Mental Health Progress and Privileged Note

NURS 6650 Client Assessment Entry 1 Week Three Comprehensive Client Assessment Entry Week Three Comprehensive Client Assessment Entry Many families experience challenges and discourse throughout their lives that can be resolved with proper communication and understanding. This resolution can be more difficult for 6650 Client Entry 2 individuals with a familial history of mental illness. Families with several members having mental disorders may be more unyielding to acceptance of other’s perspectives. The Psychiatric Mental Health Nurse Practitioner (PMHNP) must address such problems with sensitivity and patience. Individuals with mood disorders are often able to express themselves but do not feel comfortable or encourage to do so in certain places or around specific people. This is a comprehensive assessment paper of client BT and her family genogram, extending three generations. Demographics Information BT is a 32-year-old African American female who presents with her sisters, who are her triplets. They report increased feelings of sadness and constant fighting her sisters since their mother passed away two years ago. She reports wishing things could back to the way it used to be. Her biggest concern is that her sister blames her a lot for stressing their mother prior to her dying of a heart attack. Mental Health Progress and Privileged Note

Presenting Problem This client presents with complaints of increased sadness, anger, mood swings, and difficulty sleeping. She shares that these symptoms are often triggered, ongoing for months, and results in her physically fighter her sisters or breaking items. History of Present Illness BT reports a history of anxiety, bipolar disorder, and insomnia since she was a teenager. She takes Trazadone 100mg once daily and Lamictal 50mg twice a day. She says that her symptoms are exacerbated by stress and family drama. She was formerly taking Seroquel 100mg and Zoloft 50mg daily and reported she didn’t like the side effects of sluggishness and stomach upset. She works as an investment banker and She says she sometimes goes many days without any symptoms and stop taking her medications then something will trigger her suddenly and she 6650 Client Entry 3 will black out. She shares that the only person she could talk to, was her mom prior to her passing away, who didn’t believe in counseling or telling others of personal or familial matters. She believes her friends are more like her family and they encouraged her to seek medical assistance. She denies any legal history and reports she’s been suspended in high school. She reports that her dad died when she was 13 years old from cancer and she gets sadder on the anniversary of his death. Medical History She denies any medical history apart from seasonal allergies and takes Claritin as needed. She has an allergy to dust, iodine, and kiwi. Developmental History She does not show any signs of developmental delays. She did not have any developmental issue or trauma growing up. She has a college level education and articulates well in full sentences. She has clear and concise thought. None of her siblings or parents had any developmental delays as well. Substance use History She reports drinking alcohol occasionally and stopped smoking marijuana and cigarettes seven years ago. Psychosocial History This client lives alone with her dog, a German Shepard. A few of her favorite activities include shopping, singing, choreographing dances online, and teaching/mentoring. She reports formerly singing in her choir and small gatherings. She shares that she recently started journaling and was surprisingly pleased with the relief that has brough her. History of abuse/Trauma: 6650 Client Entry 4 BT denies any physical or sexual abuse. She reports some verbal abuse from her dad. She says he would sometimes belittle everyone then shower them with gifts. She claims to know it’s a form of emotional manipulation and still doesn’t doubt that her father genuinely loves her. Mental Health Progress and Privileged Note

Familial Medical and Psychiatric Review She reports her mother had a history of high cholesterol, hypertension, and congestive heart failure. Her father had a history of prostate cancer and COPD. He was a smoker for many years. Her mother has history of seasonal depression and maternal grandmother had bipolar disorder. She claimed her father did not have any psychiatric disorder and that his mother had depression and was hospitalized for a small while after a breakdown. Body Systems Assessment General: BT is alert and oriented x4-to self, time, purpose, and location. She ambulates with a steady gait. She is single and engaged to her boyfriend of four years. Her most recent physical was March 2020; whereas, dental visit, and vision test were February 2020. She denies any prior hospitalizations. She presents appropriately dressed, and well-groomed. Her hair was tidy, and she didn’t have any bad odor. Apart from her sweaty palms, her skin is dry and intact with a color appropriate for ethnicity. Neurological: BT denies any past physical or mental trauma, dizziness, headaches, visual or auditory disturbances, numbness or tingling. Eyes: Her eyes are brown in color, with equal, round, and reactive to light as well as accommodation pupils. She reports a history of Lasik eye surgery. She denies any double or blurry vision nor use of contacts or eyeglasses. Ears: She has intact hearing bilaterally. She says her last hearing test was during her physical exam. Hearing appears intact with appropriate color for her ethnicity. 6650 Client Entry 5 Nose: She denied any difficulty breathing at the time. Her nasal septum is midline, and her left nasal passage is patent. She has a history of sinusitis and reports nasal congestion mostly in cold weathers as well as her occasional seasonal allergies. Throat and Mouth: Her oral mucosa is moist and pink, no lesions or swelling observed. Head and Neck: She denies any aches or tenderness. She has no obvious swelling, pain, laceration, or bleeding observed and symmetry to both head and neck Respiratory: Her lung sounds clear to auscultation bilaterally, without crackles, dyspnea, shortness of breath, or wheezing. Cardiovascular: She has normal S1 and S2 heart sounds; no gallops, nor heart murmur heard upon auscultation. Gastrointestinal: Her bowel sounds are present in all four quadrants, normoactive. She denies any recent nausea or vomiting, diarrhea, and constipation. She denies straining, says she has regular bowel movements. Genitourinary: She reports normal urine flow, light yellow in color with no dysuria, hematuria, or foul odor. She reports normal/regular menstrual cycle lasting for four days. Her last cycle was December 04, 2020. Musculoskeletal: She ambulates well with steady gait and has full range of motion in all extremities. Her strength is equal on both sides.

Hematologic: She denies any bruising or bleeding, no obvious signs observed, and her hematocrit and Hemoglobin levels are normal. She denies ever taking any blood thinner, or supplements Lymphatic: Upon palpation, she had no enlarged or abnormal lymph nodes. Endocrine: She denies polyuria, no constant thirst or frequent sweating Psychiatric: She has a history of anxiety, bipolar depressive disorder, and insomnia. 6650 Client Entry 6 Mental Assessment Review Cognition: This client is alert and oriented to person, place, time or situation (x4). Her thoughts are clear, concise and coherent. Appearance: She appears well dressed and hair tidy. Attitude and Behavior: She is anxious and cooperative Speech: Her speech is clear, concise and audible at normal speed and rate. Motor Activity: She ambulates with steady gait and has full range of motion Affect and Mood: She is in a pleasant mood with some anxiety. Temperament: She displays no aggressive behaviors during session. Attention, concentration, and perception: Her attention and concentration are intact, and her perception is normal. She denies hearing any additional voices or seeing things no one else can. Thought Processes: Her thoughts are logical and organized. She denies auditory or visual hallucination. Remote and Recent Memory: She is able to demonstrate great memory recall. Digit span: She’s to demonstrate good digit span. Insight and Judgment: Intact; She sometimes blacks out and throws objects at people, becoming violent Vitals and Neurological Examination Vital Signs: B/P- 129/71 HR- 67 RR- 17 T- 99.1F Height: 5’7” Weight: 180 pounds BMI: 28.2 6650 Client Entry 7 Client is alert and attentive. She appeared a bit anxious, tapping her thigh as she was talking, had sweaty palms. She had a normal affect. She had strong motor function and balance. She had equal strengths in both hands and walked with a steady gait. Her senses were intact bilaterally. Diagnostic and Lab Testing There are many tests practitioners can perform for this client. For instance, she has a history of marijuana use, she may benefit from a urine test to assess for substance usage or abuse. A thorough assessment of the client’s past and current medication prescribed would be helpful for a practitioner in organizing her treatment. Mental Health Progress and Privileged Note

This will let one know what works or does not and why as well as if a retry could be conducted. She also mentioned drinking alcohol, so it is imperative to emphasize the sedative effect of her mood stabilizer, especially when combined with alcohol. Positron Emission Tomography (PET) shows decreased metabolism in the orbital gyrus, caudate nuclei, and cingulate gyrus among individuals with GAD (Saddock et al., 2014). Drawing a picture may also be performed to assess for anxiety, as affected individuals draw rapidly. Lastly, a complete blood work should also be done for assessment of renal and kidney function. Differential Diagnosis One possible differential diagnosis for this client is Generalized Anxiety Disorder (GAD). GAD is a common and chronic disorder in which the affected individuals may experience recurrence often. It is best to identify the trigger of one’s anxiety and assist them in rationalizing their fears. Anxiety code in the Diagnostics and Statistical Manual (DSM-5) is ICD10 and 300.0 (41.1). Anxiety entails excessive anticipation, avoidance, worrying, and irrational fear (American Psychiatric Association, 2013). These stressors can be constant and influence erratic behavior that may mirror mania like paranoia or crippling fear from thoughts of impending doom. GAD can be challenging to treat as it is recurrent and is more successful with the use of Cognitive Behavior Therapy. 6650 Client Entry 8 Another differential diagnosis for this client is Bipolar Disorder with Depression (BPD). BPD entails extreme mood variations or swings between depression and overt excitement. Benzodiazepines are effectives in treating bipolar disorders, especially in acute manic episodes as an additional maintenance therapy (Saddock et a., 2014). The Diagnostics and Statistical Manual Five (DSM-5) code for BPD is 309.81 (F31.30). BPD often starts in late teen year for many people, like my client. The manic episodes associated with BPD can affect one’s interpersonal relationship, causes them to be a burden or embarrassment due to the disruptive and inappropriate behaviors. Other influencing factors for BPD include genetic factors, neuroinflammation, and social rhythm (Pei-chen et al., 2017). Interestingly, BPD has a strong familial correlation or hereditary influence. About 25% of first-degree relatives are affected by BPD (Saddock et al., 2014). Nierenberg et al (2007), also adds that “individuals with a positive family history were more likely white, less likely black, more likely female, more likely employed, less likely married, and more likely to be seen in psychiatric treatment settings. They were also more likely to have their initial major depressive episode before age 18.” This is to emphasize the specificity in the instances where such likelihood is possible. Case Formulation This case presents a thirty-two-year-old African American woman with no medical history and psychiatric history of anxiety, bipolar disorder 1, and insomnia. She presents to the clinic with reports of increased sadness, anxiety, blacking out, irrational behavior, and difficulty sleeping. She reports constantly worrying about her family and the future to come, especially with her wedding to plan. She and her siblings were close growing up and became distant when they all went to different universities. She has a history of suspension from fights in school, throwing objects, blacking out when angry, mood swings and, disruptive behavior. She claims that her behavior can be seen positively at work, like she’s fierce and affirmative. She denies her 6650 Client Entry 9 husband having any problem with her behavior that he can be the same way but he’s mostly calm and quiet. She shares that some of her interests includes singing, dancing, and journaling. Treatment Plan Pharmacologic intervention is best for clients with anxiety and BPD. Mental Health Progress and Privileged Note

Lithium is the first line drug of choice for BPD, especially during the manic phase. However, there are many other medications that can address both the mania and anxiety with less harmful side effects. This client could benefit from medication modification. She may need her Lamictal increased to three times a day, reaching the maximum daily dose of 150mg prior to switching to a different medication. Compared to other mood stabilizers, Lamictal is on the lower end of the list of bad side effects, with its worse being the stevens johns syndrome rash. Lamictal does not require blood monitoring like other mood stabilizers and has antidepressant and antimanic effects. This should also decrease the anxiety symptoms and if not a benzodiazepine like lorazepam or diazepam can be added as needed. This is the best plan for this client especially during her manic or acute phases, so she is not a danger to herself or others. She has mentioned blacking out in the past and throwing objects. One must calm her down first before counseling. Psychotherapy like CBT or ration emotive therapy can then be added for understanding and behavior remodification (Wheeler, 2014). The goal is to empower BT to use more of her words to communicate her feeling. This process may require emotional cognitive therapy. Sciberras et al (2018), shares that CBT can be successful in refining essential regions of performance in individuals with almost all forms of mental illnesses. Proper explanation of the medications’ effects and scheduled doses is essential to this client’s wellness. PMNHP must emphasize the importance of medication adherence for her betterment which will be assessed in the visit. Summary 6650 Client Entry 10 Furthermore, mental disorders stem from ailments or unbearable stressors that often result in reduced to no ability to manage the demands of life. Mental illnesses like BPD affects everyone and requires a lot of patience and supports. Affected family members must practice active listening, acknowledgement of perceptions and expectations. These supporting friends and family can facilitate the affected individual’s wellness by participating in their treatment program or attending therapy sessions if requested. I believe everyone needs help sometimes and the likelihood of one having support when in needed can worsen or enhance their mental health. Everyone strives for mental wellness and the ability to attain and sustain such actualization is often lost or not possessed by many. Thus, the advanced practitioner must keep this in mind when facing resistance to change or met with slow progress. Part 2: Family Genogram 6650 Client Entry 11 This is a genogram of my client BT, her siblings, as well as deceased parents, and grandparents. Below depicts the genogram of my thirty-two-year-old African American woman BT. Paternal Great Grandmother Janet Paternal Grandma Abigail Sister: WT-32 Father James Paternal Grandpa Elijah-70 Paternal Great Grandfather Joseph Great Grandma Suzette Great Grandpa Nathan Client: BT-32 Maternal Grandpa John Mother -Tiana Great Grandpa Daniel Great Grandma Gloria Sister: VT 32 Maternal Grandma. Sharon Maternal Great Grandpa Samuel Maternal Great Grandmother Sandra References 6650 Client Entry 12 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Nierenberg, A. A., Trivedi, M. H., Fava, M., Biggs, M. M., Shores-Wilson, K., Wisniewski, S. R., Balasubramani, G. K., & Rush, A. J. (2007). Family history of mood disorder and characteristics of major depressive disorder: a STAR*D (sequenced treatment alternatives to relieve depression) study. Journal of psychiatric research, 41(3-4), 214– 221. https://doi.org/10.1016/j.jpsychires.2006.02.005 Pei-Chen Hsu, Hsin-Chi Chen, Mei-Jou Lu, Ru-Band Lu, & Ching-Lan Lin, E. (2017). Mental Health Progress and Privileged Note

Care of Individuals With Bipolar Disorders. Journal of Nursing, 64(3), 19–26. https://doiorg.ezp.waldenulibrary.org/10.6224/JN.000036 Sadock, B. J., Sadock, V. A., & Kaplan, H. I. (2014). Kaplan & Sadock’s pocket handbook of clinical psychiatry. Philadelphia: Lippincott Williams & Wilkins. Sciberras, E., Mulraney, M., Anderson, V., Rapee, R. M., Nicholson, J. M., Efron, D., Lee, K., Markopoulos, Z., & Hiscock, H. (2018). Managing anxiety in children with ADHD using cognitive-behavioral therapy: A pilot randomized controlled trial. Journal of Attention Disorders, 22(5), 515–520. https://doiorg.ezp.waldenulibrary.org/10.1177/1087054715584054 Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse (2nd ed.). New York, NY: Springer Publishing Company. …Mental Health Progress and Privileged Note