Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example

Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example

This assessment provides a comprehensive psychiatric mental health assessment of my younger sibling, codenamed Jack Doe. JD provided verbal and written consent for the psychiatric interview and the treatment plan. JD appears to understand and respond to the psychiatric process, risks, and benefits. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Client ID: Initials: JD,DOB: 18 –year-old male, Demographic: Caucasian, Gender: M

Subjective.

Chief complaint: The patient complains of “outbursts of anger, inability to control himself, and punching objects around the house when agitated.” (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Source of reliability: Reliability of information is good. The client is in the right state of mind.

Present Illness: Client complains of persistent outbursts of hunger, inability to control hunger, punching objects when agitated. The patient strained relationships with peers in the neighborhood and at school. He contemplates the hardship, loneliness, and novelty of a boarding school since the mother assured him of joining a boarding school if he does not change his social relations. The client contemplates chopping his legs to avoid going to boarding school or university distant from home. The client believes that he is not handsome enough to be liked by or associated with anyone. He has a history of alcohol consumption, binge eating, and reckless driving. Mostly, the client complains of feeling empty, experiences paranoia, suicide, or homicide ideation. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Current psych meds:  None reported.

Past Medical Hx: Denies: cardia, respiratory, endocrine, or neurological issues. No surgical history. Denies: history of chronic illnesses, including HIV, TB, Hep C, or MRSA. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Past Psychiatric Hx: Diagnosed with a generalized anxiety disorder (GAD) at age 10. Condition managed through talk therapy and antidepressant (Sertraline 50mg orally QD). No previous outpatient treatment or hospitalization was reported. Denies trauma history.

Safety concerns: Reported: violence to self and others.

Substance use/abuse: Reported: Alcohol abuse. No ETOH or narcotic abuse.

Current Medications: Sertraline 50mg orally QD for anxiety

Past family, social history: No previous employment or military record. Charged with reckless driving. Christian. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Family psych hx: Lives with the parents and four siblings. No history of psychiatric illness in the family. Normal childhood until age 9 when anxiety symptoms became severe.

Education/Employment/Disability: In Grade 12. Average performer. Performance is currently deteriorating.  

Primary support system: Parents.

Hobbies: Baseball.

Review of systems:

Constitutional: Denies: fever, child, or weight loss.

HE: Denies: Headaches or acute eye pain/vision changes.

ENT: Denies: Loss of hearing, sense of smell, or sore throat.

Cardiac: Denies: Chest pain or edema. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Respiratory: Denies: Cough, wheeze, or dyspnea.

GI: Denies N/V/C/D. Variable eating pattern.

GU: Not sexually active. Denies: dysuria or hematuria

Pulmonary: Denies: shortness of breath.

Abdominal: Denies: abdominal pain, abnormal bowel sounds, or movement.

Neuro: Denies: Fatigue, headache, focal weakness, or seizures.

Musculoskeletal: Denies: Muscle tension, joint pain, or tingling.

Skin: No rash or itchiness.

Objective:

Objective:

Vitals: BP: 119/85 P: 95 Ht: 5’3’’ Wt: 132.2lbs BMI: 23.4 kg/m²

Appearance: Well-groomed for the occasion.

Attitude/interaction: Appear to be in psychological distress.

Activity level/behavior: Interactive.

Orientation: Alert and oriented × 4.

Speech: Clear and fluent.

Thought content/process/perception: Logical, linear, and goal-oriented. No negative perception was noted.

Mood/affect: Mood is described as “normal” with a broad emotional range and congruent affect.

Judgment/insight/cognitive/memory: Normal judgement and insight. Cognition and memory are grossly intact with the ability to abstract. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Attention: Had some difficulty with attention and concentration during the exam.

Testing: UDS negative.

Assessment:

1. Borderline Personality Disorder (BPD). ICD-10 code F60.3. JD experiences impaired personality functioning, unstable emotions, hostility, anxiousness, separation insecurity, impulsivity, emptiness, and unstable relationships (Blevins et al., 2015). This is the primary diagnosis. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)
2. Separation Anxiety Disorder (SAD). ICD-10 code F93.0. JD presents DSM5 SAD diagnostic symptoms of distress in anticipation of family separation, which significantly impacts social functioning and academic performance (American Psychiatric Association, 2013).  This diagnosis is refuted. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)
3. Attention-Deficit/Hyperactivity Disorder (ADHD). ICD-10 code F90.2. JD presents DSM5 ADHD diagnostic symptoms, including inattention, hyperactivity, and impulsivity, such as inability to sustain mental focus, interrupts, and intrudes others (American Psychiatric Association, 2013). This diagnosis is refuted.
4. Major depressive disorder (MDD). ICD-10 codeF33.1. JD presents DSM5 diagnostic symptoms of MDD such as a sense of worthlessness, irritability, inability to concentrate, and suicide/homicide ideation that impairs social functioning (American Psychiatric Association, 2013). This diagnosis is refuted. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)
5. Intermittent explosive disorder (IED). ICD-10 codeF63.81. JD presents DSM5 diagnostic symptoms of IED, including behavioral outbursts and aggressiveness leading to the destruction of property or physical assault (American Psychiatric Association, 2013). This diagnosis is refuted. (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Plan:

Increase Sertraline 50mg orally QD for anxiety and depressive symptoms (Timäus et al., 2019). Recommend Dialectical Behavioral Therapy to help the client gain mindfulness, regulate his emotions, and tolerate distress. DBT allows the client to learn behavioral skills targeting BPD symptoms such as emotional instability, fear of separation, unstable relationships and self-esteem, self-destructive behaviors (May, Richardi, & Barth, 2016). Educate them on tolerance and approach mechanisms to help the patient achieve appropriate social interaction and emotional regulation skills. In emotion regulation, JD will learn to identify and manage emotional reactions (Gross, 2015). Moreover, involving parents in supporting BPD trait management is vital in achieving healthy behavioral patterns (Dunn et al., 2020). (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Safety Risk/Plan:  JD is too stable and is at risk to himself and others. Educate the parents on their role in the client’s treatment plan.

Referral: Behavioral therapist.

Next Visit: 4 weeks

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.   (Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example)

Dunn, A., Cartwright-Hatton, S., Startup, H., & Papamichail, A. (2020). The Parenting Experience of Those With Borderline Personality Disorder Traits: Practitioner and Parent Perspectives. Frontiers in psychology, 11, 1913.(Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example) https://doi.org/10.3389/fpsyg.2020.01913

Gross, J. J. (2015). The extended process model of emotion regulation: Elaborations, applications, and future directions. Psychological Inquiry, 26(1), 130-137. https://doi.org/10.1080/1047840X.2015.989751

May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as a treatment for borderline personality disorder. Mental Health Clinician, 6(2), 62-67(Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example) . https://doi.org/10.9740/mhc.2016.03.62

Timäus, C., Meiser, M., Bandelow, B., Engel, K. R., Paschke, A. M., Wiltfang, J., & Wedekind, D. (2019). Pharmacotherapy of borderline personality disorder: what has changed over two decades? A retrospective evaluation of clinical practice. BMC psychiatry, 19(1), 1-11 .(Psychiatric Mental Health Assessment of a Child or Adolescent Comprehensive Nursing Paper Example) https://doi.org/10.1186/s12888-019-2377-z