NUR 504 506
Miss Cookie
RealisticTreatmentPlan.pptxRealistic Treatment Plan
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Introduction
Hello Everyone,
This presentation is designed for nurse practitioners and other advanced practice providers, emphasizing the integration of evidence-based practice and the pivotal role of the nurse practitioner in psychiatric care.
It highlights subjective and objective data, assessment, and a comprehensive treatment plan.
The content is grounded in DSM-5-TR criteria and current U.S. clinical guidelines.
It is designed for nurse practitioners and advanced practice providers in psychiatric care.
You will learn how to collect, synthesize, and apply clinical data to develop individualized treatment plans.
Welcome, everyone. I will walk you through a detailed clinical case, highlighting subjective and objective data, assessment, and a comprehensive treatment plan grounded in the DSM-5-TR criteria and the most current U.S. clinical guidelines. This presentation is designed for nurse practitioners and other advanced practice providers, emphasizing the integration of evidence-based practice and the pivotal role of the nurse practitioner in psychiatric care. By the end of this session, you will have a deeper understanding of how to collect, synthesize, and apply clinical data to develop an individualized treatment plan. Thank you for joining, and let’s begin our journey through this patient’s story and care plan.
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Subjective Data – Chief Complaint & Demographics
A 28-year-old African American female reports six weeks of persistent sadness and loss of interest.
She describes difficulty getting out of bed most mornings and feeling “numb.”
She works full-time as a software engineer and lives alone in an urban apartment.
Employment stressors, living situation, and cultural background may affect symptom presentation.
These social determinants inform a culturally sensitive, patient-centered treatment approach.
The chief complaint for this case is a 28-year-old female patient who presents with persistent feelings of sadness and loss of interest in daily activities for the past six weeks. She reports difficulty getting out of bed most mornings and describes her mood as “numb.” Demographically, she is a single African American female, employed full-time as a software engineer, living alone in an urban apartment. Understanding her demographic context is essential, as factors like living situation, employment stressors, and cultural background can influence both symptom presentation and treatment adherence. We will explore how these social determinants intersect with her psychiatric symptoms and inform a culturally sensitive, patient-centered treatment approach.
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History of Present Illness (HPI) & Eight Dimensions
Depressive symptoms began gradually six weeks ago, coinciding with a major work deadline.
Mood is persistently low daily, with a PHQ-9 score of 16 indicating moderate severity.
High job demands and social isolation are key contextual stressors.
Insomnia, poor concentration, and anhedonia worsen with long work hours and news consumption.
Temporary relief occurs when talking with friends, but she feels she “can’t shake this sadness.”
The History of Present Illness outlines that the patient’s depressive symptoms began insidiously six weeks ago, coinciding with a major project deadline at work. For the eight dimensions: onset is gradual; timing is persistent daily low mood; severity is moderate, with a PHQ-9 score of 16; context includes high job demands and social isolation; associated symptoms include insomnia, poor concentration, and anhedonia; alleviating factors are minimal, with temporary relief when talking with friends; aggravating factors include long work hours and news consumption; and patient’s perception is that she “can’t shake this sadness.” Documenting these eight dimensions helps build a nuanced psychosocial narrative and informs targeted interventions.
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Review of Systems (ROS)
She reports fatigue, early morning awakening, reduced appetite, and a five-pound weight loss (Ros et al., 2024).
Occasional headaches occur, with no cardiovascular, respiratory, or gastrointestinal complaints.
She denies suicidal ideation or psychotic symptoms but has passive thoughts of “sleeping forever.”
There are no signs of substance misuse.
A full ROS helps rule out medical contributors and ensures patient safety.
The Review of Systems reveals multiple domains impacted by her mood disturbance. She reports fatigue, early morning awakening, appetite reduction with a five-pound weight loss, and occasional headaches. There are no cardiovascular complaints, respiratory issues, or gastrointestinal disturbances beyond decreased appetite. She denies suicidal ideation or psychotic symptoms but acknowledges passive thoughts like “I wish I could sleep forever.” There are no signs of substance misuse. This comprehensive ROS ensures we capture both psychiatric and medical contributors, thus screening for medical comorbidities that can mimic or exacerbate depressive disorders and ensures patient safety (Ros et al., 2024).
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Objective Data – Current Medications & Allergies
The patient takes OTC ibuprofen for headaches and an oral contraceptive daily.
She has no documented drug allergies and tolerates ibuprofen well.
She occasionally drinks chamomile tea for sleep but uses no herbal supplements otherwise.
Verifying medications and allergies prevents drug interactions during pharmacotherapy.
The absence of psychiatric medications simplifies initiation of first-line antidepressants.
Currently, the patient is not on any prescribed psychiatric medications. She takes over-the-counter ibuprofen for headaches as needed and an oral contraceptive for birth control. There are no documented drug allergies, and she tolerates ibuprofen without adverse reactions. She denies use of herbal supplements, except for occasional chamomile tea for sleep. Verifying current medications and allergies is critical to avoid drug interactions and allergic reactions, especially when initiating pharmacotherapy. In her case, the absence of psychiatric medications simplifies the introduction of first-line antidepressants while ensuring a safe treatment initiation process.
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Past Medical & Family Psychiatric History
Past medical history includes seasonal allergic rhinitis and an appendectomy at age 12.
Maternal grandmother had major depressive disorder; father has generalized anxiety disorder (Monroe et al., 2024).
No family history of bipolar disorder or psychosis.
Familial patterns highlight genetic predispositions and inform differential diagnosis.
Awareness of anxiety risk guides consideration of adjunctive therapies.
Her past medical history includes seasonal allergic rhinitis and a surgical appendectomy at age 12, both managed without complications. For family psychiatric history, her maternal grandmother was diagnosed with major depressive disorder, and her father has a history of generalized anxiety disorder. There is no family history of bipolar disorder or psychosis. Understanding familial psychiatric patterns provides insight into genetic predispositions and risk factors (Monroe et al., 2024). This information helps in differential diagnosis and in emphasizing the importance of monitoring for comorbid anxiety, which may influence treatment selection and the need for adjunctive therapies.
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Social History
She lives alone with limited social support and infrequent family contact out of state.
Two close friends check in weekly; she smokes half a pack of cigarettes daily.
She denies alcohol misuse and illicit drug use.
High-stress employment, minimal exercise, and financial constraints affect her coping.
Strengthening social support and community resources will be key psychosocial interventions.
The patient lives alone in a one-bedroom apartment, maintaining limited social support. She reports infrequent contact with her family, living in another state, and has two close friends who check in weekly. She smokes half a pack of cigarettes daily, reports no alcohol misuse, and denies illicit drug use. Employment is high-stress, with long hours and tight deadlines. Exercise is minimal, limited to walking her dog on weekends. She sleeps alone on a twin mattress in her living room due to financial constraints. Her social history underscores risk factors for isolation and limited coping resources. We will leverage social support and community resources as part of the psychosocial intervention plan.
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Labs, Screening Tools & Vital Signs
Vital signs are within normal limits: BP 118/76, HR 72, RR 16, T 98.4 °F, BMI 22.
Lab work (CBC, metabolic panel, thyroid, vitamin D) is all within normal ranges.
PHQ-9 score of 16 confirms moderate depression; GAD-7 score of 8 indicates mild anxiety.
Normal labs rule out medical causes such as hypothyroidism.
Repeat PHQ-9 and GAD-7 at follow-ups to objectively track treatment response.
Initial vital signs show a blood pressure of 118/76 mmHg, heart rate of 72 beats per minute, respiratory rate of 16 breaths per minute, temperature of 98.4°F (36.9°C), and BMI of 22 kg/m². Laboratory workup includes a complete blood count, metabolic panel, thyroid function tests, and vitamin D levels, all within normal limits. The PHQ-9 score of 16 indicates moderate depression, and the GAD-7 score of 8 suggests mild anxiety. These screening tools quantify symptom severity and track treatment response. Normal labs rule out medical causes of mood symptoms such as hypothyroidism. We will repeat the PHQ-9 and GAD-7 at each follow-up to monitor progress objectively.
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Mental Status Examination (MSE)
Appearance is disheveled with poor eye contact; speech is soft and slow but coherent (Mendez, 2022).
Mood is “sad” with a constricted affect; thought process is linear without psychosis.
She denies suicidal or homicidal ideation but admits passive death wishes.
Cognition is intact, with orientation to person, place, and time and normal concentration.
Insight is fair and judgment appears intact, supporting a diagnosis of major depression.
On mental status examination, the patient appears disheveled with poor eye contact. Speech is soft and slow but coherent. Mood is “sad,” and affect is constricted. Thought process is linear without loosening of associations, and there are no delusions or hallucinations. She denies suicidal or homicidal ideation at this time but admits passive death wishes (Mendez, 2022). Cognition is intact; she is oriented to person, place, and time, with normal attention and concentration on serial sevens. Insight is fair, acknowledging her symptoms, and judgment appears intact. The MSE confirms depressive symptomatology without psychotic features, guiding us toward a diagnosis of major depressive episode.
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Assessment – Primary & Differential Diagnoses
Primary diagnosis: Major Depressive Disorder, Single Episode, Moderate (DSM-5-TR 296.22).
She meets five or more symptoms for at least two weeks, including mood and anhedonia.
Consider Adjustment Disorder with Depressed Mood due to work stress.
Rule out Persistent Depressive Disorder given insufficient chronicity.
Bipolar II is unlikely without hypomanic symptoms; remain vigilant for spectrum features.
Based on DSM-5-TR criteria, the primary diagnosis is Major Depressive Disorder, Single Episode, Moderate (296.22). She meets the requisite five or more symptoms for at least two weeks, including depressed mood, anhedonia, sleep disturbance, weight change, fatigue, diminished concentration, and feelings of worthlessness. Differential diagnoses include Adjustment Disorder with Depressed Mood, due to a stressor at work, and Persistent Depressive Disorder (Dysthymia), given the chronicity requirement. Bipolar II disorder is less likely given the absence of hypomanic symptoms. We must remain vigilant for emergent anxiety features or bipolar spectrum symptoms, adjusting our treatment plan accordingly.
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Plan – Pharmacologic Treatment
Initiate sertraline 50 mg daily, titrating to 100 mg over four weeks as tolerated (Park, 2021).
Sertraline chosen for its safety profile and efficacy in depression and mild anxiety.
Counsel on potential GI upset and sexual side effects, recommending morning dosing with food.
Schedule follow-up in two weeks to assess tolerability and adjust dose collaboratively.
Monitor adherence and side effects through shared decision-making.
The pharmacologic plan follows the American Psychiatric Association’s guidelines, initiating sertraline at 50 mg daily for moderate MDD. We will titrate up to 100 mg as tolerated over four weeks based on response and side effects. Sertraline is selected for its favorable side effect profile, safety in monotherapy, and evidence for improving both depressive and mild anxiety symptoms (Park, 2021). The patient will receive medication counseling regarding potential gastrointestinal upset and sexual side effects, with recommendations to take the dose in the morning with food. We will schedule a follow-up in two weeks to assess tolerability and adjust the dose if needed, prioritizing shared decision-making.
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Non-Pharmacologic Interventions & Follow-Up
Refer for CBT with emphasis on cognitive restructuring and behavioural activation (Dryden, 2021).
Encourage a structured daily routine with scheduled pleasurable activities.
Plan weekly therapy sessions for three months, tracking progress via PHQ-9.
Arrange follow-ups at two, six, and twelve weeks, with interim telehealth check-ins.
Engage social work to address housing and financial stressors.
Non-pharmacologic interventions include referral for cognitive behavioral therapy, focusing on cognitive restructuring to address negative automatic thoughts. We will integrate behavioral activation strategies, encouraging structured daily routines with scheduled pleasurable activities (Dryden, 2021). The patient will engage in weekly therapy sessions for at least three months, with progress monitored using the PHQ-9. Follow-up appointments are set at two, six, and twelve weeks post-medication initiation, with interim check-ins via telehealth as needed. Lab monitoring is not required for SSRIs, but we will monitor for side effects, adherence, and emerging suicidal ideation at each contact. Incorporation of social work services will address housing and financial stressors, supporting holistic recovery.
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Clinical Guidelines, Research Integration & Role of NP
Treatment aligns with the 2024 APA Practice Guideline for Major Depressive Disorder.
Combined sertraline and CBT shows up to 70% response at 12 weeks (Dryden, 2021).
Nurse practitioners lead assessment, diagnosis, treatment initiation, and management.
Emphasize patient education, self-management strategies, and interdisciplinary coordination.
Integrating pharmacologic and psychosocial interventions optimizes continuity of care
This treatment plan adheres to the latest U.S. clinical guidelines, including the APA’s 2024 Practice Guideline for the Treatment of Patients With Major Depressive Disorder. Recent studies underscore the efficacy of combined sertraline and CBT in moderate MDD, with response rates up to 70% at 12 weeks. As nurse practitioners, our role encompasses comprehensive assessment, diagnosis, initiation of treatment, and ongoing management, including safety planning and coordination with interdisciplinary teams. We advocate for patient education, empower self-management strategies, and liaise with psychiatrists, therapists, and social services. By integrating evidence-based pharmacologic and psychosocial interventions, NPs ensure continuity of care and optimize patient outcomes (Dryden, 2021).
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References
Dryden, W. (2021). Single-session integrated CBT (SSI-CBT):. Single-Session Integrated CBT, 11-19. https://doi.org/10.4324/9781003214557-3
Mendez, M. (2022). Overview of the mental status examination. The Mental Status Examination Handbook, 41-50. https://doi.org/10.1016/b978-0-323-69489-6.00005-x
Monroe, S. M., Slavich, G. M., & Gotlib, I. H. (2024). Life stress and family history for depression: The moderating role of past depressive episodes. Journal of Psychiatric Research, 49, 90-95. https://doi.org/10.1016/j.jpsychires.2013.11.005
Park, K. (2021). Pharmacologic treatment. A Strategic Approach to Knee Arthritis Treatment, 143-169. https://doi.org/10.1007/978-981-16-4217-3_9
Ros, F., Riad, R., & Guillaume, S. (2024). Deep clustering framework review using multicriteria evaluation. Knowledge-Based Systems, 285, 111315. https://doi.org/10.1016/j.knosys.2023.111315
