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Running Head: PATIENT FAMILY ASSESSMENT 1

PATIENT FAMILY ASSESSMENT 2

Patient Family Assessment

Student’s Name:

Professor’s Name:

Date:

Patient’s Family Assessment

When we talk about a comprehensive assessment of the family of a client or patient, we it typically means is the practice used to inform the decision making procedure through identifying, considering and also weighing the dynamic that influences the patient and his family. The family usually tends to be the source of attention and security for the patient. In that case, the complete assessment of the family is considered in order to determine the welfare of the patient together with his family during situations that influence their safety matters, dangers of future treatment, capacity of parent protectiveness and during the compromise of a well-being of the patient. In other words, this type of assessment is employed to gather information which will help in defining where a specific problem may rise.

Demographic information: The patient involved dwells with her two parents, her older brother and a nanny, who is not connected to her by blood. This family’s is of Hispanic origin and both of her parents were brought up by both their biological parents. The patient is eight years old and her brother fifteen years of age.

Presenting problem: The living condition of this family did not satisfy the social worker that paid them a visit. He went ahead and concluded that their living conditions did not suite the living condition that is expected by the state; hence it needed intervention because it was not conducive for child growth. Also the two children seemed to be neglected because they seemed tired and the parents were convinced they are okay because they believed that at their age they were worse.

History or current illness: A few days ago the girl child was diagnosed with a severe case of typhoid which was one of the factors that capture the attention of the social worker. He was thinking that the diagnosis was due to the living condition of their home. Because the social worker had found out about the negligence part, he was convinced that the children were not well taken care of by the parents.

Past psychiatric history: The patient had no psychiatric history. None of his family member had the condition as well.

Medical History: Apart from regular colds and flu which is very normal because of the weather, the patient never had any serious issues when it comes to her health. This is according to the history records that the social worker pulled from the hospital that they visited.

Substance use history: After a strict scrutiny if the girl child’s parents and brother, I determined that the patient had never had any contact with any drugs or substance whatsoever. Despite that fact, the father admitted to being a regular smoker but he said that he neither smokes in the presence of the children nor in their house.

Developmental history: The patient was checked by a pediatrician; which was suggested by the social worker and there seemed to be no evidence of any developmental problems. The brother of the patient was also healthy physically and the parents were well nourished. The patient had toys in her room meaning she has a normal childhood.

Family psychiatric history: There were no cases of psychiatric conditions in the family, from their parents to the great grandparents of the patient. However, the daughter seemed to have instances of depressive disorder and the father did not believe in such illnesses.

Psychosocial history: It was evident that the parents did not care that much for their family but they proved to be a bit hard working. The parents had a healthy relationship with each other and they tend to understand each other. The patient’s brother seldom play with his sister and she also spends most of her time in her room whenever she is not in school.

History of abuse and/or trauma: The daughter seemed to be depressed at some point while the brother showed no sign of trauma. Being members of the Hispanic origin, the parents admitted to having a rough childhood. Because of this, the parents believed that giving food and shelter to their children was more than enough. Therefore they did not give their kids the attention and care that they need as children

Physical assessment: The children have no physical abnormalities and they are in great shape. There are sign of physical negligence since the girl is slender and appears to be distressed. Her vital signs included: a height of 50 inches, weight of 130lbs, temperature was normal 370C, RR was 16, BP 120/59 and Pulse 78BPM. The behaviors of the children are worrying because the girl spends most of her time in her bedroom while the brother is always outside and comes back to the house at night. The parents are not bothered in anyway.

Mental status exam: The family is capable of speaking fluent English language, they have learned their rights as American Citizens. The father is very quiet during the visit, the mother seems to care, the brother is just present while the girl looks overwhelmed and tired.

Differential diagnosis: The little girl, after being diagnosed with typhoid, had been taken to the hospital and received treatment. After a thorough investigation, it was confirmed that she had contracted the disease from school where there seemed to be a small outbreak. The girl was very sick, but the parents were not aware that she was suffering from depression for a while. This clearly depicted the fact that they never interact or look out for their feelings and attitude.

Case formulation: The two parents that got married had come to the United States to seek for greener pastures. It was found out that the parents were not in any way responsible for their daughter’s typhoid contraction because it was out of their control. They however, are not always keen with whatever activity their children take part in either at school or at home. The parents believe that providing them with food, shelter and other basic needs are enough because they never had such during their childhood. The father however drinks during the weekends while the mother does not drink or do drugs.

Treatment Plan: I believe that the parents need to be taught the skills of taking care of their children and worrying for their mental and physical well-being. Therefore they will take parenting classes which will help them with the problem. The first objective is that the parents will always have a family time every night to ensure that everyone is well and of clear mind and the parents will be taught on how to hold these meetings in their classes. The second objective is for the parents to ensure the parents are aware of mental diseases and create the habit of visiting hospitals regularly; this will be reached through development of schedules with their doctor to ensure they do not fail to attend any session. The classes will take an estimated period of two months and the family should receive social support from their friends and family.

Genogram

Son

Daughter

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Paniagua, F. A. (2018). ICD-10 versus DSM-5 on Cultural Issues. SAGE Journal, 1–14. https://doi.org/10.1177/2158244018756165

Valdez, J. N. (2012). Psychotherapy with bicultural Hispanic clients. Psychotherapy Theory Research & Practice, 37(3), 240-246. https://doi.org/10.1037/h0087712}

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.