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6650_week_3_journal.docxPracticum Experience Journal Week 3
Student Name:
E-mail Address:
Practicum Placement Agency's Name:
Preceptor’s Name:
Preceptor’s Telephone:
Preceptor’s E-mail Address:
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Week 3: Journal Entry
Comprehensive Family Assessment
Demographic Information: Caucasian American upper class family
Presenting Problem: “Our son continues to struggle with using drugs and partying"
History of Present Illness: The clients present due to their son abusing drugs and partying. The mother is a 43 y/o Caucasian female (L.R.), the father is a 48 y/o Caucasian male (W.R.) and the son is a 20 y/o male. They report that their son began using drugs and partying during his senior year of high school. The parents report that the relationship with their son is “broken” and they are worried about his wellbeing. They live in a single home household, the father is a medical doctor and the mother is a stay at home mom.
Past Psychiatric History: Mother has a history of depression and anxiety that is controlled with medication. Father has no previous psychiatric history. The son has no previous psychiatric history.
Medical History: None identified
Substance Abuse History: The son report that he smokes cannabis daily, he also has been abusing Xanax by mouth approximately 3-4 times per week and will drink alcohol 3-4 times per week.
Developmental history: No developmental delays noted
Family psychiatric history: The maternal grandmother has a history of bipolar type 2, no other known family psychiatric history
Psychosocial history: The father works full time as a well-known medical doctor in the community. The mother is a stay at home mom. The son is currently unemployed and not attending any college courses.
History of abuse/trauma: The father denies any history of physical, sexual or emotional abuse, the mother reports a history of physical and emotional abuse in childhood from her father. Son denies any history of physical, sexual or emotional abuse.
Review of Systems:
HEENT: “needs to be added.”
SKIN: “needs to be added.”
CARDIOVASCULAR: “needs to be added.”
RESPIRATORY: “needs to be added.”
GASTROINTESTINAL: “needs to be added.”
GENITOURINARY: “needs to be added.”
NEUROLOGICAL: AAOx4
MUSCULOSKELETAL: No weakness, full ROM, steady gait.
HEMATOLOGIC: “needs to be added.”
LYMPHATICS: “needs to be added.”.
PSYCHIATRIC: “needs to be added.”
ENDOCRINOLOGIC: “needs to be added.”
Physical Assessment:
Vital signs: “needs to be added.”
Neck: “needs to be added.”
Chest/Lungs: “needs to be added.”
Heart/Peripheral Vascular: “needs to be added.”
ABD: “needs to be added.”
Skin/Lymph Nodes: “needs to be added.”
Mental Status Exam
Level of alertness: Father: alert Mother: alert Son: alert
Orientation: Father, Mother and Son: person, place, time and situation
Mood: Father: anxious, worried Mother: anxious, worried Son: Guarded
Affect cong. w/thought content
SI/HI: Father: denies Mother: denies Son: denies
Hours slept: 8
Speech: Father: normal rate & rhythm Mother: normal rate & rhythm Son: normal rate & rhythm
Language: Father: logical, goal-directed Mother: Son:
Thought processes: coherent & goal-directed
Associations: intact
Thought content: no delusions elicited
Hallucinations: denies
Attention: adequate
Concentration: adequate
Intellect: average per vocabulary
Fund of knowledge: adequate
Insight/Judgment: fair
Diagnosis DSM-5
Cannabis Abuse (F12.1)
Sedative, hypnotic or anxiolytic related abuse (F13.1)
Individualized Treatment Plan
Addiction or drug abuse not only affects that individual but will affect the family as a whole. In fact, addiction is sometimes referred to as a “family disease.” Successful treatment, therefore, often incorporates the family of the person struggling with addiction (Daley, 2013). This family is seeking family therapy due to the son’s drug use and lack of relationship with the parents. Family therapy typically lasts approximately 8 to 20 sessions depending on the case.
This family therapy will be focused on assisting the client to gain insight to his drug abuse and help him identify that there is a problem. Also to improve the mental health and wellbeing of the family unit, repair relationships between the parents and son, improve communication styles, and to help the family recognize enabling behaviors (Daley, 2013).
PATERNAL
MATERNAL
F Marie, 80
Bipolar
M John, 86
No psych hx
M Michael, 77
F Claire, 87
No psych hx
M William, 63
No psych hx
F Richard, 52
MVA
Accident
a
F Lucy, 43
Depression and anxiety
M Jason, 20
Substance use
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Washington, DC: Author.
Daley D. C. (2013). Family and social aspects of substance use disorders and treatment. Journal of food and drug analysis, 21(4), S73-S76.
Wheeler, (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
Zhou, X., Reynolds, C. R., Zhu, J., Kamphaus, R. W., & Zhang, O. (2018). Evidence-based assessment of ADHD diagnosis in children and adolescents. APPLIED NEUROPSYCHOLOGY-CHILD, 7(2), 150–156. https://doi-org.ezp.waldenulibrary.org/10.1080/21622965.2017.1284661
Group Therapy Progress Note
American Psychological Association | Division
Client: #2 Mother of JD Date: 12/8/18
Group name: Family therapy Minutes: 60
Group session # 2 Meeting attended is #: 2 for this client.
Number present in group 2 of 2 scheduled Start time: 10am End time: 11am
Assessment of client
1. Participation level: ❑X Active/eager ❑Variable ❑ Only responsive ❑ Minimal ❑Withdrawn
2. Participation quality: ❑ Expected ❑X Supportive ❑x Sharing ❑x Attentive ❑ Intrusive
❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________
3. Mood: ❑ Normal ❑Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: ____worried
4. Affect: ❑X Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________
5. Mental status: ❑X Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused
❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________
6. Suicide/violence risk: ❑X Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt
7. Change in stressors: ❑ Less severe/fewer ❑X Different stressors ❑ More/more severe ❑ Chronic
8. Change in coping ability/skills: ❑ No change ❑X Improved ❑ Less able ❑ Much less able
9. Change in symptoms: ❑ Same ❑X Less severe ❑ Resolved ❑ More severe ❑ Much worse
10. Other observations/evaluations: __CLIENT ENGAGES OFTEN IN GROUP AND IS VERY SUPPORTIVE. SHE SHARES COPING SKILLS THAT HAVE BEEN EFFECTIVE WITH HER TRIGGERS DURING THE WEEK.
Journal on stressors, challenges and successes
Journal experiences that trigger negative emotions or reactions.
