Care Across the Lifespan I

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Focused SOAP Note and Client Case Presentation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP PRAC 6665C: Psychiatric Mental Health Nurse Practitioner Care Across the Lifespan I 

Jannia Mendez MSN APRN PMHNP BC

October 11, 2022

Subjective:

CC (chief complaint): “I’m taking medication. I need an outlet like work.”

HPI: K.G is a 25-year-old male accompanied by his mother. He is alert and oriented to self, time, place and situation. He is also calm and cooperative. The client reports his anxiety and depression has improved. However, the client reports that since his last visit, he has been smoking marijuana and drinking alcohol everyday. His mother reports he drinks excessively to the point of passing out. The client reports he has been taking his medication but needs an outlet like work. The client says he is sleeping well and rates his satisfaction with life as a five out of ten, where ten represents total happiness.

Substance Current Use: The client is currently drinking alcohol and smoking marijuana daily. He is also a daily tobacco smoker.

Medical History:

· HIV, dyslexia, ADHD

· Current Medications: Paliperidone ER 6 mg tablet, extended-release 24 hr, Take one tab nightly, BIKTARVY 50-200-25 mg tablet

· Allergies: No allergies reported.

· Reproductive Hx: The client is sexually active. No children.

ROS: Psychiatric: The client reports changes in his moods, depression, sadness, anxiety, hopelessness and worthlessness. He denies suicidal ideations, homicidal ideations, visual or auditory hallucinations at the time of interview.

GENERAL: The client is alert and oriented to place person, time, and event. He looks well-nourished, and there are no apparent signs of distress.

· HEENT: The skull of the client is normocephalic and atraumatic. He does not report any significant vision changes or pain in his eyes. He does not also report any difficulties in swallowing or auditory challenges.

· SKIN: Appropriate for age, race and ethnicity. No abnormalties noted.

· CARDIOVASCULAR: There is no report of orthopnea, edema, or chest pain.

· RESPIRATORY: No wheezing or coughing. The client denies experiencing any dyspnea.

· GASTROINTESTINAL: The client does not report any pain or discomfort

· GENITOURINARY: The client does not report any hematuria or dysuria.

· NEUROLOGICAL: The client does not report any focal weaknesses, numbness, blackout, or seizures.

· MUSCULOSKELETAL: The client does not report any joint pains or swellings.

· HEMATOLOGIC: The client does not report abnormal bleeding or bruising.

· LYMPHATICS: No inflammations are reported.

· ENDOCRINOLOGIC: There are no reports of polydipsia or polyuria.

Objective:

Diagnostic results: Vitals: Height 69 inches, weight: 179.5, BMI: 26.51, BP: 112/66 mmHg, Temperature: 98.7 F, Pulse: 89 bpm, Respiratory Rate: 18 bpm

Assessment:

Mental Status Examination

The client is slightly dishevleled but appropriately dressed for the occasion and season. During the mental status examination, the client is calm and cooperative. He has a fair attitude and pleasant demeanor. The client appears apprehensive when topics such as adherence to medication are brought up. He has a full affect, slightly restless and avoids eye contact. The client expressed the desire to adhere to his medication regimine and participate in therapy. He was also receptive to education on the risks and dangers of using marijahana and drinking alcohol while taking psychotropic medications. The client verbalized understanding of provided education.

Diagnostic Impression:

Schizoaffective disorder, bipolar type (disorder) (F25.0/295.70)

Some prominent features of schizoaffective disorder bipolar type are psychosis and mood symptoms (Schnitzer et al., 2020). Its hallmarks include mood disorders and depression (Schnitzer et al., 2020). The symptoms of schizoaffective disorder are broad but include manic or depressive episodes and psychosis (Schnitzer et al., 2020). Some other symptoms characteristic of schizoaffective disorder bipolar type are an individual neglecting their hygiene and appearance (Schnitzer et al., 2020). Individuals suffering from the disorder are also likely to experience mood swings which may see the individual pendulum between exuberance and melancholy (Schnitzer et al., 2020). Clients with schizoaffective disorder are also likely to engage in risky sexual behavior, which may expose them to sexually transmitted infections.

Substance abuse (disorder) (F19.10)

Substance abuse disorder is a mental health condition where the affected individual has a persistent impulse to use a substance and is unable to reduce, stop or control the use of the substance (Finegan, 2021). Such individuals continue using a substance even when they know its adverse effects on their health. The individual also uses the substances in more significant amounts than when they previously began using them (Finegan, 2021). Eventually, an individual builds tolerance to the substance and may need to use a more significant amount to achieve the same effect a smaller amount previously did. Alcohol and marijuana are two of the most commonly abused substances among individuals suffering from substance abuse disorder (Finegan, 2021).

Difficulty sleeping (Z72.820/V69.4) Sleep deprivation

Sleep deprivation is a mental health condition where the affected individual lacks a regular sleeping and waking cycle. The individual can go on prolonged periods where they do not sleep. It is a state where a person does not get enough sleep due to a sleep disorder, psychiatric illness, chronic illness, effects of a medication, or life events *. Without enough sleep, an individual’s cognitive and mental functioning can be impaired since they are not getting the rest they need.

Reflections:

One of the main learning points regarding this case was the extent to which schizoaffective disorder can influence risky sexual behavior in an individual. Impaired decision making combined with risky sexual behavior leaves a high likelihood for STI exposre. Individuals with schizoaffective disorder also often struggle with substance abuse issues. This incividual has competed an inpatient substance abuse program within the past six months. However, he has relapsed several times and has yet to accomplish any notable sobriety. One of the ethical considerations that should be considered in this case is client autonomy. Although his mother accompanies him, he is an adult and, as such, can make autonomous decisions. Non-maleficence should also be considered to ensure no harm comes to the client while treating him and prescribing psychotropic medications. Due to his history of substance abuse, stringent eduducation on the risks and dangers of non-adherance to taking medications as ordered must be reiterated during every encounter.

Case Formulation and Treatment Plan: 

This individual has no recent reports of psychosis. Therefore, this client should continue taking Paliperidone ER 6 mg tablet, extended-release 24 hr, taking one tab nightly as ordered. This medication seems to be stabalizing the client’s symptoms. The client should also be subjected to cognitive behavioral therapy to help address his abuse of marijuana and alcohol. Cognitive behavioral therapy has been proven effective in managing clients' substance abuse disorders (Magill et al., 2019). In addition to cognitive behavioral therapy, the client can also be subjected to motivational interviewing to encourage ambivalence towards abusing alcohol and marijuana (Hawk & D’Onofrio, 2018).The client should also be educated to ensure they understand the severe health effects of continuing to abuse alcohol and marijuana. This individual should be encouraged to attend AA meetings and Focus on Recovery. Furthermore, a follow-up appointment should be scheduled after four weeks to evaluate his progress. The client and the mother should verbalize the treatment plan to indicate they have a full understanding of risks and benefits.

References

Finegan, B. A. (2021). Substance Abuse Disorder. In  Preoperative Assessment (pp.

301-304). Springer, Cham. https://doi.org/10.1007/978-3-030-58842-7_48

Hawk, K., & D’Onofrio, G. (2018). Emergency department screening and interventions

for substance use disorders.  Addiction science & clinical practice,  13(1), 1-6.

https://doi.org/10.1186/s13722-018-0117-1

Hudson, A. N., Van Dongen, H., & Honn, K. A. (2020). Sleep deprivation, vigilant

attention, and brain function: a review.  Neuropsychopharmacology,  45(1), 21-30. https://doi.org/10.1038/s41386-019-0432-6

Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M., Tonigan, J. S., & Carroll, K.

(2019). A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition.  Journal of consulting and clinical psychology,  87(12), 1093. https://doi.org/10.1037/ccp0000447

Schnitzer, K., Beckmann, D., & Freudenreich, O. (2020). Schizoaffective disorder:

treatment considerations.  Psychiatric Annals,  50(5), 200-204. https://doi.org/10.3928/00485713-20200409-01