Comprehensive Client Family Assessment Psychotherapy

Assess clients presenting for psychotherapy
Develop genograms for clients presenting for psychotherapy
To prepare:

Select a client whom you have observed or counseled at your practicum site.
Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.
The Assignment
Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):

Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse/trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan
Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Required Readings
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
Required Media
Laureate Education (Producer). (2013b). Hernandez family genogram [Video file]. Baltimore, MD: Author.

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Practicum Experience Time Log and Journal Template

Student Name: Student Name

E-mail Address:

Practicum Placement Agency’s Name:

Preceptor’s Name

Preceptor’s Telephone:

Preceptor’s E-mail Address:

Comprehensive Client Family Assessment Psychotherapy

Demographics Information:

The client is a 91-year-old Caucasian female who resides at home by herself with home health care. Her primary language is English. The client is a retired widow who has one son that lives nearby. The client has Medicare for insurance and her religious preference is Presbyterian.

Presenting Problem:

“My heart was beating fast and my pacemaker is set at 60. I got really dizzy and did not feel well. I was taken to the hospital where my heart was in tachycardia. I stayed in the hospital for several days, so now I am weak and need therapy.”

History of Present Illness:

The client has a history of atrial fibrillation and presented to Baylor Hospital of McKinney with palpitations on 12/06/2018. The client was found to have a urinary tract infection and started on oral antibiotics. The client was seen by Electrophysiology and was found to be in an AV nodal re-entry tachycardia and was treated. While in the hospital, the client complained of right hip pain radiating around to the back. Due to this, the client was referred to rehabilitation. Currently the pain is extending to the left leg.

Past Psychiatric History

The client has had long term issues with anxiety and was diagnosed with generalized anxiety by her general practitioner in her 50’s. The client’s current regime consists of Ativan 0.5mg p.o. BID. The client states this medication and dosage works well for her. The client also has insomnia and takes Ambien 5mg p.o. at night. Client denies any other psychiatric disorders at this time and has not received any psychotherapy or counseling for her anxiety.

Medical History:

The client presents at this time with stable vital signs and is afebrile. Client is 5 ft tall and weighs 130lbs with a BMI of 25.3. Client has a normal weight and height for her age and gender. Vitals are normal. Client is allergic to Bactrim, Imodium, Tetracycline, Doxycycline, and Cipro. Client has no history of falls and her pneumonia and flu vaccines are up to date. Client wears glasses and has had a recent eye examination. The client’s other comorbidities include: CAD, hypertension, tricuspid valve stenosis, arthritis, anemia, peptic ulcer disease, and macular degeneration.

Developmental History:

Developmental Stages: The client states to her knowledge her birth was normal and there were no issues during her mother’s pregnancy. The client states she was active as a small child and participated in sports from a young age. The client states she was “very independent” as a child and wanted to do everything herself, i.e. picking out her own clothes and dressing herself. Client states she progressed through school without any difficulty and made A’s in most of her subjects. Client states she was closest to her sister, but had several friends which were both male and female in which she interacted well with. These facts support the client having appropriate gross and fine motor achievements as well as speech, language, and social achievements throughout her lifetime (Parry, 2005). The client’s sister is deceased and there are no other family members to interview for her developmental progress. The client states her mom did not smoke and did not drink alcohol during her pregnancy and stated it was the time of the prohibition era.

Psychosocial History

The psychosocial history is an important part of an assessment. It evaluates an individual’s mental health and social well-being as well as assessing the individual’s self-perception and how they function in their community (Lengel, 2017).

The client has a son who lives 10 minutes from her home and is her primary support system. Prior to her hospitalization, the client lived by herself and was self-sufficient except for someone who cleaned her house every other week. Additionally, the client has a daughter who lives in Austin which she sees approximately four times per year. The client’s oldest son lived in Flagstaff, AZ, but died approximately one year ago from gastric cancer. The client’s parents are deceased as well. The client has one friend she is contact with via telephone which she has known for 70+ years. The client is retired, but worked as a teacher for many years while raising her children. The client has been a vigorous reader throughout her lifetime and continues to read regularly. The client states she was married twice during her life and has surpassed both husbands. The client was married to her first husband for 50 years before he expired. The client later married her second husband when she was 72 years old, and had known him since first grade. The client was married to her second spouse for 14 years before his passing.

Family Psychiatric History

The client states her mother had issues with insomnia as an older adult; however, there were no other known psychiatric illness she was aware of in with her parents. The client states she believes her grandfather may have had depression, but it was never diagnosed.

History of Abuse/Trauma

Client denies any history of abuse or trauma during her life time.

Review of Systems

Client’s last physical exam was performed by her general practitioner in August, 2018. Last eye exam was in October and a dental exam is pending in January.

Constitution: Client states she normally sleeps well and gets 7-8 hours of sleep at night, but due to her recent hospitalization she has had some sleep disturbances due to interruptions by hospital staff during the night. No history of chills, fever, night sweats, or weight loss.

Eyes: Wears glasses, Macular Degeneration.

Ears: Wears hearing aids bilaterally.

Nose: Denies problems with sense of smell or nose bleeds. Occasional congestion from mild seasonal allergies.

Throat and Mouth: Partial bottom dentures only. No adverse dysfunction noted.

Head and Neck: Denies history of head injury or loss of consciousness. The head is symmetrical with no bumps to the scalp. No JVD, lymphadenopathy, or thyromegaly noted. Comprehensive Client Family Assessment Psychotherapy

Respiratory: Lung sounds clear with no adventitious breath sounds heard. No cough or hemoptysis noted.

Cardiovascular: Significant for coronary artery disease, chronic atrial fibrillation, status post cardiac pacemaker, and recent re-entry tachycardia.

Gastrointestinal: Appetite disturbance since hospital admission, but is improving. Bowel movements every two to three days. Negative for nausea, vomiting, diarrhea, or hematochezia. Significant for peptic ulcer disease.

Genitourinary: Significant for urinary tract infection with frequent urination.

Musculoskeletal: Positive for osteoarthritis. Client can move all extremities, but has pain to hips, knee, and left foot. Generalized weakness.

Psychiatric and Neurologic: History of general anxiety disorder (GAD). No history of brain injury.

Mental Status Exam:

Appearance: Clients appearance is appropriate for age; patient is neat and well fed.

Attitude and Behavior: Client is cooperative and pleasant during the interview. Eye contact readily made. Attitude and behavior appropriate.

Speech: The client is talkative with normal rate, volume, and tone. Speech coherent with no latency noted.

Motor Activity: Client sitting up in bed, no tremors, lip smacking, or repetitive behaviors visualized.

Affect and mood: Mood anxious with underlying depressive symptom. Client initially appeared happy; however, became tearful during further interview. Affect congruent with mood.

Temperament: Pleasant temperament. Client has appropriate concentration and attention.

Perception: Client denies hallucinations or illusions.

Thought Processes: The client’s thought processes are organized and logical with good insight.

Thought Content: The client denies delusions, and there are no obsessions or preoccupations.

Sensorium and Cognition: Client is alert and oriented to person, place, time, and situation.

Memory. Short-term and long-term memory grossly intact.

Abstract thought: Not tested at this facility.

Intelligence: Client is very astute for her age and education level.

Insight: The client’s insight was appropriate.

Judgement: The client’s judgement is appropriate. Her thought processes are well planned with no impulsivity noted.

Physical Assessment and Neurological Examination

Vital Signs: BP-116/63, HR-60, RR-18, T-97.7

Height/Weight: Ht: 5’0”, Wt: 130lbs.

BMI: 25.3

Neurological Exam

Mental Exam: Client is alert and oriented to person, place, time, and situation. Client is calm and cooperative.

Lab/Diagnostic Testing

Psychiatric diagnosis, such as Generalized Anxiety Disorder (GAD) or Adjustment Disorder (AjD), do not have specific laboratory work which can be used to diagnose them. Due to the age of the client and her recent hospitalization for AV nodal re-entry tachycardia, it is of importance to order basic blood work, such as: a chemistry and complete blood count to monitor her electrolytes for cardiac function and monitor blood levels for possible infectious processes. These lab test may indicate an organic illness which may be causing and/or increasing symptoms of her anxiety or causing depressive symptoms which may be related to AjD.

Overall, the client’s lab work results were not profoundly out of range. Her sodium level is one point under the normal reference range. The client is not on diuretics nor does she have issues with vomiting or diarrhea. However, one complaint is weakness, and hyponatremia does contribute to weakness. In addition, the client’s H/H is slightly low, which can also contribute to weakness. Within a hospital setting, the H/H values are not typically treated with a blood transfusion. These values will be monitored for symptoms of anemia or any abnormal bleeding. The prealbumin is also low; however, the client did state she was not eating well while in the hospital, and she had a UTI which is resolved with antibiotics. Both of these circumstances could contribute to a lower prealbumin in a 91-year-old-woman (Acute Academy of Acute Care Physical Therapy, 2017). Comprehensive Client Family Assessment Psychotherapy