Assignment: Practicum – Assessing Client Families
Assignment: Practicum – Assessing Client Families
Part 1: Comprehensive Client Family Assessment:
Create a comprehensive client assessment for your selected client family that addresses (without violating HIPAA regulations) the following:
- 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 and/or trauma
- Review of systems
- Physical assessment
- Mental status exam
- Differential diagnosis
- Case formulation
- Treatment plan
Part 2: Family Genogram:
Develop a genogram for the client family you selected. The genogram should extend back at least three generations (parents, grandparents, and great grandparents)Assignment: Practicum – Assessing Client Families.
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Assessing Client Families
Ideally, family members are supposed to rely on each other for support, feedback, and strength. Family problems can manifest in the healthiest of families, resulting in challenging, frustrating, and painful interactions among family members. Family therapy, according to Nichols (2014), believes that changing the family changes the lives of each family member. Change that takes place at a family level is believed to be long-lasting because it helps improve the family structure. A comprehensive family assessment helps assess both functional and dysfunctional family issues and aids the Advanced Practice Nurse (APN) in conducting competent family therapy.
As reported by Wheeler (2014), APPNs should be competent in conducting comprehensive family assessments. A comprehensive family assessment helps assess both functional and dysfunctional family issues. The assessment also aids the APN in conducting competent family therapy. This paper will address a comprehensive client assessment including the mental status examination (MSE), differential diagnosis, case formulation, and a treatment plan of a selected client family. The paper will also discuss the Mental Status Examination (MSE) of the rest of the family members. The names used for this assignment are not the real names of the clients.
Demographic Information
Melissa is a 39-year old Caucasian female patient who is an inpatient in a psychiatric unit admitted for a psychotic episode. Melissa has been married to 42-year old John for ten years, and together, they have a 9-year old daughter Morgan. John is a high school teacher, while Melissa is an accountant who works for a tax company. The couple and their daughter live in a single-story rental home which they have been renting for six months. John and Melissa relocated to Texas from Arizona six months ago to be close to Melissa’s mother. Melissa has two older siblings, Margaret and Mandy. Assignment: Practicum – Assessing Client Families
Presenting Problem
Melissa and John were seeking family therapy because they could not agree on whether Melissa was ready to be discharged to home after being in the hospital for two days. Melissa was in the psychiatric unit for an episode of psychosis, as determined by the attending psychiatrist. Melissa has a history of Bipolar II disorder and has been maintained on medications since eight years ago. She also has a history of Post-Traumatic Stress Disorder (PTSD) and hypertension. She reports that her father died in a hit-and-run accident while crossing the road when Melissa was 12 years old, and Melissa witnessed the accident.
Melissa had insisted that she wanted to be discharged to home because she felt better. The doctor was not in agreement and decided not to discharge her. Melissa then decided to sign a 4-hour letter, and so she could go home. Upon notifying John of Melissa’s intent to be discharged, he asked the doctor not to discharge Melissa until she was well enough to go back home. The disagreement between Melissa and her husband prompted the family session with the therapist and the physician. John did not believe Melissa was safe to return home, but Melissa thought John was avoiding her because he did not want her near their daughter in that condition. Assignment: Practicum – Assessing Client Families
The family members that were present were Melissa, John, and Melissa’s mother, Louise. During the assessment, the therapist must create an environment of open communication and be open to listening to all parties with a non-judgmental attitude. Minuchin et al. (2007) as cited by Nichols and Tafuri (2013) encourages therapists to ask open-ended questions and allow the family members a chance to tell their stories and express their feelings to help them feel understood and to gain their trust.
History of Present Illness
According to John, Melissa got ready and left for work one Monday morning. John had dropped Morgan off at school, and Melissa was expected to pick her up after school. The school called John an hour after Morgan was supposed to be picked up and reported that the mother had not picked Morgan. John tried to contact Melisa, but Melissa did not answer the phone. John then rushed to the school and picked up their daughter and reported the matter to the police out of concern.
Melissa was later found in her car, about three miles from their house, stating the people told her not to get out of her car; otherwise, she would die. According to the police report, Melissa was talking to herself when they found her and stated she was afraid to continue driving because she did not want to get to her destination. She did not specify why she did not want to get to her destination. John admitted that he and his wife fought two days before the incident because Melissa had not been taking her medications. Melissa’s reason for not taking her medications was because she believed her dizziness was due to low blood pressure from taking Minipress even though she had not checked her blood pressure Assignment: Practicum – Assessing Client Families.
Melissa’s History
Past Psychiatric History: Melissa has a history of PTSD and Bipolar II disorder. Until recently, both conditions have been controlled on medications. She has no current or past legal issues.
Medical History: Melissa has a history of hypertension. Her last vital signs taken an hour before the therapy session was BP-138/86, Pulse-88, Respirations-18, Temperature-98.2, SPO2-99% on room air. Her BMI is 30, but she denies any weight gain in the past three months. Melissa’s immunizations are up to date. Her last physical examination was two years ago. She has no surgical history and has no food, drug, or environmental allergies.
Substance use History: Melissa has no history of illicit drug use. She drinks some wine socially.
Developmental History: To her knowledge, Melissa’s birth was a normal vaginal delivery with no complications. Her mother did not drink alcohol, smoke cigarettes, or use illicit drugs while pregnant with Melissa or when Melissa was growing up. Melissa’s father passed away when Melissa was 12 years old. Melissa was raised in a single-parent home after her father’s death. Her mother was a Registered Nurse who worked in home health care until her retirement.
Family Psychiatric History: Melissa reported no family history of drug use, mental or psychiatric illness on both her maternal and paternal side of the family.
Psychosocial History: Melissa has a full-time job. She lives with her husband and 9-year old daughter. She has been married to John for ten years.
History of Abuse and/or Trauma: Melissa experienced trauma when a hit-and-run driver killed her father. She, however, denies any physical, emotional, or sexual abuse. According to Asas et al. (2016), childhood traumatic events are associated with various clinical characteristics of bipolar disorder, its earlier onset, a rapid-cycling course, and psychotic features Assignment: Practicum – Assessing Client Families.
Review of Systems
Melissa stated she has a history of hypertension. She denies any other medical history.
Physical Assessment
General: Melissa is alert, oriented, and appears healthy. She does not have any chills, fever, or fatigue.
HEENT: No visual loss, blurred vision, double vision, or tearing. No decreased hearing, hearing loss, sneezing, congestion, or sore throat.
Skin: No rash or itching. The skin is pink, looks healthy with good skin turgor.
Cardiovascular: Reports no chest pain, chest pressure or chest discomfort. No palpitations or edema.
Respiratory: Respirations are regular and unlabored. No shortness of breath, chest congestion, or cough.
Gastrointestinal: Reports no nausea, vomiting, diarrhea, constipation, abdominal pain, blood the in stool, or loss of appetite.
Genitourinary: No dysuria or frequency of urination.
Neurological: No dizziness, syncope, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
Musculoskeletal: No muscle or joint pain or stiffness.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: No visible swelling in the neck
Psychiatric: Melissa has PTSD and bipolar disorder. She, however, denies any hallucinations, suicidal, or homicidal ideations.
Allergies: No rhinitis or any other symptoms of seasonal allergies Assignment: Practicum – Assessing Client Families.
Mental Status Examination (MSE)
The mental status examination is necessary for every client before the initiation of a therapy session. Since the MSE is the psychological equivalent of a physical examination, it includes both the subjective and objective assessment. When interpreting the examination, Norris, Clark, and Shipley (2016) reported that the examiner should take into account the client’s culture, level of education, literacy, and social factors such as lack of sleep, hunger, or other stressors, because these factors can affect performance. Thus, the MSE that will be conducted on Melissa will take into account the factors mentioned above by Norris et al. (2016).
General Observation: Melissa was dressed casually but neatly in her home clothes since she was not on suicide watch. She has piercings but did not have earrings on, per facility policy. She appears a little anxious as she sat between her mother and her husband. Melissa is coherent, speaks in a normal tone with normal volume. While talking, she looks into the eyes of the therapist and her mother but avoids looking at her husband Assignment: Practicum – Assessing Client Families.
Thinking: Melissa is direct, fluent, and goal-oriented. She, however, loses her thought process a few times and has poor insight into her condition.
Emotion: Melissa is alert and oriented to self, time, situation, and place. Her affect is congruent with the mood. She is anxious but does not appear frustrated or agitated.
Cognition: Melissa has poor insight into her condition as she denies that she hears voices even though appears to be listening to some internal stimuli. She pauses mid-sentence, stares at the therapist, and continues talking. When asked why she paused, she responds, “nothing, I thought John said something.”
Differential Diagnosis
Melissa has a diagnosis of PTSD 309.81 (F43.10) and bipolar II disorder (BD) 296.89 (F31.81). She was admitted with auditory hallucinations and had poor insight of her condition. She still appears to be listening to some internal voices even though she denies it. She denies any suicidal ideations and takes her medications without prompting. She does not exhibit any signs or symptoms of either BD or PTSD. She has no other symptoms except auditory hallucinations. The differential diagnosis in Melissa’s situation would be “Other specified schizophrenia spectrum and other psychotic disorder” 298.8 (F28). According to (Association, 2013), this category is used when a clinician chooses not to identify a specific reason that the presentation does not quite meet the criteria for any specific schizophrenic spectrum. In this situation, Melissa presents with symptoms of schizophrenia, such as persistent auditory hallucinations, but does not meet the schizophrenia diagnosis Assignment: Practicum – Assessing Client Families.
Case Formulation
Melissa was admitted to the psychiatric unit, accompanied by security and her husband. She was initially brought to the emergency department by the police after she was found sitting in her car, refusing to come out. Melissa heard voices telling her if she got out of the car, she would die. She had no other symptoms, but her presenting symptoms warranted admission to the psychiatric unit for further evaluation. Melissa lives with her husband and their 9-year old daughter. When she requested to be discharged to home, the physician declined her request based on her condition. Melissa then chose to sign a 4-hour letter, to which the physician responded by ordering a 24-hour hold on her discharge.
Melissa decided to call her husband so he could pick her up. The husband was not too comfortable after he spoke to the doctor and determined that Melissa was still hallucinating and would not be safe at home. John then requested a meeting with the therapist and the physician. The meeting was attended by the therapist, the psychiatrist, Jolene, John, and Melissa. The physician determined that Melissa was still having hallucinations and that her symptoms were not related to her PTSD or BD. The symptoms did not quite meet the schizophrenia spectrum criteria, thus the need to continue observing Melissa in an inpatient setting.
Treatment Plan
Melissa and her family attended the family session, as recommended by both the physician and the therapist. The goal was for Melissa to understand the need for continued inpatient care. Even though Melissa continued to deny having any more hallucinations, the meeting was fruitful as Melissa agreed to stay in the hospital until the physician determined that she was safe to go home. In the meantime, she will continue attending group therapy with other patients, taking her medications, and having access to the unit phone so she could speak to her daughter.
General Observation: John was not dressed for the weather as he was wearing a pair of jeans and a T-shirt. He appeared calm and composed as he sat close to his wife. John was coherent and spoke in a normal tone. He listened attentively to the physician and the therapist and responded appropriately when it was his turn to speak.
Thinking: John was logical, direct, fluent, and goal-oriented, and did not lose his thought process.
Emotion: John is alert and oriented to self, time, situation, and place. John’s affect is congruent with the mood. He appears calm and cooperative
Cognition: John has good insight into his wife’s condition. He is oriented and does not seem to lose his thought process. John is focused on getting his wife the help that she needs until she can return home safely.
Louise’s MSE
General Observation: Louise was dressed casually and appropriately for the weather. She did not appear to have any piercings or tattoos. She was quiet and calm as she sat next to Melissa. She did not contribute to the discussion except for when she agreed with John that Jolene still needed inpatient care. Louise appeared concerned and confused as to what was going on with her daughter.
Thinking: Louise was logical, fluent, and goal-oriented. She did not lose her thought process and had fair insight into her daughter’s condition.
Emotion: Louise was alert and oriented to self, time, situation, and place. Louise’s affect is congruent with the mood. She appeared concerned but calm and cooperative.
Cognition: Louise appears fairly insightful about her daughter’s condition. She did not contribute much to the discussion, and, therefore, made it difficult to assess her cognitive status. Assignment: Practicum – Assessing Client Families
Part 2: Family Genogram
Paternal Great Grandparents Maternal Great Grandparents
Shadreck
Gaylord
Martha
Madeline
Paternal Grand Parents Maternal Grand Parents
Jolene
Dorothy
Derrick
Kenny
Parents
Louise
Eugene
Mandy
Melissa
Margaret
Conclusion
A comprehensive assessment of a family or group is necessary for the case formulation and treatment plan. Melissa’s case presents an ideal family of a couple and the patient’s mother. The couple’s daughter Morgan is 9-years old and was not part of the family session. This session was different from the ones that are conducted solely by a therapist as it involved the physician. However, the therapist was the main person in the whole process. Even in family therapy, Kurpad (2018) stated that the therapist still needs to maintain confidentiality to ensure an effective therapeutic alliance. The patient should also be given the option to choose which family member they would want to be included in the therapy session. In the situation above, Melissa decided to have her mother and her husband present. Informed consent should be obtained, and coercion avoided as that would be unethical.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Asas, M., Henry, C., Andreassen, O. A., Bellivier, F., Melle, I., & Etain, B. (2016). The role of childhood trauma in bipolar disorders. International Journal of Bipolar Disorders, 4(2), 15-42. https://doi.org/10.1186/s40345-015-0042-0
Kurpad, S. S. (2018). Ethics in psychosocial interventions. Indian Journal of Psychiatry, 60(4), 571-574. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_26_18
Nichols, M. P. (2014). The essentials of family therapy (6th ed.). Boston, MA: Pearson.
Nichols, M., & Tafuri, S. (2013). Techniques of structural family assessment: A qualitative analysis of how experts promote a systemic perspective. Family Process, 52(2), 207-215. https://doi.org/org.ezp.waldenulibrary.org/10.1111/famp.12025
Norris, D. R., Clark, M. S., & Shipley, S. (2016). The mental status examination. American Family Physician, 94(8), 636-641. Retrieved from www.aafp.org/afp
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse. A how-to guide for evidence-based practice (2nd ed.) New York, NY: Springer Publishing Company, LLC Assignment: Practicum – Assessing Client Families
