Nursing homework
travuco03
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files (4)Instructions.docx
PediatricMentalHealthAssessment2.pptx
- GraduateComprehensivePsychiatricEvaluationTemplate.docx
- PsychiatricSOAPNoteRubric.docx
Instructions.docx
Step 1: You will use the Graduate Comprehensive Psychiatric Evaluation Template Download Graduate Comprehensive Psychiatric Evaluation Templateto:
1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
2. Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
· For the Comprehensive Psychiatric Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).
Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See Comprehensive Psychiatric Evaluation Presentation 2 for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
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S = |
Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
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O = |
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
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A = |
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
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P = |
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
Other: Incorporate current clinical guidelines NIH Clinical GuidelinesLinks to an external site. or APA Clinical GuidelinesLinks to an external site., research articles, and the role of the PMHNP in your evaluation.
· Psychiatric Assessment of Infants and ToddlersLinks to an external site.
· Psychiatric Assessment of Children and AdolescentsLinks to an external site.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Graduate Mental Status Exam Guide Download Graduate Mental Status Exam Guide
Successfully Capture HPI Elements in Psychiatry E/M NotesLinks to an external site. AAPC Admin. (2013, August 1). Successfully capture HPI elements in psychiatry E/M notes. Advancing the Business of Healthcare. https://www.aapc.com/blog/25848-successfully-capture-hpi-elements-in-psychiatry-em-notes/
PediatricMentalHealthAssessment2.pptx
Pediatric Mental Health Assessment: Child Development and Behavioral Analysis
Student’s Name
Institution
Course
Instructor
Date
Chief Complaint and History of Present Illness
Chief Complaint: Parent reports excessive crying and difficulty with transitions.
History of Present Illness: Symptoms started six months ago, worsening over time.
OLDCARTS: Symptoms occur daily, worse in unfamiliar environments, no clear relief.
Behavioral observations: Frequent tantrums, difficulty with eye contact, self-soothing.
Developmental concerns: Delayed speech, poor motor coordination, repetitive behaviors.
Social/environmental factors: Parental divorce, recent move, changes in routine.
The parent reports that their child has been experiencing excessive crying and difficulty with transitions. Symptoms started six months ago and have progressively worsened. Using the OLDCARTS method, symptoms occur daily, intensify in unfamiliar environments, and show no clear relief. Observations include frequent tantrums, poor eye contact, and self-soothing behaviors. Developmental concerns involve delayed speech, poor motor coordination, and repetitive behaviors. Social and environmental factors such as parental divorce, a recent move, and routine changes may contribute to the symptoms.
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Review of Symptoms (ROS)
General: Difficulty sleeping, frequent night awakenings, inconsistent appetite.
Neurological: No history of seizures, occasional staring spells, hypotonia observed.
Respiratory: No recurrent infections, occasional wheezing with exercise.
Gastrointestinal: Frequent constipation, picky eating, possible food sensitivities.
Behavioral: Self-harm (headbanging), difficulty with transitions, frequent meltdowns.
Sensory: Overreacts to loud noises, avoids certain textures, dislikes bright lights.
The child experiences difficulty sleeping, frequent night awakenings, and an inconsistent appetite. Neurologically, there is no seizure history, but occasional staring spells and hypotonia have been observed. Respiratory symptoms include occasional wheezing with exercise but no recurrent infections. Gastrointestinal concerns include frequent constipation and possible food sensitivities. Behaviorally, the child exhibits self-harm behaviors such as headbanging and struggles with transitions. Sensory processing difficulties are evident as the child overreacts to loud noises, avoids certain textures, and dislikes bright lights.
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Objective Data and Mental Status Exam
Appearance: Clean but prefers wearing the same outfit daily.
Behavior: Avoids direct eye contact, minimal response to name being called.
Speech: Limited vocabulary, echolalia, struggles with verbal expression.
Mood/Affect: Frequently anxious, appears detached, occasional outbursts.
Thought Process: Repetitive thought patterns, difficulty in abstract thinking.
Cognition: Difficulty following multi-step directions, poor attention span.
The child appears clean but insists on wearing the same outfit daily. Behaviorally, they avoid direct eye contact and show minimal response when called by name. Speech is limited, characterized by echolalia and struggles with verbal expression. Mood and affect are frequently anxious, and they appear detached with occasional outbursts. The thought process is repetitive, with difficulty in abstract thinking. Cognition assessments indicate trouble following multi-step directions and a poor attention span, suggesting the need for further evaluation.
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Developmental and Family History
Prenatal history: No complications, full-term birth, normal APGAR scores.
Perinatal history: No NICU stay, normal newborn screening results.
Developmental milestones: Walked at 18 months, speaks in single words at 3 years.
Psychiatric history: No previous formal diagnosis, concerns raised at age 2.
Family psychiatric history: Parent with anxiety disorder, sibling with ADHD.
Social history: Lives with both parents, attends daycare, limited peer interaction.
The child’s prenatal history is unremarkable, with a full-term birth and normal APGAR scores. No NICU stay or complications were reported perinatally. Developmentally, the child walked at 18 months and spoke single words at three years, indicating delayed milestones. No prior psychiatric diagnosis exists, though concerns were raised at age two. Family history includes a parent with an anxiety disorder and a sibling with ADHD. Socially, the child lives with both parents, attends daycare, and has limited peer interaction, which may influence behavioral challenges.
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Differential Diagnosis
Autism Spectrum Disorder (ASD): Delayed social communication, repetitive behaviors.
Attention-Deficit/Hyperactivity Disorder (ADHD): Impulsivity, hyperactivity, inattention (Rosello et al., 2022).
Separation Anxiety Disorder: Extreme distress when leaving parents.
Sensory Processing Disorder: Avoidance of textures, sounds, and crowded places.
Oppositional Defiant Disorder (ODD): Frequent defiance, irritability, aggression.
Adjustment Disorder: Emotional distress following recent life changes.
The primary differential diagnoses include Autism Spectrum Disorder (ASD) due to delayed communication and repetitive behaviors. Attention-Deficit/Hyperactivity Disorder (ADHD) is considered due to inattention and impulsivity. Separation Anxiety Disorder is also likely, given extreme distress when apart from caregivers. Sensory Processing Disorder is suggested by avoidance of textures and loud sounds. Oppositional Defiant Disorder (ODD) is included due to frequent defiance and irritability. Lastly, Adjustment Disorder is considered due to the child’s distress following recent life changes (Rosello et al., 2022).
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Diagnostic Screening Tools
Ages and Stages Questionnaire (ASQ): Assess developmental delays across domains.
Modified Checklist for Autism in Toddlers (M-CHAT): Screens for ASD symptoms.
Pediatric Symptom Checklist (PSC): Identifies emotional/behavioral issues.
Vanderbilt ADHD Rating Scale: Assesses hyperactivity and inattentiveness.
Sensory Profile Questionnaire: Evaluates hypersensitivities and hyposensitivities.
Strengths and Difficulties Questionnaire (SDQ): Assesses emotional well-being.
Diagnostic tools include the Ages and Stages Questionnaire (ASQ) to assess developmental delays and the Modified Checklist for Autism in Toddlers (M-CHAT) to screen for ASD symptoms (Granana, & Otalvaro, 2021). The Pediatric Symptom Checklist (PSC) helps identify emotional and behavioral issues. The Vanderbilt ADHD Rating Scale evaluates hyperactivity and inattentiveness. The Sensory Profile Questionnaire identifies sensory processing challenges, and the Strengths and Difficulties Questionnaire (SDQ) assesses emotional well-being and behavioral concerns.
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Treatment Plan
Pharmacologic: Consider melatonin for sleep disturbances, no stimulants yet.
Behavioral therapy: ABA therapy for reinforcement of positive behaviors.
Environmental modifications: Noise-canceling headphones, sensory-friendly space.
Educational support: IEP evaluation, speech therapy referral.
Parental training: Teach positive reinforcement and structured daily routines.
Follow-up plan: Monthly therapy check-ins, reevaluation in six months.
Pharmacologic treatment includes considering melatonin for sleep disturbances while avoiding stimulants at this time. Behavioral therapy involves Applied Behavior Analysis (ABA) for positive reinforcement. Environmental modifications include noise-canceling headphones and a sensory-friendly space (Monceaux et al.,2024). Educational support entails Individualized Education Plan (IEP) evaluation and speech therapy referral. Parental training focuses on structured daily routines and positive reinforcement techniques. Monthly therapy check-ins and reassessment in six months will help monitor progress and adjust treatment as needed.
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Patient and Family Education
Explanation of diagnosis and how symptoms impact daily functioning.
Importance of early intervention services and structured support.
Strategies to manage sensory overload and behavioral outbursts.
Providing tools for improved communication and social engagement.
Encouraging parental self-care and coping strategies for stress.
Local resources: Support groups, occupational therapy centers, advocacy programs.
It is crucial to explain the child’s diagnosis and how symptoms impact daily functioning. Parents should understand the importance of early intervention services and structured support. Strategies for managing sensory overload and behavioral outbursts should be provided. Parents should receive tools for improving communication and social engagement (Garofallou & Silva, 2023). Encouraging self-care and stress management for parents is also essential. Finally, providing information about local resources, including support groups, therapy centers, and advocacy programs, will assist families in navigating the child’s condition.
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Follow-up and Refferals
Pediatric neurologist referral for further evaluation of cognitive concerns.
Speech and occupational therapy assessments for developmental support.
Educational psychologist evaluation for early intervention recommendations.
Regular psychiatric follow-ups to monitor progress and adjust treatment.
Encouraging play-based therapy to enhance social and emotional development.
Crisis intervention plan: Emergency contacts and local mental health resources.
The child requires a referral to a pediatric neurologist for further evaluation of cognitive concerns. Speech and occupational therapy assessments will support developmental growth. An educational psychologist evaluation will aid in early intervention recommendations. Regular psychiatric follow-ups will monitor progress and adjust treatment strategies. Play-based therapy should be encouraged to enhance social and emotional skills. In case of symptom escalation, a crisis intervention plan will provide emergency contacts and local mental health resources.
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Conclusion
Summary: Child exhibits behaviors consistent with ASD, sensory issues, and anxiety.
Importance of early, structured interventions for better long-term outcomes.
Emphasizing a family-centered approach to therapy and home modifications.
Role of a multidisciplinary team in holistic treatment planning.
Encouraging ongoing monitoring, adaptive interventions, and community support.
Thank you and contact information for further discussions and inquiries.
The child presents with behaviors indicative of ASD, sensory processing challenges, and anxiety. Early intervention with structured therapies is critical for long-term improvement. A family-centered approach with parental support and education is essential. A multidisciplinary team, including therapists, educators, and medical professionals, will provide comprehensive care. Ongoing monitoring and adaptive interventions will ensure continued progress. Community resources will play a key role in supporting the child’s development. Thank you for your time; please reach out for further discussion or inquiries.
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References
Garofallou, L., & Silva, L. (2023). An At-Home Guide to Children’s Sensory and Behavioral Problems: Qigong Sensory Treatment for Parents and Clinicians. Taylor & Francis.
Granana, N., & Otalvaro, A. R. (2021). Neurodevelopment and the Ages and Stages Questionnaire, (ASQ-3). In Diagnosis, management and modeling of neurodevelopmental disorders (pp. 319-328). Academic Press.
Monceaux, B., Smith, K., & McPherson, P. (2024). The Treatment of Dually Diagnosed Individuals with Sleep Disturbances and Intellectual Disabilities. Handbook of Psychopathology in Intellectual Disability: Research, Practice, and Policy, 343-379.
Rosello, R., Martinez-Raga, J., Mira, A., Pastor, J. C., Solmi, M., & Cortese, S. (2022). Cognitive, social, and behavioral manifestations of the co-occurrence of autism spectrum disorder and attention-deficit/hyperactivity disorder: A systematic review. Autism, 26(4), 743-760.
