PMHNP PRAC 6665/6675 Clinical Skills List

Walden PMHNP PRAC 6665/6675 Clinical Skills List

PMHNP PRAC 6665/6675 Clinical Skills List

Target Patient Population: 40 children/adolescents and 40 adults/older adults

PMHNP PRAC 6665/6675 Clinical Skills List

Desired Clinical Skills for Students to Achieve
Comprehensive psychiatric evaluation skills in:
·       Recognizing clinical signs and symptoms of psychiatric illness across the lifespan
·       Differentiating between pathophysiological and psychopathological conditions
·       Performing and interpreting a comprehensive and/or interval history and physical examination (including laboratory and diagnostic studies)
·       Performing and interpreting a mental status examination
·       Performing and interpreting a psychosocial assessment and family psychiatric history
·       Performing and interpreting a functional assessment (activities of daily living, occupational, social, leisure, educational).
Diagnostic reasoning skill in:
·       Developing and prioritizing a differential diagnoses list
·       Formulating diagnoses according to DSM 5 based on assessment data
·       Differentiating between normal/abnormal age-related physiological and psychological symptoms/changes
Pharmacotherapeutic skills in:
·       Selecting appropriate evidence based clinical practice guidelines for medication plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management)
·       Evaluating patient response and modify plan as necessary
·       Documenting (e.g., adverse reaction, the patient response, changes to the plan of care)
Psychotherapeutic Treatment Planning:
·       Recognizes concepts of therapeutic modalities across the lifespan
·       Selecting appropriate evidence based clinical practice guidelines for psychotherapeutic plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management, modality appropriate for situation)
·       Applies age appropriate psychotherapeutic counseling techniques with individuals and/or any caregivers
·       Develop an age appropriate individualized plan of care
·       Provide psychoeducation to individuals and/or any caregivers
·       Promote health and disease prevention techniques
Professional skills:
·       Maintains professional boundaries and therapeutic relationship with clients and staff
·       Collaborate with multi-disciplinary teams to improve clinical practice in mental health settings
·       Identifies ethical and legal dilemmas with possible resolutions
·       Demonstrates non-judgmental practice approach and empathy
·       Practices within scope of practice
·       Demonstrate ability
Selecting and implementing appropriate screening instrument(s), interpreting results, and making recommendations and referrals
·       Demonstrates selecting the correct screening instrument appropriate for the clinical situation
·       Implements the screening instrument efficiently and effectively with the clients
·       Interprets results for screening instruments accurately
·       Develops an appropriate plan of care based upon screening instruments response

Documentation of Completed Competency/Clinical Skill (PMHNP PRAC 6665/6675 Clinical Skills List)

 Competency/Clinical SkillCOMPLETED   PRECEPTOR SIGNATURE  DATE

PMHNP PRAC 6665/6675 Clinical Skills List

 Competency/Clinical SkillCOMPLETED  PRECEPTOR SIGNATURE  DATE

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Example

Patient Information:

Name: J.L.

Age: 22 years

Race: African American

Sex: Female

Occupation: College student.

Subjective:

CC (chief complaint): “ Am hopeless and unworthy in this world.”

HPI: J.L. is a 22-year-old African American female who presents to the psychiatric clinic with complaints of feeling hopeless and unworthy in the world for 4 weeks. J.L. is a college student. She reports having been well until she broke up with her boyfriend about two months ago. Since the breakup, her mood has been constantly low, and she has difficulty falling asleep. However, she started feeling hopeless and unworthy and no longer enjoys hobbies such as playing basketball. Her performance in school has diminished significantly. J.L. blames herself for the divorce. J.L. thinks it is better if she takes her own life, although she has not attempted suicide. She also reports fear and anxiety. She denies hallucinations and delusions.

Past psychiatric history: No previous psychiatric illnesses. No previous psychiatric or substance use treatment.

Substance Current Use: She reports using marijuana with friends but stopped 1 year ago. She used to take 1 standard drink per day, but after the divorce, she takes 3 standard drinks per day. She denies tobacco use and use of other illicit drugs.

Medical History: She does not suffer from any chronic illness, such as diabetes, asthma, or hypertension. She has no previous hospitalizations. No history of childhood illness or trauma. All immunizations are up to date. No previous surgeries or blood transfusion.

  • Current Medications: None.
  • Allergies: No known food and drug allergies.
  • Reproductive Hx: Menarche at 14 years. Last LMP 18th August 2022. She is sexually active and heterosexual, and her sexual debut was at 20 years. She is currently single and has never gotten pregnant. Denies contraceptive use.

Social history: She is the firstborn. Has a younger brother who is in high school. A college student. Stays with her mother. She broke up with her boyfriend 2 months ago. She likes playing basketball. She is a Christian and enjoys making friends. No previous encounter with law enforcement agents. Exercises regularly and observes a balanced diet.

Family history: Her maternal grandfather had paranoid schizophrenia and died at 76 years, while her maternal grandmother is 70 years and has diabetes. Her paternal grandfather is 78 years and has hypertension, while her paternal grandmother is 72 years alive and well. Her mother suffered postpartum depression during the birth of her brother, while the father has a generalized anxiety disorder.

ROS:

  • GENERAL: Reports weight loss and fatigue. Denies nausea, night sweats, and hotness of the body.
  • HEENT: Denies head trauma, blurring of vision, vision loss, yellow sclera, ear pain, ear discharge, hearing loss, sneezing, runny nose, nasal congestion, dysphagia, or sore throat.
  • SKIN:
  • CARDIOVASCULAR: Denies paroxysmal nocturnal dyspnea, chest pain, palpitations, or peripheral limb edema.
  • RESPIRATORY: Denies cough, wheezing, difficulty breathing, or shortness of breath.
  • GASTROINTESTINAL: Reports loss of appetite. Denies constipation, diarrhea, abdominal discomfort, or vomiting.
  • GENITOURINARY: Denies dysuria, frequency, nocturia, odd odor, burning on urination, hematuria, vaginal pruritus, or abnormal vaginal discharge.
  • NEUROLOGICAL: Denies headache, loss of consciousness, ataxia, numbness, tingling in extremities, and dizziness.
  • MUSCULOSKELETAL: No back pain, joint pain, joint swelling, muscle aches, or stiffness.
  • HEMATOLOGIC: No anemia, easy bruising, or bleeding.
  • LYMPHATICS: Denies history of splenectomy. No lymphadenopathy.
  • ENDOCRINOLOGIC: No polyuria, polydipsia, cold, or heat intolerance.

Objective:

Physical Exam:

Vital Signs: Temperature- 98.2 F, Pulse- 80 beats per minute, Respiratory rate 16 breaths per minute, BP- 112/72 mmHg, Height 5’4, Weight 118 lbs

General: A young African American adult female, well-kempt, appropriately dressed, appropriate for her stated age, and good body built. Not in obvious respiratory distress, well hydrated, and of good nutrition status. No cyanosis, pallor, jaundice, peripheral edema, or lymphadenopathy.

HEENT: Normocephalic and atraumatic head with equal hair distribution. Both eyes present with white sclera and pink conjunctiva. Pupils equally and bilaterally react to light. Intact extraocular movements. Intact optic disc with no retinal hemorrhages. Both ears present, no visible skin lesions, tympanic membrane pearly gray with normal light reflex. Pink non-edematous nasal mucosa, no nasal septum deviation. Oral mucosa pink with no lesions, tongue midline and pharynx without exudates.

Neck: Soft neck, trachea centrally located, no thyroid enlargement, non-distended neck veins, and no cervical lymphadenopathy.

Chest/Lungs: Symmetrical chest that moves with respiration. No visible skin lesions or thoracotomy scars. No tenderness and masses on superficial and deep palpation. Equal chest expansion and tactile fremitus. Resonant on percussion. Vesicular breath sounds, no crackles or rhonchi on auscultation.

Cardiovascular: Normoactive precordium. Point of maximal impulse in the fifth intercostal space midclavicular line. S1 and S2 heard, clear and distinct. No murmurs, gallops, heaves, or thills.

Abdominal: Non-distended abdomen that moves with respiration, Umbilicus everted, and no obvious scars or masses. No tenderness or masses on both superficial and deep palpation. Liver palpable 1 cm below the right costal margin with a liver span of 7 cm. spleen and both kidneys impalpable. Tympanic on percussion. Bowel sounds were present. No renal or aortic bruits.

Neurological: GCS 15/15, oriented to time, place, and person, intact memory, and intact speech. All cranial nerves were intact. No neurological deficits were noted. Good motor and sensory function. Good bowel and bladder function. No abnormal gait was noted. No spinal tenderness, and cerebellar functions were intact.

Musculoskeletal: Good muscle bulk, power of 5/5 across all muscle groups, and a good range of motion across all joints. Normotonia and normoreflexia.

Diagnostic results: J.L. presents with feelings of hopelessness and worthlessness that appears to have been precipitated by a divorce. These are associated with suicidal ideation, depressed mood, anhedonia, weight loss, insomnia, anorexia, and feeling of disproportionate guilt. According to Bains and Abdijadid (2022), this constellation of symptomatology is common in major depressive disorder.

The DSM-5 outlines the criteria for major depressive disorder as follows; Five or more symptoms of the following nine symptoms; depressed mood, anhedonia, sleep disturbance, depressed mood, fatigue, appetite/weight changes, psychomotor disturbances, suicidal ideation, and attention impairment for at least 2 weeks with one of the symptoms being depressed mood or anhedonia (American Psychiatric Association, 2022).

Additionally, there should be clinically significant distress or functional impairment. Similarly, symptoms should not be due to organic or psychoactive substances. Finally, schizoaffective and other psychotic disorders must be excluded (American Psychiatric Association, 2022). The differential diagnoses include substance-induced depressive disorder since she has features of depression in the setting of alcohol use. Similarly, other medical conditions that can lead to depression, such as hypothyroidism, must be excluded. Finally, J.L. reports fear and anxiety, common comorbidities in major depressive disorder.

Assessment:

Mental Status Examination: The patient is a 22-year-old African American female. She is well-kempt, dressed appropriately, and is appropriate for her stated age. She is cooperative and oriented to time, place, and person. She does not maintain eye contact. Her speech is coherent and clear. She projects a negative affect and a low mood. Her thought process is logical and coherent, with no flight of ideas. She has no hallucinations or delusional thinking. She has suicidal ideation. Her memory is intact, and has good judgment and insight.

Diagnostic Impression: The most appropriate diagnosis for J.L. is a major depressive disorder. J.L. presents with symptoms that characterize depression, such as depressed mood, anhedonia, fatigue, anorexia, weight loss, insomnia, feelings of guilt, worthlessness, hopelessness, and suicidal ideation for more than 2 weeks (American Psychiatric Association, 2022). Additionally, these symptoms have significantly impaired her social and academic functioning and cannot be attributed to another medical disorder or psychoactive substance. The aforementioned features of her presentation are in accordance with the DSM-5 criteria for the diagnosis of major depressive disorder. Additionally, she is a female in her third decade of life, which is the typical age of onset of depression (Bains & Abdijadid, 2022). Finally, there is an evident psychological trigger which is separation from her boyfriend.

Reflections: The current case isolates the impact of psychological stressors such as divorce on the emotional well-being of an individual. The preceptor’s diagnosis of major depressive disorder is the most convenient as the patient’s manifestation fulfills the DSM-5 criteria for diagnosis of major depressive disorder. The present case study has enhanced my skills in assessing and evaluating a patient with suspected depression. As psychiatrists, we should be empathic in our approach to our patients and allow patients to express their concerns.

Similarly, we should anticipate the needs of our patients. Our approach and treatment of our patients should be founded on ethical and legal principles. In addition to privacy and confidentiality, patient autonomy should be observed. All treatments should be in the best interest of the patient. The patients must be involved in care and decision-making. Finally, all our treatments should be evidence-based. Given this case again, I will carefully explore other causes of depression and other comorbidities. Similarly, I will establish a therapeutic relationship that will allow the exchange of information. Finally, I will be able to encourage the patient and avoid questions on subjects that the patient doesn’t wish to expound on.

Case Formulation and Treatment Plan:

  • Investigations: Screening for the severity of depression using patient health questionnaire- 9 and Beck Depression Inventory, AUDIT- C test, and CAGE test to screen for alcohol use disorder, screening for anxiety using generalized anxiety disorder-7, and a suicide screening questionnaire to assess for suicide (Park & Zarate, 2019). Thyroid function tests to rule out hypothyroidism. Other laboratory tests include complete blood count, complete metabolic panel, vitamin B12, folate, serum and urine toxicology, HIV testing, and syphilis screening.
  • Pharmacotherapy: Escitalopram 15 mg PO once daily. According to Boyce and Ma (2021), SSRIs such as escitalopram are considered first-line for major depressive disorder, and escitalopram appears to have fewer general adverse effects than other SSRIs.
  • CBT: Cognitive behavioral therapy is the psychotherapy of choice for major depressive disorder (Vasile, 2020). It should be done for approximately 16 weeks. Twice weekly for the first 4 weeks and once weekly for the remaining weeks (Vasile, 2020).
  • Patient education: She should be enlightened on the importance of medication adherence and importance of alcohol cessation. According to Kranzler and Soyka (2018), alcohol use is associated with increased morbidity and mortality in individuals with depression. Additionally, the patient should be enlightened on good sleep hygiene practices, medication side effects, stress reduction, and improved nutrition.
  • Follow-up and referral: A referral to a psychiatrist. Follow-up should be after 6 weeks of therapy to determine treatment efficacy and necessary adjustments. The patient should be linked to alcohol anonymous and support groups for social support.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Bains, N., & Abdijadid, S. (2022). Major Depressive Disorder. https://pubmed.ncbi.nlm.nih.gov/32644504/

Boyce, P., & Ma, C. (2021). Choosing an antidepressant. Australian Prescriber44(1), 12–15. https://doi.org/10.18773/austprescr.2020.064

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: A review. JAMA: The Journal of the American Medical Association320(8), 815–824. https://doi.org/10.1001/jama.2018.11406

Park, L. T., & Zarate, C. A., Jr. (2019). Depression in the primary care setting. The New England Journal of Medicine380(6), 559–568. https://doi.org/10.1056/NEJMcp1712493

Vasile, C. (2020). CBT and medication in depression (Review). Experimental and Therapeutic Medicine20(4), 3513. https://doi.org/10.3892/etm.2020.9014