Comprehensive Client Assessment
Section, Psychotherapy with Individuals
07/13/2022
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Comprehensive Client Assessment /
Client or patient Assessment is the initial phase of client evaluation in the nursing process. This
stage enables nurses gather crucial client information in order to offer the best care with effective
outcomes.
CC: I realized am entering on a gloomy phase of my life. My situation is not getting better and I
have feelings of committing suicide.
HPI: Madison is a 15-year-old patient who presented cases of depression, suicidal thoughts and
plans to harm herself. When her mother was deceased last year, she was overwhelmed and
developed thoughts of overdosing on prescribed pills.
Substance use: None
Medical history: admitted in a psych facility the beginning of last year.
Current med: Abilify 5mg PO at bedtime.
Allergies: NKA
Reproduction status: gone through all stages of development
ROS:
General: No chills, fatigue or any visible fevers
Cardiovascular: No coughs, CP
Gastrointestinal: No vomiting or pain in the abdomen
Lymphatic: Normal sized lymph nodes..
Respiratory: no coughing
Skin: no bumps or swellings
Objective: the client exhibits foul and depressed mood, seems disoriented and confused.
Diagnostic results: Major depressive disorder. According to DSM-5, negativity level that are
presumably high, a challenging and problematic childhood, stressors of life such as retrenchment
and couple divorce can all lead to depression. People with immediate family members who at
one time in their lifetime experienced depression have a high probability of having depressive
disorder (DSM-5). DSM-5 stipulates that one must show five or more of this symptoms, a mood
that is depressed and disregarding forms of pleasure (American Psychiatric Association, 2013).
Assessment:
Mental status exams: the client reports that she is not in a good mood at all. However, throughout
the interview, she remains calm and collected. She is very attentive and pays attention to every
details from the assessment report. The clients thought process is coherent and makes sense.
Differential Diagnosis
Depression (ICD) (296.20-296.36) – depression involves not just being in foul and depressed
mood but also loss of interest in day-to-day activities that are pleasurable. However, not
everyone presents these symptoms. Other signs may include; unresolved anger, being overly
fatigued, slow in real time reaction and easily irritable (Dunphy, Winland-Brown, Porter, &
Thomas, 2011). The DSM-5 criteria for depression indicates that one has to be in a depressed
mood every day for two weeks. Reduced interest in seeking pleasure. Feelings of unwarranted
guilt and being less important (APA, 2013). Depression can also have thoughts of self-harm and
suicide in which the patient in this case wants to overdose on prescribed pills.
Thyroid disorder (ICD) (E03.9) – some thyroid disorders can have symptoms that are very
similar to depression. Hyperthyroidism can result to general body weakness, extreme anger,
depression and loss in body weight (Dunphy, Windland-Brown, Porter, & Thomas, 2011).
According to DSM-5, one experiences nervousness, easily irritable, difficult in falling asleep
most of the times and general loss of weight (APA, 2013)..Blood screening could be the best
possible method to rule out this disorder. However, the client’s blood test that was initially done
did not indicate possibilities of Hyperthyroidism.
Reflections: I have noted from the case study presented that Major depressive disorder shares
similar symptoms with other disorders like depression, anxiety and Thyroid disorder. This
implies that, health care providers must be very keen when doing the diagnosis to avoid
confusion brought about by similarity of symptoms. For group therapies, members must be
educated on the most appropriate interventions to manage and control Major depressive disorder.
CASE FORMULATION PLAN
The patient should not skip on any prescribed dosage and should continue taking medicines. The
client should exercise regularly to regulate her mood and increase body energy levels. The client
should adhere to a balanced diet meal. Join group therapy. According to Barth, Munder, Gerger,
Nuesch, Trelle, Znoj, Juni, and Cuijpers (2013) Antidepressants and psychotherapy comprise of
the most used method of treating Major Depressive Disorder. People who had a combined care
recovered more rapidly as compared to those who received separately. However, client are
advised a treatment care that is most suitable and easily adaptable. Barth. Et.al. (2013) posits
that depression can be also be treated through sheer exercising. They found that, exercise has a
similar effect on depression as when using antidepressant. They indicated those 40 minutes 7
days a week could have a significance influence of lowering the effects of mild depression.
References
American Psychiatric Association. (2013)..Diagnostic and statistical manual of mental
disorders(5th ed.). Arlington, VA: American Psychiatric Publishing.
Barth, J., Munder, T., Gerger, , H., Nuesch, E.,Trelle, S., Znoj, H., Juni., P., Cuijpers (2013).
Comparative efficacy of seven, psychotherapeutic interventions for patients with
Depression: A Network meta-analysis. PLoS Med 10(5): e1001454.
Doi:10.1371/journal.pmed.1001454
Dunphy, L. M., Windland-Brown, J. E., Porter, B. O, & Thomas, D. J. (2011). Primary care:
The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A.
Davis Company.
