Nursing unit 4 assignment

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Unit 4 Case Study: An elderly client with a history of depressive disorder was brought to the emergency room after cutting his hands. Read the scenario below and then follow the assignment directions on Tab 2.

Case Study Scenario:

Rick is a 72-year-old man previously diagnosed with depressive disorder. He was brought to the emergency room by his wife after he cut his hands with a hacksaw, sustaining damage to various structures and needing surgical intervention. His wife describes that she was going back to work after an extended leave to care for her husband after a recent hospital admission and that this was his first day home by himself. Her son came to check on Mr. Rick and found him on the floor bleeding profusely and called the ambulance.

Mr. Rick retired as an electrician about 8 years ago. Over the past 5 years, his wife describes an increasing indifference to events. For example, when their basement was flooded due to a water leak, Mr. Rick opened the door to the basement, saw the water, and closed the door, saying nothing. This was uncharacteristic of him in the context of his job and training. His wife tells you that the first symptom noted was “not caring about things,” which could be interpreted as apathy. She notes that the reason he retired early was that he could not keep up with the requirements of his job.

There has been an apparent functional decline. While he is independent in all his activities of daily living, other than cooking, he is dependent on most instrumental activities of daily living. His most recent MoCA score was 16 out of 30. Several comorbid medical conditions are of concern, including hypertension, type 2 diabetes mellitus, and obstructive sleep apnea.

He was assessed for depressed mood by a psychiatrist and started on escitalopram 10 mg daily 1 year ago. There was a mild improvement, but after a few months, he attempted suicide through an overdose. He was admitted to the inpatient psychiatric ward. During that admission, he used shoelaces to tie a ligature around his neck and to the bedroom furniture in an attempt to end his life.

His mood improved over the following few weeks, and he was discharged home with support, including a mental health nurse visiting once a week. His wife had stayed with him at home during the past month, and he was distressed when she left him, even for short periods. He was often tearful even when she was home, and he felt things would never get better. The current episode of self-harm happened on the day she returned to work.

Assignment Instructions

Use the SOAP note template to complete the documentation with the information provided.

· Formulate appropriate diagnoses and design a treatment plan.

· Explain what further information you will explore to aid in accurate diagnosis.

· What treatment management is recommended for this patient with self-harm?

Assignment Requirements:

Before finalizing your work, you should:

· be sure to read the assignment description carefully (as displayed above);

· consult the grading rubric (located in Course Resources, Grading Rubrics submodule) to make sure you have included everything necessary; and

· utilize spelling and grammar check to minimize errors.

Your writing assignment should:

· follow the conventions of Standard English (correct grammar, punctuation, etc.);

· be well ordered, logical, and unified, as well as original and insightful;

· display superior content, organization, style, and mechanics; and

· use APA 7th edition format.

PMHNP_Clinical_SOAP_Note_Template_2402C.docx

Patient Name: XXX

MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00 End Time: 10:54

Billing Code(s): 90213, 90836

(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

Reviewed Allergies: NKA

Current Medications: Fluoxetine 10mg daily

ROS: no complaints

O-

Vitals: T 98.4, P 82, R 16, BP 122/78

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A - with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses

2.

3.

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Non-pharmacological Tx: Psychotherapy Modality used: CBT

Pharmacological Tx: (be specific and give detailed Rx information)

Education: discussed smoking cessation

Reviewed medication side effects and adherence importance

Follow-up: in one week or earlier if any depressive symptoms worsen.

Referrals: none at this time

NU673_Assignment_Rubrics.docx
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