Care Across The Lifespan I Assignment

Journal

Welcome to the last week of your practicum! As you have proceeded through the practicum experience, you have been regularly challenged to reflect on your growth and development as you made progress on your goals. Additionally, your Preceptor has evaluated your skills and has provided feedback. As you end this practicum, consider what you have gained from the experiences in your practicum setting. Did you meet your goals and objectives? What were the challenges and how did you manage them? What were the successes and what lessons can you take from those experiences and apply to future experiences? Use your reflections to seek opportunities for growth in the areas you found challenging, while simultaneously celebrating your successes. Care Across The Lifespan I Assignment

This week, your complete a reflective journal on your practicum experience

Critical reflection of your growth and development during your practicum experience in a clinical setting has the benefit of helping you to identify opportunities for improvement in your clinical skills, while also recognizing your strengths and successes.

Use this Journal to reflect on your clinical strengths and opportunities for improvement, the progress you made, and what insights you will carry forward into your next practicum.

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To Prepare

Refer to the “Population-Focused Nurse Practitioner Competencies” found in the Week 1 Learning Resources, and consider the quality measures or indicators advanced nursing practice nurses must possess in your specialty of interest.
Refer to your Clinical Skills Self-Assessment Form you submitted in Week 1, and consider your strengths and opportunities for improvement.
Refer to your Patient Log in Meditrek, and consider the patient activities you have experienced in your practicum experience and reflect on your observations and experiences.

Journal Entry (450–500 words)

Learning From Experiences

Revisit the goals and objectives from your Practicum Experience Plan. Explain the degree to which you achieved each during the practicum experience.
Reflect on the three (3) most challengin g patients you encountered during the practicum experience. What was most challenging about each? Care Across The Lifespan I Assignment
What did you learn from this experience?
What resources were available?
What evidence-based practice did you use for the patients?
What would you do differently?
How are you managing patient flow and volume?
How can you apply your growing skillset to be a social change agent within your community?

Communicating and Feedback

Reflect on how you might improve your skills and knowledge, and communicate those efforts to your Preceptor.
Answer the questions: How am I doing? What is missing?
Reflect on the formal and informal feedback you received from your Preceptor.

Focused SOAP Note and Client Case Presentation

Tina Cherry

College of Nursing-PMHNP, Walden University

NRNP PRAC 6665C: Psychiatric Mental Health Nurse Practitioner Care Across the Lifespan I

Jannia Mendez MSN APRN PMHNP BC

Subjective:

CC (chief complaint): “I am pretty mentally ill.”

HPI: PL is transmale, 17 years old, using the pronouns he/him. He has been accompanied to the clinic by his grandmother diagnosed with depression, PTSD, ADHD, autism, and anxiety. He says he has been trying to change his medications, but his psychiatrist will not allow him. The patient says that, generally, he is sleeping fine. On a scale of one to ten, where ten is total happiness, the patient rates his life as a six out of ten. He says he is generally moody and has been experiencing side effects from the medications he is currently on. The patient denies any suicidal or homicidal ideation. He admits to experiencing hallucinations and reports that he has a low mood most of the time. He says that he was verbally, emotionally, and physically abused by his grandmother and father during his childhood.

Substance Current Use: Never used tobacco, occasional drinker, and smokes marijuana weekly.

Medical History:

Current Medications: olanzapine 15 mg nightly, buspirone 10 mg TID, Effexor 150 mg daily, and Wellbutrin 100 mg daily.
Allergies: Allergic to Paxil influences mental behavior. Also allergic to zthrromycin, which causes vomiting and nausea.

Reproductive Hx: birth gender is female.

ROS:

GENERAL: Individual is appropriately dressed for the occasion but not well groomed.
HEENT: The patient’s skull is normocephalic and has no evidence of trauma. Vision is also normal with no recent changes. The patient has no auditory issues and passes the whisper test. The throat is normal with no inflammations.
SKIN: there are no breakages in the patient’s skin, and it is sufficiently moist.
CARDIOVASCULAR: The patient does not report any pains in the chest, edema, or orthopnea.
RESPIRATORY: There is no wheezing or dyspnea. The patient does not experience any shortness of breath.
GASTROINTESTINAL: The patient does not report any pains in the abdomen.
GENITOURINARY: No dysuria or hematuria was reported, and no discomfort when passing urine.
NEUROLOGICAL: The patient has not experienced any seizures, numbness, or focal weakness.
MUSCULOSKELETAL: The patient’s gait is normal, and no joint pains are reported.
HEMATOLOGIC: The patient does not report any blood clots or bleeding issues.
LYMPHATICS: The patient has no inflammations, and the lymph nodes are normal.
ENDOCRINOLOGIC: Polyuria and polydipsia are not reported.

Objective:

Diagnostic results:

Vitals: Height 5’2”; Weight 185 lbs; BI 33.84; Reported pain 0/10

GAD-7 total score: 14 PHQ-9 Total score: 21, MDQ (+)

Assessment:

Mental Status Examination:

The patient is well-oriented to time, person and place. During the examination, the patient changed in mood and appeared depressed. The patient is also experiencing sadness that is interfering with their normal functioning. During the examination, it is evident that the patient suffers from anxiety. The patient is also visibly nervous during the examination. Signs of sleep disturbance are evident from the examination, and the patient also has suicide ideation. The patient is also experiencing feelings of worthlessness and hopelessness. PL also presents with hallucinations and delusions.

Diagnostic Impression:

Moderate Bipolar Disorder

Moderate bipolar disorder is also called cyclothymic disorder (Ghaziuddin & Ghaziuddin, 2021). An individual experiencing moderate bipolar disorder is likely to present with cyclic lows and highs that can be apparent in considerable mood swings that also affect their energy levels (Ghaziuddin & Ghaziuddin, 2021). The cyclic lows and highs are also likely to lead to reduced energy levels affecting the individual’s ability to function normally (Ghaziuddin & Ghaziuddin, 2021). The changes in moods can take place rapidly and abruptly at any time. The individual will often have short periods of normal moods before their moods swing again (Ghaziuddin & Ghaziuddin, 2021). Moderate bipolar disorder is likely to appear in the adolescent stage to early adulthood. Symptoms of moderate bipolar disorder include needing very little sleep, being easily distracted, racing thoughts, being isolated, losing weight and appetite, suicide ideation, a considerable loss of energy, and low self-esteem (Ghaziuddin & Ghaziuddin, 2021). Care Across The Lifespan I Assignment

Posttraumatic Stress Disorder

PTSD is a mental health disorder that is caused as a result of a person experiencing or witnessing trauma. Some trauma that may lead to PTSD includes serious injury, sexual violence, death threats, terrorist acts, war, natural disasters, and many others (Watkins et al., 2018). An individual with PTSD is likely to experience disturbing and intense thoughts linked to the traumatic experience they underwent or witnessed, even if significant time has passed since the event. The individual may involuntarily relive the experience through nightmares or flashbacks that they cannot control or stop (Watkins et al., 2018). The individual may also feel intense sadness, anger, or fear while estranging from those around them. For a diagnosis of PTSD to arrive at, the individual has to have been exposed to trauma which may be firsthand or indirect (Watkins et al., 2018). Some of the symptoms of PTSD include intrusive, involuntary memories about the traumatic event, avoidance of reminders about the trauma, changes in moods and cognition, and irritability (Watkins et al., 2018).

Reflections

In this case, one of the main learning points was comorbidity. Comorbidity is the presence of more than one disorder in one patient (Auerbach et al., 2019). I learned that it is not rare for individuals to be diagnosed with more than one mental health disorder. One of the major challenges with comorbidities is getting an accurate diagnosis because of the overlap of symptoms the patient may present with (Auerbach et al., 2019). Treatment can also be challenging because an intervention for a specific disorder may have unintended effects on other disorders in the individual. In this case, one of the ethical considerations is patient autonomy (Shobassy, 2021). The patient is convinced that he should change his medications and is aware of their advocacy rights. However, the patient is also below 18 years old, which may mean that he is not capable of making such decisions on his own. In addition, he is accompanied by an adult, his grandmother, whom he accuses of having verbally, emotionally, and physically abused him in the past. A legal consideration linked to the issue of patient autonomy would be to determine what the state laws say about such a case. In some states, older adolescents have some autonomy rights (Shobassy, 2021).

Case Formulation and Treatment Plan:

The patient should continue taking olanzapine 10mg nightly. In addition, they should take Effexor 75 mg while continuing with Wellbutrin 100 mg daily. The patient should be scheduled for a follow-up appointment to evaluate how he responds to the changes in his prescription and if he is still experiencing adverse drug reactions. The patient should continue taking venlafaxine in the clinic appointment and begin bupropion taper. The patient should be started on Latuda 20mg, taken once daily during the same visit. The patient and his grandmother should monitor the medications for any side effects. In the case of an emergency, the patient or the grandmother should visit the hospital or contact 911. In order to ensure the patient and the grandmother have understood the treatment plan, they should both verbalize it. Care Across The Lifespan I Assignment

References

Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., … & WHO

WMH‐ICS Collaborators. (2019). Mental disorder comorbidity and suicidal thoughts and behaviors in the world health organization world mental health surveys international college student initiative. International journal of methods in psychiatric research, 28(2), e1752. https://doi.org/10.1002/mpr.1752

Ghaziuddin, M., & Ghaziuddin, N. (2021). Bipolar disorder and psychosis in autism. Psychiatric

Clinics, 44(1), 1-9. https://doi.org/10.1016/j.psc.2020.11.001

Shobassy, A. (2021). Legal and Ethical Issues. The Psychiatric Hospitalist: A Career Guide,

215.

Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-

based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258

Care Across The Lifespan I Assignment