Initial Psychiatric Interview Comprehensive Nursing Paper Example

Initial Psychiatric Interview Comprehensive Nursing Paper Example

Informed Consent The patient (with initials I.H) has given both verbal and written consent to the psychiatric interview process, whose details are captured and the subsequent psychiatric / psychotherapy treatment envisaged in the plan. ID has the ability and capacity to give appropriate responses and, in the mental healthcare provider’s opinion, appears to comprehend the benefits risks and seems ready to review any extra consent required during the treatment discourse. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Subjective Verify Patient Name: Inoa Haukea (IH) DOB:1993 Minor: N/A Accompanied by: No one Demographic: Hawaiian Pacific Islander domiciled in Washington D.C with lower social-economic suburbs. Gender Identifier Note: Female CC: ‘ I have oscillated between moments of increased energy and excitement and moments of lack of energy and feeling worthless. In agitation, feel like I can kill someone’ (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Verify Patient: Name,

Assigned identificatio

n number (e.g.,

medical record

number), Date of

birth, Phone number,

Social security

number, Address,

Photo.

Include demographics,

chief complaint,(Initial Psychiatric Interview Comprehensive Nursing Paper Example)

subjective patient

information, and the 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…” HPI: IH is a 29-year-old female Pacific Islander originally from Hawaii Islands and currently engaged to her boyfriend of nine months.(Initial Psychiatric Interview Comprehensive Nursing Paper Example) She is currently working as waitress in a local hotel in the lower socioeconomic communities of Washington D.C. She presents to Topnotch Acute Care Center care of alternating moments of charged energy and excitement followed by lows of enervation and feelings of low self-esteem. She desires to establish psychiatric care secondary to the cyclic fluctuations of her mood with excitement that lasts for a week and a maximum of 10 days.. She desires not to have her parents and grandparents feel like they need to support her. In her low moods she reports crying a lot, getting easily irritated and increased anxiety. She however admits that despite these symptoms she copes with her hotel work. She has received psychiatric treatment for depression and has passive homicidal ideation where she once threatened her elder brother with sure death if he continued playing loud music in her presence. She reports a history of verbal abuse from her alcoholic father and sexual abuse form her a friend of her father. Pertinent history in record and from patient: She reports having a history of depression and reported past medical history of Graves Diseases. During assessment: Patient describes their mood She complains of racing thoughts, fast paced talk, engage in impulsive shopping, accompanied by thoughts of grandeur, and periods of sleeplessness. She recounts that in one of the charged energy moments she was sexually overactive and slept with multiple partners. She states that having music in the background or taking a walk helps her get composed Patient self-esteem appears to start from being self-conscious comparing herself to the Virgin Mary about her condition then slowly dip towards low self-worth where she feels she is an irredeemable prostitute. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

SI/ HI/ AV: The patient currently denies harboring suicidal ideations but confirms having passive homicidal ideations for those who cross her path during the low moments. She denies hallucinations be they auditory or visual. Allergies: NKDA Past Medical Hx: Medical history Graves’ Disease that was successfully managed using Radioactive iodine. She reports negative for any history of chronic medical conditions like HIV and Diabetes Surgical history: Negative for surgical history Past Psychiatric Hx: Reports having depression when she broke up with her first boyfriend, whom she feels was the only man who has truly loved but still betrayed her by having an affair with her cousin. Previous psychiatric diagnoses: Depression She admits she has received therapy for depression in her early twenties and remembers one therapist diagnosed her with bipolar disorder though she was unsure whether it was type I or type II. She reports the cause of discontinuing her therapy was when she moved from Hawaii Islands to Washington DC in 2020 to try her luck here in 2020. Previous medication trials: None reported Safety concerns: History of Violence to Self: Negative History of Violence to Others: Positive anyone who crosses her path when in low moods risks being murdered by the patient. Auditory Hallucinations: None (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Visual Hallucinations: None Mental health treatment history discussed: History of outpatient treatment: Received counseling for depression from a relationships expert. (Initial Psychiatric Interview Comprehensive Nursing Paper Example) Previous psychiatric hospitalizations None reported Prior substance abuse treatment. Denies use of drugs or illicit substances Trauma history: Negative for physical trauma, but she admits emotional trauma from the sexual violations she received from her father’s friend. Substance Use: Denies use of prohibited substances and drugs. Current Medications (Contraceptives): Long-acting -reversible contraceptives Supplements: B- vitamin supplementation and iron supplementation Past Psych Med Trials: None reported. Family Medical Hx: Father heroin addict, diagnosed with depression comorbid with Bipolar II Disorder. Mother Has depression comorbid with anxiety. Managed with Lexapro, brother, diagnosed with depression managed with Prozac. Maternal grandmother suicide at 66 years. Paternal uncle 42 years – died c/o car accident driving under the influence of alcohol Developmental diagnoses no family member had any developmental milestones challenges. Social History: Occupational History – currently employed as a waitress in a local hotel Military service History: None reported Education history: Has a Bachelor’s degree in catering and Front office management post-graduate diploma (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Developmental History: Negative for developmental milestone challenges Legal history: has never appeared in a court of law as an accused. Spiritual/Cultural Consideration: Describes herself as a devout Mormon ROS: Constitutional: Negative for fever, chills, and recent unexplained changes in weight. Reports moments of increased energy followed by periods of extreme fatigue Eyes: Negative for pruritus, visual disturbances, lacrimation, or photophobia. ENT- Denies difficulties in hearing, no ear ache, and no discharge and does not use hearing aids. Negative for epistaxis, no nasal obstruction, or discharge. Negative for bleeding gums, the tongue has normal pinkish coloration, no voice charges, or difficulties swallowing. Last dental exam March 2021.(Initial Psychiatric Interview Comprehensive Nursing Paper Example) Cardiac: Negative for chest pain, irregular heartbeat swellings of the ankle or feet, no hypertension Respiratory: Negative for dyspnea, cough, wheezing, PND, orthopnea, cyanosis. GI: Negative for abdominal pain, no eructation, jaundice, changes in bowel movements, rectal bleeding, or flank pain. GU: Negative for polyuria, oliguria, dysuria, incontinence, and increased frequency or urgency to pass urine. Musculoskeletal: Negative for joint or muscle pain. No swelling or deformity in joints, no redness. Skin: Negative for unusual skin coloration, has normal hair distribution, no changes in skin texture, no moles or rashes. Positive for a contusion to RT side of the face below the cheek. Neurologic: Negative for seizures, loss of consciousness, ataxia, No sensory disturbances (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Psychiatric: Positive for mania and sadness Endocrinal: Negative for heat or cold intolerance, No throat/ neck swellings Hematologic: Negative for easy bleeding or bruising, no anemia, no lymph node enlargement Allergic: No known allergies to medication, food, or environmental factors Reproductive: Admits use of LARCs, No STIs or anorgasmia (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Objective Vital Signs: WNL Temp:97.8 BP:126/80 HR:71 bpm R:18/min O2: 98% Pain: 0 Ht: 64 inches Wt:138 BMI: 23.7 BMI Range: Normal LABS: Thyroid Function Test- 4.19mU/L Urine analyses – Aldosterone 23.5 nmol/24 hr. Physical Exam: General: A/O *4 patient is appropriately groomed for the occasion, talking excessively sometimes but remains coherent Head: Normal cephalic, positive for a contusion to the RT of the face below the RT maxilla (Initial Psychiatric Interview Comprehensive Nursing Paper 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, MSE, risk

assessment, and

psychiatric screening

measure results.

ENT: PERRLA, no scleral icterus, both cornea, and conjunctiva are clear, normal nares, normal mucosa, midline septum, normal lips, mucosa and tongue, all teeth intact Nails: cap refill less than 2 seconds. Lungs: On auscultation bilaterally clear, no labored breaths, no wheezes, honchi, or rales Cardiovascular: RRR, normal S1and S2, negative for murmur, rubs, or gallop Abdomen: soft, non-tender. All four quadrants and nine regions of the abdominal cavity were found negative to guarding or rebound tenderness. Negative for masses and rigidity. (Initial Psychiatric Interview Comprehensive Nursing Paper Example) Extremities: Normal in color, size, and temperature. Pulses found 2+ bilaterally in both upper and lower extremities. Negative for edema, cyanosis, clubbing, or bruits. Neuro: Patient is alert and oriented to time, place, and date; receptive and expressive abilities intact. Full range of movement in all extremities, All extremities have a 5/5 strength bilaterally, CN- 2 to 12 intact, Reflexes: 2+ throughout. MSE: Appearance and behavior: Well-groomed maintains good hygiene standards. Speech and Language: Coherent can name items displayed, categorize them, follow instructions, speech of good tone and fluency, is expressible but rapid sometimes, Mood: Patient denies suicidal ideation confirms passive homicidal ideations. Admits challenges controlling her mood. Thought process/ Content: Negative for hallucinations phobias but deluded at times Insight and judgment: Can express her problems, understand the diagnoses of Bipolar disorder Memory and attention: Patient is alert and oriented to name, date time location with good recall. Memory is short and remote intact. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Higher cognitive functions. Normal functioning can name five countries in America and their Presidents, can work out simple mathematics problems. Abstract thinking good can understand similarities between vocabulary items. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Assessment DSM5 diagnosis: with ICD-10 codes Dx 1:2022 ICD-10 CM Diagnosis Code F31: 81 Bipolar II Disorder Confirmed Patient admits to experiencing manic episodes that manifest as racing thoughts, pressured speech, insomnia, euphoria, and grandiosity that lasts up to ten days. The patient is 29 years old, while the onset for Bipolar II disorder is in the 20s and 30s.(Initial Psychiatric Interview Comprehensive Nursing Paper Example) She also reports not suffering from marked impairment in her social and occupational life. According to Gitlin & Malhi (2020), ICD -10 requires two discrete mood episodes, one being of depressive episode and the other hypomanic. The normal lab results and findings combined with these two episodes in IH helped confirm the Bipolar II disorder diagnosis. The normal lab results helped rule out pathogenic or physiologic causes of the patient’s symptoms. Dx: 2 2022 ICD-10- CM Diagnosis Code F31.9 Refuted According to Datto et al. (2016), the signs of Bipolar I disorder overlap with those of Bipolar II Disorder in the spectrum. However, IH symptoms as reported are considered unlikely because she admits to not having marked impairment and has never been admitted to the hospital for psychiatric reasons. Notably, a patient with bipolar I will most likely experience a full manic episode necessitating admission to a psychiatric institution, unlike their bipolar II who experience a less severe hypomanic episode. I used this distinction to rule out Bipolar 1 disorder. Dx 3: 2022 ICD -10-CM Diagnosis Code F34.0 Cyclothymic Disorder- Refuted (Initial Psychiatric Interview Comprehensive Nursing Paper 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

Perugi et al. (2017) posit that cyclothymic disorder is characterized by its early onset, persistent spontaneous and reactive mood fluctuations accompanied by marked degrees of impulsive behaviors. To rule out cyclothymic disorder, I used the moderately elevated depression characteristic in Bipolar II. Therefore, it was refuted because the patient’s symptoms meet the threshold of hypomania but fall short of manic-depressive episodes. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Plan

(Note some items may

only be applicable in

the inpatient

environment)

Safety Risk/Plan: At this point, the patient is found to be of low risk to self (no suicidal ideations) and moderately to others (has passive homicidal intentions with no plan or weapon of choice). Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: Aripiprazole is a second-generation used as a first-line medication to treat and manage Bipolar II disorder. The first-line medication to use is Asenapine 5mg. The starting dose is 5-10 mg bid PO with an effective dose set at 10mg bid (Bobo, 2017). (Initial Psychiatric Interview Comprehensive Nursing Paper Example) The aforementioned researcher further notes that adding psychotherapy like cognitive behavioral therapy would significantly reduce the recurrence by half or more compared to standard care. Patient Education, including health promotion, maintenance, and psychosocial needs. The treatment plan also incorporates patient education on adhering to the prescribed dosage and dose. It has a component that educates the patient and their family members to recognize if the disease is getting worse and make a plan for the family members to take care of the Bipolar II patient. The provider will gather collateral information from others to decide whether the patient is a safety risk to self and others. Referrals: If the symptoms do not alleviate, non-psychiatrist’s professionals to whom the patient can be referred are a General Practitioner to consult on anxiety and depression or an endocrinologist. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Follow-up: Including the return to clinic (RTC) with a time frame and reason and any labs tests needed for the next visit. The patient is to report to the clinic for a follow–up after four weeks or earlier if the symptoms worsen.

References

Bobo, W. V. (2017, October). The diagnosis and management of bipolar I and II disorders: clinical practice update. In Mayo Clinic Proceedings (Vol. 92, No. 10, pp. 1532-1551). Elsevier. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Datto, C., Pottorf, W. J., Feeley, L., LaPorte, S., & Liss, C. (2016). Bipolar II compared with bipolar I disorder: baseline characteristics and treatment response to q analysis of five placebo-controlled clinical trials of acute bipolar depression. Annals of General Psychiatry, 15(1), 1-12. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Gitlin, M., & Malhi, G. S. (2020). The existential crisis of bipolar II disorder. International Journal of Bipolar Disorders, 8(1), 1-7. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

Perugia, G., Hantouchec, E., & Vannucchia, G. (2017). Diagnosis and treatment of cyclothymia: the “primacy” of temperament. Current Neuropharmacology, 15(3), 372-379. (Initial Psychiatric Interview Comprehensive Nursing Paper Example)

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