Nursing.

Psychotherapy_for_the_Advanced_Practice_Psychiatri..._----_Part_I_Getting_Started.pdf

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APPENDIX 3.1

Outline of the Comprehensive Psychiatric Database

I. Identifying data A. Age B. Sex/Gender preference C. Race/Ethnicity D. Marital status E. Children F. How arrived? G. Who referred? Why? H. Mental health providers? I. Sources of information J. Number of times seen in this setting

II. Client-identifi ed problem A. What the client states he or she wants help with B. Verbatim statement

1. “I’m depressed.” 2. “My mother brought me. I don’t need help.”

III. History of current illness A. Onset, duration, or change in symptoms over time

1. Organized chronologically 2. Client’s perception of changes in himself or herself over time 3. Others’ perception of changes in the client (e.g., spouse, employer, and friend)

B. Precipitating factors 1. Why now?

C. Baseline functioning D. Last period of stability

IV. Psychiatric history A. Inpatient

1. Location, dates, and lengths of stay 2. Diagnoses 3. Previous episodes of current symptoms 4. Previous episodes of other disorders not described in history of current illness 5. Legal status 6. Use of medications or other treatments, including doses, blood levels,

clinical response 7. Perception of helpfulness

B. Outpatient 1. Dates, duration, and frequency of sessions 2. Location, type, and focus of treatment or therapy 3. Perception of helpfulness

Wheeler, K. (Ed.). (2013). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from waldenu on 2020-09-10 18:55:19.

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138 I GETTING STARTED

V. Medical history A. Past and current medical problems

1. Illnesses, operations, and hospitalizations, especially history of open or closed head injury, birth trauma, seizure disorder, and encephalitis or meningitis

B. Past and current medications 1. Dosages, blood levels, and clinical response 2. Adherence

C. Primary care physician, specialists, and phone numbers D. Allergies (and reactions)

VI. History of substance use and abuse A. Episodes of alcohol abuse

1. What, how much, and consequences (e.g., charges for driving under the infl uence [DUI], other legal sequelae, and loss of relationships, jobs, and opportunities)

2. Does the client or others think he or she has a problem? 3. Typical pattern of use 4. History of blackouts, seizures, complicated withdrawal, or delirium tremens 5. History of suicide ideation, gestures, or attempts while intoxicated or

withdrawing 6. Longest period of sobriety 7. What facilitates sobriety? 8. Previous treatments (e.g., detoxifi cation, rehabilitation, counseling, and

Alcoholics Anonymous) B. Episodes of illicit or prescription drug abuse

1. What, amount, route of administration, and consequences (e.g., DUIs, other legal sequelae, and loss of relationships, jobs, and opportunities)

2. Does the client or others think he or she has a problem? 3. Typical pattern of use 4. History of suicide ideation, gestures, or attempts while intoxicated or

withdrawing 5. Longest period of sobriety 6. What facilitates sobriety? 7. Previous treatments (e.g., detoxifi cation, rehabilitation, counseling, and

Narcotics Anonymous) C. Tobacco

1. Number of cigarettes or packs per day 2. Years client has smoked 3. Cessation attempts

D. Caffeine 1. Form (coffee, cola, tea, and pills) 2. Amount consumed per day 3. Cessation attempts

E. Over-the-counter drugs or “herbal” medications 1. What, how much, purpose, frequency, side effects, and interactions with

prescribed medications 2. Perceptions of helpfulness or effi cacy

VII. Developmental history A. Developmental milestones and family of origin

1. Information about mother’s pregnancy and delivery 2. Were developmental milestones reached as expected? 3. Childhood temperament and important family events (e.g., death,

separation, and divorce) Wheeler, K. (Ed.). (2013). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from waldenu on 2020-09-10 18:55:19.

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3 ASSESSMENT AND DIAGNOSIS 139

4. Information about early experiences and relationships (e.g., school experi- ences, academic performance, delinquency, family of origin relationships, family stability, early sexual experiences, and history of abuse or neglect)

5. Important cultural or religious infl uences 6. Values, beliefs, or framework for meaning

B. Educational history C. Occupational and military history

1. Number and types of jobs; reasons for termination 2. Highest rank attained; conditions of discharge 3. History of disciplinary problems or combat

D. Legal history VIII. Family history

A. Psychiatric or substance use disorders 1. Have any family members undergone psychiatric or substance abuse

treatment (inpatient or outpatient), attempted or completed a suicide, had problems with drugs or alcohol, and behaved strangely?

2. Have any family members successfully used any psychotropic medications for the same or similar symptoms?

3. Family attitudes toward mental illness B. Pertinent medical disorders in blood relatives (e.g., seizure disorder or

thyroid disease) IX. Social history

A. Current social situation 1. Living arrangements (e.g., where, with whom, for how long, how stable,

and how satisfactory or desirable) 2. Employment (e.g., where, for how long, how stable, and how satisfactory

or desirable) 3. Financial (e.g., current sources of income, how stable, and how adequate) 4. Insurance coverage

B. Breadth of client’s social life 1. Is he or she a loner or involved in an intimate relationship? 2. How diffi cult is it to get into and out of relationships?

C. Past and present levels of functioning 1. Marriage, parenting, and work 2. Client strengths and strategies used to manage stress, resources, or positive

memories (draw a line and place important positive memories and events) 3. Current functional defi cits (e.g., activities of daily living, task performance,

and relationships) X. Trauma history

A. Ten most signifi cant disturbing events in life B. Violence

1. To self a. What, when, where, how, why; warning signs or symptoms, triggers,

and consequences b. How intense, specifi c, and controllable is current ideation

2. To others or property a. What, when, where, how, why; warning signs or symptoms, triggers,

and consequences b. How intense, specifi c, and controllable is current ideation

3. Current access to weapons a. What, where, why; plan for use; plan for disposition of weapon b. How will disposition of weapons be verifi ed?

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140 I GETTING STARTED

XI. Psychiatric review of systems (ROS) A. Includes all symptoms not part of the current episode or presentation B. May have to ask specifi c questions about the presence or absence of these

symptoms 1. “Are you now or have you ever had any of the following …”

C. Anxiety symptoms 1. Shortness of breath, heart palpitations, panic attacks, sweating, fl ushing,

hyperventilation, sense of doom, fear of death or collapse, cold or clammy skin, and tingling sensations in extremities

D. Mood symptoms 1. Sadness, irritability, anergia, fatigue, lethargy, tearfulness, increased or

decreased appetite or energy, changes in sleep or libido, suicide ideation, homicide ideation, hypomania (e.g., spending sprees, increased energy, and religious preoccupation beyond baseline), and feelings of hopeless- ness, helplessness, or worthlessness

E. Psychotic or cognitive symptoms 1. Hallucinations, delusions, thought insertion, thought blocking, thought

broadcasting, fl ight of ideas, hyper-religiosity, tangentiality, looseness of associations, and circumstantiality

XII. Mental status examination (MSE) A. Informal: begins immediately on contact with the client and includes an

informal assessment of the client’s characteristics 1. Appearance 2. Manner of relating 3. Use of language 4. Mood and affect 5. Content of speech 6. Perceptions 7. Abstracting ability 8. Judgment 9. Insight

B. Formal: focused, structured assessment of the client’s characteristics 1. Appearance: overall appearance, dress, grooming 2. Attitude: attitude toward examiner (e.g., hostile, cooperative, evasive) 3. Behavior and psychomotor activity: gait, carriage, posture, activity level 4. Speech a. Rate, amount, tone, impairment, aphasia 5. Mood and affect

a. Mood (i.e., how the client reports feeling) in relation to affect (i.e., emotional expression observed by the therapist)

b. Depth and range of emotional expression 6. Perception

a. Hallucinations i. Auditory

ii. Visual iii. Gustatory: taste (temporal lobe dysfunction?) iv. Olfactory: smell (temporal lobe dysfunction?) v. Tactile: Skin sensations (alcohol withdrawal and intoxication?)

vi. Kinesthetic: feeling movement when none occurs vii. Hypnagogic: occurs while falling asleep

viii. Hypnopompic: occurs while waking up

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3 ASSESSMENT AND DIAGNOSIS 141

b. Illusions: misinterpretations of actual sensory stimuli c. Depersonalization: feels detached and views self as unreal d. Derealization: experiences objects and persons outside of self as unreal

7. Thought process a. The pattern of a client’s speech allows the therapist to observe the

quality of the thought process, including its fl ow, logic, and associations. Abnormalities include the following:

i. Loose associations (LOAs) ii. Tangentiality

iii. Circumstantiality iv. Thought blocking (TB) v. Thought insertion (TI)

vi. Flight of ideas (FOAs) vii. Perseveration

viii. Echolalia 8. Content of thought

a. Delusions i. Paranoid or persecutory

ii. Grandiose iii. Nihilistic iv. Somatic v. Bizarre

b. Ideas of reference c. Obsessions d. Suicidal thoughts e. Homicidal thoughts

9. Judgment a. An assessment of social judgment involves determining whether a

client understands the consequences of his or her actions b. Must recognize differences in cultural values when assessing

judgment c. “What would you do if you found a sealed, stamped, addressed

envelope on the sidewalk?” 10. Insight

a. Must assess whether a person is aware of a problem, the cause of the problem, and what type of help is needed to address the problem

11. Cognition a. A formal mental status examination measures the ability of the brain to

function by assessing the following cognitive functions: i. Consciousness: alert, confused, drowsy, somnolent, obtunded,

delirious, stuporous, and comatose ii. Orientation: knows who he or she is, where he or she is, and what

day it is iii. Memory: can remember what was eaten for breakfast today;

has remote memory for long-past events iv. Recall: can recall three objects after 5 minutes v. Registration: can name three objects immediately

vi. Attention: can spell world forward and backward vii. Calculation: can do serial 7’s or count backward from 20

viii. Language: can name items, repeat a phrase, follow simple commands, read, write, and copy a design

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XIII. Diagnostic and Statistical Manual of Mental Disorders, fi fth edition (DSM-5) differential diagnosis A. On a single axis, lists the principal psychiatric, neurodevelopmental,

neurocognitive, and other disorders requiring further assessment, along with the corresponding ICD code(s)

B. Includes so-called “rule-out” and/or “provisional” diagnoses C. ICD-9 codes are listed before each disorder name, followed by ICD-10 codes

in parentheses D. ICD-9 codes will be used in the United States through September 30, 2014.

IDC-10 codes will be used starting October 1, 2014. XIV. Case formulation

A. Presents a brief summary of the client and rationalizes the diagnoses 1. Minimal identifying data, including past diagnosis 2. Abbreviated recapitulation of presenting symptoms, onset,

and course 3. Draws from all sections of the database as needed

B. Outlines the contributing factors, precipitants, and stressors C. Summarizes the logic behind the differential diagnoses D. Identifi es information still needed to confi rm the diagnoses

XV. Treatment plan A. Biologic

1. Medications (e.g., name, dose, route, for what purpose, and client’s level of understanding of medication education)

2. Diagnostic tests (e.g., where, when, and who will administer) 3. Referrals for primary care

B. Psychological 1. Therapeutic modalities to be used and with what focus

a. Individual psychotherapy? b. Group psychotherapy? c. Family therapy? d. Case management?

C. Social 1. Support or self-help groups 2. Mobilization of family resources 3. Vocational rehabilitation 4. Financial planning

D. Strengths 1. Overt identifi cation of client strengths, values, and beliefs to support or

draw from in implementing the identifi ed treatment plan

Data from APA (2006); Gordon and Goroll (2003); Marken, Schneiderhan, and Munro (2005); Morrison (2008); Sadock, Sadock, and Ruiz (2009); Scully and Thornhill (2012); Shea (1998).

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