Nursing Homework

Video notes

During the assessment, the patient appeared visibly anxious, fearful, and restless, exhibiting frequent fidgeting, repetitive touching of her face, and scratching her arms. She repeatedly verbalized, feeling scared and demonstrated difficulty remaining still throughout the interaction. The patient acknowledged a history of drug and alcohol use but expressed that she feels in control of her substance use. When discussing rehabilitation, she stated, “You're going to have to convince me to go to rehab,” suggesting reluctance toward seeking treatment. She also made a statement about possibly getting a drink of water. Throughout the assessment, the patient continued to display jittery behavior, repetitive scratching, and persistent expressions of fear and anxiety. Her presentation suggests significant emotional distress, with observable psychomotor agitation and ambivalence toward substance use treatment.

Name: Lisa Tremblay

Gender: female

Age: 33 years old

T- 100.0 P- 108 R 20 180/110 Ht 5’6 Wt 146lbs

Background: Lisa is in a Naples, FL detox facility thinking about long term rehab. She is

considering treatment for her Hep C+ but needs to get clean first. She has been abusing opiates,

approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”),

and 1/2 gallon of vodka daily. She has past drug paraphernalia possession arrest. Her admission

labs. abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS

positive for opiates, THC. Positive for alcohol or other drugs. BAL .308; other labs within

normal ranges. She reports sexual abuse as child ages 6-9 perpetrator being her father who went

to prison for the abuse and drug charges. She is estranged from him. Mother lives in Maine, hx

of agoraphobia and benzodiazepine abuse. Older brother has not contact with family in last 10

years, hx of opioid use. Sleeps 5-6 hrs., appetite decreased, prefers to get high instead of eating.

Allergies: azithromycin

Symptom Media. (Producer). (2017). Training title 82 [Video].

https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa

tch/training-title-8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 

Objective: What observations did you make during the psychiatric assessment?  

Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

· American Psychiatric Association. (2022). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site.  (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders

· Boland, R. & Verduin, M. L. & Ruiz, P. (2022).  Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

· Chapter 4, “Substance Use and Addictive Disorders”

· Chapter 2 only section 2.17, “Adolescent Substance Abuse”

· Chapter 27 “Ethics and Professionalism”

· Chapter 28 “Forensic and Legal Issues”