WNL Tox screen: Negative Alcohol: Positive HCG: N/A Physical Exam: MSE: Musculoskeletal: (Initial Psychiatric Interview Comprehensive Nursing Essay Example) Pain in joints from history of osteoporosis Appearance: Appears withdrawn and depressed but alert, calm, and cooperative. Patient maintains minimal eye contact Psychomotor activity appears within normal Orientation: Self and situation aware but impaired awareness of time and place Mood: Depressed and anxious Gait: Unsteady AIMS Done?: No Speech: 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: Loose concentration and confused thought process Abnormal/Psychotic Thoughts: No Hallucination/Delusion Attention: Slightly Impaired Concentration: Inconsistent Insight/ judgement comment: Impaired but patient is able to articulate need. Insights appear fair. Cognition is impaired Fund of knowledge: Average Slightly impaired short-term memory and impaired long-term memory Language: Challenging word finding and sentence construction (Initial Psychiatric Interview Comprehensive Nursing Essay Example) |
| This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.(Initial Psychiatric Interview Comprehensive Nursing Essay Example) | |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Dx: – Dementia F02.81 (confirmed) 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’s 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. Dx: – Alzheimer’s Disease ICD10: G30.9 ( refuted) Alzheimer’s 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, 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 Autoimmune, swallowing problems, infection like prion disease substance abuse, hormone hypothyroidism, electrolyte disturbance and depression Dx: – Parkinson’s Disease ICD10: G20 Parkinson’s disease is also progressive and affects the brain’s 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. Dx: – Manic Depressive Disorder (refuted) 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. 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) |
| Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability | |
| Plan (Note some items may only be applicable in the inpatient environment) | Inpatient: Psychiatric. 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. Safety Risk/Plan: The patient is found to be stable and has control of behavior. Patient poses minimal to no risk to self and others. 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’s neurotransmitters’ balance and improve memory and ability to conduct activities of daily living and treat moderate confusion. Continue prescription for Metformin 250 mg for the patient’s T2DM and HTN 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 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 ☒ > 50% time spent counseling/coordination of care. Time spent in Psychotherapy 20 minutes Visit lasted 75 minutes Billing Codes for visit: XX XX XX ____________________________________________ NAME, TITLE Date: Click here to enter a date. Time: X |
References
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)
Weller, J., & Budson, A. (2018). Current understanding of Alzheimer’s disease diagnosis and
Treatment. F1000Research, 7.(Initial Psychiatric Interview Comprehensive Nursing Essay Example)
Foley, T., & Swanwick, G. (2014). Dementia: diagnosis and management in general practice. Irish College of General Practitioners Quality in Practice Committee: Dublin.(Initial Psychiatric Interview Comprehensive Nursing Essay Example)
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