wk 5,7.8 Prac

Running head: PRACTICUM-ASSESSING CLIENTS 1

PRACTICUM-ASSESSING CLIENTS 8

Practicum-Assessing Clients

Week 5

Practicum-Assessing Clients

McLeod and McLeod (2016) argue that a client assessment is of importance in that it allows for the healthcare providers to have the ability to develop a comprehensive plan of action. This includes the determination of the plan for treating the patient of the plan for nursing care among psychotherapy patients. This paper seeks to select and assess a client and providing a family genogram. 

Demographic information

The client selected is called M. T and is female aged 27. M. T is an African American and resides in Florida. She is newly divorced and has three children two boys and one girl. M.T has been getting psychiatric medication for the past 18 months and was referred by her initial counselor as a result of a change of location. The main issue of concern is that she complains of not getting the necessary support from the father of her children and that she is challenged with the financial needs of the children. Irrespective of the fact that she has complained to the father of the children on the need for support, she has not been in a position to get the support needed.  

Presenting problem

There has not been a record of any issue of concern relating the healthcare standards. The mother has never had any health issues in the past. She was diagnosed with depression since she separated with the father of their children. M.T complains that she cannot be in a position to manage her financial status and is not in a position to maintain a healthy financial standing with the others. 

History of present illness

The patient has complained about her inability to manage her finances for the past 18 months. She has always been able to blame others for her financial challenges. The patient visits a counselor who helped in the provision of guidance and consoling before referring her to the psychiatrist who is helping her at the moment. 

Past psychiatric history

The family issues are not in a position to manage the needs as a result of the rising challenge of care. There has not been a report on any family issues and this has resulted in the deterioration in the number of psychiatric health standards. The efforts that are put in the assessment of the family health has been eliminated. In the family, there are little issues of concern on the improvement of the health standards. The family has not had any reports on issues of the behavior of psychiatry. 

Medical history

In the past time that she has not been feeling okay, the patient has reported that she has not made use of any medication. The ease in the support of the healthcare needs of patients is critical and ensures that one can eliminate any challenges of lack of reliable strategies of care. The patient indicates that during the time she has not been okay, she has always focused on visiting healthcare providers and getting guidance.

Substance use history

The information presented by the patient shows that she has not made use of any drugs in the past and she is not using any drugs. The assessment is made and it is found that the patient has not made use of any drugs recently and from her medical history, it is evident that she has not made use of the medication. 

Developmental history

During her growth, M. T has presented that she has not had any issues of concern that has influenced her development history. She has not been reported to have had any health challenges regarding the development of her body. She has been in a position to grow well as expected in her life. 

Family psychiatric history

The issues of depression have been reported in the family with the grandmother being reported to have had issues of anxiety. The challenge of concern that is seen is that there is a challenge in the assessment of the actual health issues that have been reported for the family. This could be useful for the treatment of the patient but there is a lack of enough information on the means of developing the health standards of patients. The other issues of concern that could be an indication of family psychiatric issues are the challenge of the use of alcohol. The father of M. T has been reported to have been making use of alcohol for the past 8 years. 

Psychosocial history

The patient has presented that she has friends at work and the neighbors are friendly. This is an indication that the psychosocial history is okay. The efforts to ensure that one is getting a reliable standard of patient care, and allowing for the friends to enhance their friends to be with them. The patient is seen to have a positive relationship with the other people living in the community. 

History of abuse and/or trauma

M. T has presented that as much as she has never been abused physically, she has had issues of being abused emotionally. She has had challenges with her husband where the husband before the divorce was always undermining her work. This affected her emotionally and felt abused in the marriage. 

Review of systems

General: The patient has complained that she is being influenced by the issue of care and that she does not have enough financial standards.

Head: There are no reports of migraine headaches 

ENT: The patient has presented that she does not have any issues of her ears, eyes or throat. 

Neck: With physical assessment, there is no indication of swelling in her neck

Cardiopulmonary: There are no reports of cases of cough or wheezing. There is no report of issues of pain in the chest no murmurs 

GI: There is no report of a reduction in her appetite

GU: There is no report of issue dysuria 

MS: The patient has not presented any complaints on her back or joins 

Skin: There is no report of skin rashes and the skin looks oily

Neuro: The issue of seizures 

Psych: No reports are indicating that she has had issues on her physical body figure and there are no indications of change of moods 

Physical assessment

Vital Signs: weight, 46kg, Temperature, 37.5C, Blood pressure: 110/62

Appearance: The patient is seen to be healthy with a slight tan being observed. 

Mental status exam

The mental status of the patient is seen to be okay and she presents that she is feeling okay. With the physical assessment, it is indicated that she is well oriented. 

Differential diagnosis

The health issue that is seen in this case is as a result of the challenge of divorce. The main health issue or diagnosis that is possible is an anxiety disorder or the patient is suffering from a separation disorder. 

Case formulation

The issue of concern is the rising challenge of financial standards and the challenge in the process of maintaining the family standards with the little work being done. The fear seen is as a result of the challenge of emotional abuse that M. T has faced. There is a need for the assessment and upon assessing the patient it is found that she has a separation disorder.

Treatment plan

The patient should receive support and guidance as a result of the separation. There will be a need for the guidance of the patient for up to 4 months. The objective that is to be focused on is to ensure that the mother can involve the father in the upkeep of the children.

Genogram

 

 

References

McLeod, J., & McLeod, J. (2016). Assessment and formulation in pluralistic counseling and psychotherapy. The handbook of pluralistic counseling and psychotherapy, 15-27.