To Prepare
· Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
· Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
· Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
· Include at least five scholarly resources to support your assessment and diagnostic reasoning.
· Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
· include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
· Plan: What was your plan for psychotherapy (including one health promotion activity and one patient education strategy)? What was your plan for treatment and management, including alternative therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
· Reflection notes: What would you do differently with this patient if you could conduct the session again?
|
Discuss Subjective data: |
9 (9%) – 10 (10%) The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. |
8 (8%) – 8 (8%) The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. |
7 (7%) – 7 (7%) The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies. |
0 (0%) – 6 (6%) The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing. |
|
Discuss Objective data: |
9 (9%) – 10 (10%)
The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable. |
8 (8%) – 8 (8%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. |
7 (7%) – 7 (7%)
Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. |
0 (0%) – 6 (6%)
The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing. |
|
Discuss results of Assessment: |
18 (18%) – 20 (20%) The video accurately documents the results of the mental status exam. |
16 (16%) – 17 (17%) The video adequately documents the results of the mental status exam. |
14 (14%) – 15 (15%) The video presents the results of the mental status exam, with some vagueness or inaccuracy. |
0 (0%) – 13 (13%) The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing. |
|
Discuss treatment Plan: |
18 (18%) – 20 (20%)
The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided. |
16 (16%) – 17 (17%)
The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided. |
14 (14%) – 15 (15%)
The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended. |
0 (0%) – 13 (13%)
The response does not address the diagnosis or is missing elements of the treatment plan. |
|
Reflect on this case. Discuss what you learned and what you might do differently. |
5 (5%) – 5 (5%) Reflections are thorough, thoughtful, and demonstrate critical thinking. |
4 (4%) – 4 (4%) Reflections demonstrate critical thinking. |
3.5 (3.5%) – 3.5 (3.5%) Reflections are somewhat general or do not demonstrate critical thinking. |
0 (0%) – 3 (3%) Reflections are incomplete, inaccurate, or missing. |
|
Comprehensive Psychiatric Evaluation documentation |
18 (18%) – 20 (20%)
The response clearly, accurately, and thoroughly follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. |
16 (16%) – 17 (17%)
The response accurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. |
14 (14%) – 15 (15%)
The response follows the Comprehensive Psychiatric Evaluation format to document the selected patient case, with some vagueness and inaccuracy. |
0 (0%) – 13 (13%)
The response incompletely and inaccurately follows the Comprehensive Psychiatric Evaluation format to document the selected patient case. |
NRNP/PRAC6645 Comprehensive Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
(include psychiatric ROS rule out)
Past Psychiatric History:
· General Statement:
· Caregivers (if applicable):
· Hospitalizations:
· Medication trials:
· Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Case Formulation and Treatment Plan:
References
© 2021 Walden University
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An impulse control or conduct disorder
A 62 year old male client diagnosed with antisocial personality disorder and opioid dependence present for a telehealth education session. Client is married recently paroled from Indiana D.O.C. after serving 25 yrs. of 115 yr. sentence for 4 felony counts including murder, assault, and attempted murder. Client indicated he has previous convictions in 1979 for battery w/ violence. Client indicated that he also past hx. of I.V. Opioid usage beginning at age 21. Client indicated that he has extensive hx. of anger/ rage and has participated in numerous treatment groups including anger management, substance abuse tx, behavioral modification, individual therapy ,since 1999. Client is currently on parole and living w/ his sister while he adjust to life outside of prison. Client indicated that he maintains a cordial and supportive relationship with his spouse of over 20 years, however he needs time to adjust to society before he returns to a “normal” married life.. Client indicated that he feels he needs time to develop and practice the coping skills he learned during his incarceration and work with a therapist to discuss his daily life concerns to ensure that he is not operating from the survival tactics which he employed in prison. Client indicated that although the tactics he employed during his incarceration were necessary they may prove maladaptive in society and in fact may be detrimental to his goal of maintaining his freedom and maintaining control of his emotional responses.
for an impulse control or conduct disorder
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