Assessing clients

  

To prepare:

· Select a client whom you have observed or counseled at your practicum site. ( EX 23 years old white male with depression and suicide ideations).

· Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.

The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):

· Demographic information

· Presenting problem

· History or present illness

· Past psychiatric history

· Medical history

· Substance use history

· Developmental history

· Family psychiatric history

· Psychosocial history

· History of abuse/trauma

· Review of systems

· Physical assessment

· Mental status exam

· Differential diagnosis

· Case formulation

· Treatment plan

Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Resources for reference:

Required Readings

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

• Standard 2 “Diagnosis” (pages 46-47)

Wheeler, K. (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.

• Chapter 5, “Supportive and Psychodynamic      Psychotherapy” (pp. 225–238 and pp. 245–258)

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

Young, J. M., & Solomon, M. J. (2009). How to critically appraise an article. Nature Clinical Practice. Gastroenterology & Hepatology, 6(2), 82–91.

How to Critically Appraise an Article by Young, J.; Solomon, M., in Nature Reviews Gastroenterology & Hepatology, Vol. 6/Issue 2. Copyright 2009 by Nature Publishing Group. Reprinted by permission of Nature Publishing Group via the Copyright Clearance Center.