Posted: October 5th, 2022

Week 5: Targeted SOAP Word and Affected person Case Presentation
Faculty of Nursing-PMHNP, Walden College
NRNP 6675: PMHNP Care Throughout the Lifespan 2 Practicum
Introduction
Psychosis is a psychological situation during which an individual’s concepts and perceptions are disrupted,
and the person could have problem distinguishing between what’s actual and what’s not.
A well being situation, medicines, or drug utilization can all contribute to psychosis. Delusions,
hallucinations, incomprehensible speech, and agitation are all doable indicators; the affected person has
incorrect beliefs and sees or hears issues that others don’t see or hear. The individual affected by
the illness is often unaware of his or her actions. Treatment, psychotherapy, peer help,
household help and training, and discuss remedy are all choices for remedy. Roughly each
psychological intervention is backed by proof amassed in the course of the affected person’s preliminary interview; every
affected person’s remedy begins with an intensive medical and psychological well being analysis, the incorporation
of belief, and a dialogue of previous psychological well being historical past, substance misuse historical past, household psychological
well being historical past, and so forth. On this instance, the affected person’s analysis was documented, and a
analysis was made based mostly on the knowledge collected from the affected person in the course of the analysis.
When the case was being developed, a therapeutic method was designed. The affected person is a 53-
year-old Caucasian male who was scheduled for an preliminary screening for a psychotic dysfunction after
his sister really helpful a go to to the psychiatrist as a result of affected person’s conduct modified for the reason that
mom handed away.
Affected person Preliminary: S.T Age: 53 Gender: Male
Subjective Information:
CC: “I used to be introduced right here by my sister as a result of since my mom handed away, I used to be residing on my
personal and never bothering anybody. These individuals outdoors my window they’re after me. They only
need me useless”.
HPI: When affected person was requested ” what individuals?”. Affected person mentioned ” the federal government despatched them to get
me as a result of my taxes are excessive”. Abruptly affected person requested the supplier if she will be able to see the birds or
hear any loud noise. The supplier responded by redirecting the affected person that she doesn’t hear any
voice or see something. When the supplier how lengthy he’s been listening to the voices or seeing
issues, affected person mentioned ” for weeks, weeks and weeks”. Affected person additionally mentioned the sister tapped her telephone
with the federal government. When requested about sleep, affected person mentioned ” I’ve not slept properly as a result of the
voices preserve me up for days. I attempt to watch the TV, they poison my meals on TV, I locked
all the pieces down within the fridge”. Abruptly affected person requested ” Can I smoke?”. Supplier mentioned “no you
cannot smoke right here”. Affected person admit that he smokes all day about three packs a day. Drinks alcohol
which his sister bought for him to final him for weeks. Affected person denies use of medication. Admit to
historical past of marijuana use three years in the past earlier than the mom handed away. Denies blackout, seizures,
collateral or authorized points or DUIs from use of medication or alcohol. Affected person admit that he hates
Haldol and Thorazine which he used to take. Calls his medicines poison and mentioned he isn’t
going to take it.
Substance Use Historical past: Admits to make use of of alcohol, smokes three packs of cigarette per day. Admit
historical past of marijuana three years in the past
Household Psychiatric/Psychological/Substance Use Historical past: Affected person father paranoid and schizophrenia.
Affected person’s mom: Anxiousness. Sister: unknown Grandfather: unknown. Grandmother: unknown
Psychosocial Historical past: Affected person lives alone. Mom is deceased. Father is undisclosed. Each
dad and mom are Caucasian. Affected person is presently doesn’t have pals. Instructional Degree: 10th grade.
Authorized historical past: affected person denies any historical past however mentioned the police advised him they’d as a result of affected person
calls 911 on individuals outdoors.
Psychiatric Historical past: Temper dysfunction unspecified
Medical Historical past/Surgical Historical past: Diabetes
Beginning and Developmental historical past: Vagina beginning, denies any disclosed complication and all
developmental millstones was met on time.
Present Drugs: Haldol and Thorazine (all discontinued), Metformin
Allergy symptoms: NKDA or seasonal allergy symptoms
Reproductive Hx: Affected person denies sexual historical past or abuse
APPEARANCE: Appeared matted
HEENT: No imaginative and prescient drawback. Ears regular form with no discharges. Nostril regular form; no
deviation or drainage. No sore throat or swelling across the neck.
CV: no cardiovascular abnormality
PULMO: Lungs sounds clear and no adventitious lung sounds
ABDOMEN: All bowel sounds on all 4 quadrant
GENITOURINARY: No dysfunction or drawback with this method
EXTREM: All extremities is moveable; some tremors famous in higher extremities
NEURO: alert and oriented to individual, place, time, and scenario however very unrest
SKIN: Pores and skin intact and acceptable; no rash or lesion famous
Bodily examination:
Important Indicators: none at the moment
Weight: 196 Ibs
Peak: 5’9ft
Goal:
Diagnostic outcomes: no diagnostic check ordered or required at the moment
Assessment:
Psychological Standing Examination
On arrival and in the course of the session, the affected person seemed to be of the age reported, with no
indicators of discomfort. The affected person seems to be properly fed and groomed. Clear and well-dressed.
Affected person was compliant, didn’t fidget, maintained good eye contact, and however couldn’t keep nonetheless
for lengthy durations of time. The affected person seems to be frightened and anxious. Have an effect on was wideranging, a bit of constrained, and continuously miserable. There was no anomalous motion
noticed. Keep a gentle gait and keep an upright stance. Appeared anxious , the affected person
was coherent however not significantly logical. Though the affected person didn’t have acute psychosis, he
was actively delusional and responding to inner stimuli. Affected person was delusions or paranoid
conduct, suspicious ideas and intrusive concepts plague the affected person. Affected person’s speech was regular
charge, rhythm quantity and clear. Affected person doesn’t really feel like he’ll get higher. Affected person was
historian. Affected person was attentive to the supplier. Alert and oriented occasions four. Reminiscence each lengthy
and quick time period was intact. Affected person denies suicide ideation. Affected person admits having intrusive
ideas of injuring. Throughout Assessment affected person states “the federal government despatched individuals to get me
as a result of my taxes are excessive”. Abruptly affected person requested the supplier if she will be able to see the birds or hear
any loud noise.
Differential Diagnoses
Schizophrenia: Schizophrenia is a “psychosis,” a kind of psychological sickness. A psychosis is a psychological
illness during which the sufferer is unable to differentiate between what’s actual and what’s imagined.
Folks affected by psychological illnesses can lose contact with actuality at occasions (Sadock, 2014). The
world could seem like a tangle of perplexing concepts, photographs, and noises. One type of
schizophrenia is paranoid schizophrenia. On this case, the individual’s incorrect beliefs are largely
involved with being persecuted or punished by others. Somebody’s voice could also be heard, which
the person believes is punishing them. The person could assume that she or he has been
hand-picked to hold out a top-secret process. Based on DSM-5, affected person should meet sure to be
identified with schizophrenia; delusions, hallucinations, identified speech or thought, destructive
signs, paranoid delusions, grossly disorganized or catatonic conduct throughout 6
months, signs not because of results of substance or one other medica situation (American
Psychiatric Affiliation2013). The above listed standards are all evident in our affected person.
Schizoaffective Dysfunction: In medical observe, schizoaffective dysfunction is among the most
misdiagnosed psychiatric illnesses. In truth, some teachers have requested that the diagnostic
standards be revised, whereas others have instructed that the analysis be eliminated fully from the
DSM-5. Schizoaffective sickness is well confused with different psychological problems because of standards that
embrace each psychosis and temper signs. Schizophrenia, Main Depressive Illness with
Psychotic Options, and Bipolar Dysfunction are all problems that should be dominated out throughout a
schizoaffective dysfunction workup. Based on DSM 5, to diagnose schizoaffective sickness, there
should be not less than two weeks of completely psychotic signs (delusions and hallucinations)
with none temper signs. Nonetheless, all through nearly all of the sickness’s existence, a
main temper episode (despair or mania) is current. When psychotic signs prevail for the
bulk of the sickness’s period, the analysis is more likely to be schizophrenia. Moreover,
schizophrenia requires 6 months of prodromal or residual signs, however schizoaffective dysfunction
doesn’t. Schizoaffective dysfunction is a psychotic illness just like schizophrenia.
Delusion of Persecution: A delusion is a false perception that implies an issue with the contents
of the affected individual’s ideas. The individual’s cultural or spiritual background, in addition to his or
her degree of intelligence, haven’t any bearing on the inaccurate perception. The diploma to which the individual
believes the assumption is true is a significant factor of a delusion (American Psychiatric
Affiliation2013). An individual affected by a delusion will cling to their perception regardless of proof
on the contrary. Delusion of Persecution happens when an individual believes that they (or somebody
near them) is being mistreated, that somebody is spying on them, or that somebody is planning
to hurt them. In accordance DSM-5 affected person should meet the next standards earlier than being one or
extra delusion for not less than one month, fearing strange conditions, feeling threatened with out
purpose, continuously reporting to authorities, excessive misery, extra fear, continually in search of
security and hallucinations related to the delusions. The above listed standards are evident in
our affected person
Reflection
Each psychological intervention is set by the knowledge collected in the course of the preliminary
dialog with the consumer; each consumer’s remedy begins with a complete medical and
behavioral well being examination, the creation of belief, and a dialogue of earlier psychological well being
historical past, substance abuse historical past, household psychological well being historical past, and so forth. People with whom
they’d connections that comprised efficient communication, cultural consciousness, and the
absence of compulsion had been thought of as reliable (Sadock et al., 2014).
As a PMHNP, one factor I may need completed in a different way is to fulfill the affected person first, develop
a therapeutic relationship, inquire in regards to the younger affected person’s relationship along with his dad and mom, and
then ask questions irrelevant to the scheduled go to, which might help to create a welcome
environment. With out showing to be biased, ask open-ended questions in regards to the affected person’s
character, sickness, or character. Inquire in regards to the affected person’s sexual orientation and
communication desire. Cultural competency contains parts corresponding to belief, respect for
range, respect for faith, fairness, equity, and social justice, which should all be thought of
throughout any interview or encounter between a healthcare practitioner and a affected person (Sadock et al.,
2014). After I interview a affected person about their psychological sickness signs, I have a look at how they appear,
communicate, and act to find out if there are any clues that might clarify their signs.
Case Formulation and Remedy Plan
The affected person will start particular person supportive remedy then advance to household and peer
group supportive remedy relying on degree of enchancment. The affected person will obtain an
instructional pamphlet, in addition to assignments and a follow-up session, on themes that can
Help within the therapeutic and coping course of.
Affected person might be began on Perphenazine 32mg PO QHS, Benztropine 1mg PO BID for
prevention of EPS. Training and unwanted side effects of remedy was supplied. Labs (CBC, CMP,
A1C, lipid profile) might be ordered within the subsequent go to.
Training on substance use and smoking cessation was supplied for affected person. Affected person will
be educated on significance of taking his very important indicators each day, improve fluid consumption, report change
finger sticks of blood sugar test,
In case of emergency, the supplier supplied affected person with useful telephone numbers: 911 for
emergencies and the Consumer’s Disaster Line. Reviews from docs and therapists had been evaluated for
mutual and collaborative understanding and for continuity of care.
Affected person was educated and was suggested to name their major care doctor or go to the
nearest emergency division if they’d any questions or considerations in regards to the improvement of
any undesirable or surprising final result or unwanted side effects.
Each 30 days, affected person should return to appointments for continuity of care and for supplier
to observe progress and final result of remedy however affected person will return a two week after beginning the
newly prescribed medicines for adjustment of dosing and to observe enchancment.
References
American Psychiatric Affiliation. (2013). Diagnostic and Statistical Handbook of Psychological
Issues, fifth version DSM-5 American Psychiatric Affiliation, 2013.
Bachem, R., & Casey, P. (2018). Schizoaffective Dysfunction: A analysis whose time has come.
Journal of Affective Issues, 227, 243-253. https://doi.org/10.1016/j.jad.2017.10.034
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/medical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.).
(2015). Rutter’s baby and adolescent psychiatry (sixth ed.). Wiley Blackwell.
Walden College. (2021). Case examine: Sherman Tremaine. Walden College
Blackboard. https://class.waldenu.edu

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