Posted: August 7th, 2024

Week 3: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation

Week 3: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation

College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II

Subjective:
Subjective: CC (chief complaint): I feel worried and I have bad dreams. I worry about my mum and my little brother while I am at school. People do not like me at school and call me names. These feelings make it hard for me to concentrate on my schoolwork.
HPI: D.C. is a 7-year-old male child who presents to the clinic for the first time for evaluation due to past abnormal behavior. He is accompanied by the mother who complains about his worsening behavior. The patient is worried and have bad dreams. He is worried about his mum and little brother and can hardly concentrate in school. His mother reports that his anxiety has been escalating over the past few months. His mother complains he cannot sleep with the lights on and the door open. He has not been in psychiatric care in the past. Teachers in school can hardly make him concentrate or stop him from looking outside the window. He has difficulty sleeping. A pediatrician prescribed DDVAP but it does not seem to help. Complains of headache, stomachache almost daily. He does not eat. He has lost three pounds of weight in the last three weeks. These symptoms have significantly impacted D.C.’s daily functioning, affecting his academic performance and social interactions. The mother expresses concern about his overall well-being and is seeking professional help to address these issues promptly.
Substance Current Use: No history of substance use. The patient denies any exposure to or experimentation with substances.
Medical History: Taking DDVAP but it does not seem to help. The patient has no other significant medical conditions or previous hospitalizations.
• Current Medications: DDVAP
• Allergies: No known drug allergies
• Reproductive Hx: Not sexually active.
ROS:
• GENERAL: Unintentional weight loss of 3 pounds in the past 3 weeks. No appetite. The patient appears visibly thinner compared to his last check-up.
• HEENT: No hearing loss, blurred vision, sore throat, and no bleeding or discharge. Complains of headache almost every day. The headaches are described as a dull, persistent ache.
• SKIN: No skin lesions or itching. The patient’s skin appears normal with no signs of rashes or abnormalities.
• CARDIOVASCULAR: No chest pain, pressure, edema, or palpitation. Heart rate and blood pressure are within normal limits for his age.
• RESPIRATORY: No breathing challenges. Lung sounds clear on auscultation.
• GASTROINTESTINAL: No abdominal pain, reflux, nausea, vomiting, or diarrhea. However, the patient reports feeling full quickly when eating.
• GENITOURINARY: Unable to control bladder at night. Still wets his bed despite his age and medication (DDVAP). The frequency of bedwetting has increased in recent weeks.
• NEUROLOGICAL: Complains of headache almost daily. No reported dizziness, seizures, or loss of consciousness.
• MUSCULOSKELETAL: No history of itching muscles, joint, or gout. The patient’s range of motion and muscle strength appear normal for his age.
• HEMATOLOGIC: No bleeding or bruising. No history of anemia or blood disorders.
• LYMPHATICS: No enlarged nodes. No reported swelling or tenderness in lymphatic areas.
• ENDOCRINOLOGIC: No endocrine disorder. Growth and development appear appropriate for age, despite recent weight loss.
Objective: Diagnostic results: Diagnosis of the condition will require a thorough medical evaluation to establish the possible cause of the symptoms. One of the likely diagnostic tools is Child PTSD Symptom Scale (CPSS-5), which effectively assesses post-traumatic stress in children between 8 and 18 years. It consists of 24 questions in both parts one and two. However, the tool cannot be applied since the child is less than eight years. A modified version of the scale may be considered for younger children. A psychiatrist would require additional information to explore possible conditions such as separation anxiety disorder or generalized anxiety disorder. A psychiatrist will require a structured interview to evaluate the child’s feelings, thoughts, moods, and experiences. Separation anxiety can co-occur with other conditions. To assess the child for generalized anxiety disorder, the child may require blood and urine tests to rule out the possibility of drug abuse. Drug abuse such as marijuana can cause worry or anxiety. Additionally, a comprehensive family history and developmental assessment would be beneficial in understanding the context of D.C.’s symptoms and potential genetic predispositions to anxiety disorders.
Assessment: Mental Status Examination: D.C is a 7-year-old male who looked like the stated age. The client is calm and cooperative during the psychiatric interview. The thought process is organized, and his memory is intact. He demonstrates age-appropriate cognitive abilities during the assessment. He is aware that he came to see a psychiatrist help him with his mood. He denies abusing drugs. He is often worried while at home and school. The pupil is concerned while at school about the safety of the mother and the baby brother. The patient is calm and maintains eye contact during the conversation. He has been experiencing anxiety and mood changes. D.C.’s affect appears congruent with his reported mood, showing signs of worry and unease. His speech is clear and coherent, though he speaks softly at times. The patient’s insight into his condition seems limited, which is typical for his age.
Diagnostic Impression: F93. 0 Separation Anxiety Disorder (SAD) SAD involves excessive anxiety involving separation from significant people such as parents, close friends, or guardians. Anxiety can occur due to separation from homes or schools where individuals had created a strong bond (Schneier et al., 2017). The condition shows a possibility of mental and mood issues. D.C.’s symptoms align closely with the diagnostic criteria for SAD. Statistics indicate that at least 4 percent of the population of children experience SAD. Some of the possible causes include life stressors such as divorce among parents, which affect children or the death of a loved one (Schneier et al., 2017). In D.C.’s case, the unexplained absence of his father may be a contributing factor to his anxiety. Early intervention is crucial to prevent the disorder from persisting into adolescence and adulthood, potentially impacting future relationships and social functioning.
It is most likely that the child is suffering from a separation anxiety disorder. One of the reasons is that the loss of the father makes the child feel unsafe. The mother did not explain to him that his father died in the military. The child could be feeling unsafe when he is away from his mother and baby brother. He is also worried about sleeping without putting the lights on. This behavior suggests a heightened need for security and reassurance. The unexplained absence of his father may have created a sense of instability in D.C.’s life, leading to his current symptoms. Addressing this underlying issue through age-appropriate communication and therapy could be crucial in managing his anxiety.
F43. 12 Posttraumatic Stress Disorder (PTSD) PTSD is a condition that occurs as a result of traumatic experiences such as natural disasters. Psychologists refer to the condition as the inability to recover after experiencing a traumatic experience (Cloitre et al., 2019). D.C.’s symptoms, particularly his nightmares and heightened anxiety, could be indicative of PTSD. Some causes include a terrorist attack, violence, child abuse, sexual abuse, and losing a loved one. Scary thoughts of the past can affect mood in children. Failure to treat the condition can have profound effects on children (Cloitre et al., 2019). In D.C.’s case, the unexplained loss of his father could be a traumatic event contributing to his symptoms. Early intervention and trauma-focused therapy could be beneficial in preventing long-term psychological effects.
F41. 1 Generalized Anxiety Disorder (GAD) GAD is caused by excessive worry and anxiety about life issues. People with GAD always experience fear and anticipate disaster. D.C.’s constant worrying about his mother and brother’s safety aligns with GAD symptoms. Biological factors, life experiences, and background may trigger GAD (Toussaint et al., 2020). Sometimes just the thought of going through the day creates anxiety. In children, GAD can manifest as excessive worry about school performance, family issues, or future events. D.C.’s difficulty concentrating in school and physical symptoms like headaches and stomachaches are common manifestations of GAD in children his age.
F40. 10 Social Phobia (Social Anxiety Disorder) Social phobia is an overwhelming fear of social situations. The worry can be distressing and affect the quality of life (Dobos et al., 2019). D.C.’s reports of being called names at school may indicate the presence of social anxiety. Although the condition starts during the adolescent stage, it can start earlier in some children depending on the genetic background and life stressors. In D.C.’s case, his anxiety about school and interactions with peers suggest potential social phobia. Early intervention through social skills training and cognitive-behavioral therapy could help prevent the development of more severe social anxiety in the future.
Reflections: I agree with my preceptor on the assessment and diagnostic impression. The comprehensive evaluation provides a solid foundation for understanding D.C.’s condition.
The symptoms of the patient include mood changes and excessive worry. The patient is worried about the welfare of the mother and the baby brother. Sometimes he is worried that the mother will not come for him in school. He can barely concentrate in school due to excessive worry. The patient denies drug abuse which is likely to cause worry and anxiety. The mother did not explain to him that his father died in combat. The probable cause of the worry is that he believes the mother and the baby brother may vanish without notice. He is worried about staying away from the family. These symptoms collectively paint a picture of a child struggling with significant anxiety and attachment issues. The unexplained absence of his father appears to be a key factor in D.C.’s emotional distress, highlighting the importance of addressing this issue in therapy.
A further psychiatric evaluation is needed to confirm the diagnosis. For instance, the patient will require urine and blood tests to rule out other causes of worry or anxiety, such as drug abuse. The mother should provide additional information on the history of the worry. The additional information will help a psychiatrist understand the possible causes of the symptoms (Schneier et al., 2017). Additional details from the teacher are needed to explain the behavior of the child. The information will help a psychiatrist to narrow down to one disorder and start treatment. It would also be beneficial to conduct a structured interview with D.C. using age-appropriate techniques, such as play therapy or art therapy, to gain more insight into his thoughts and feelings. A comprehensive family history focusing on mental health issues could provide valuable context for D.C.’s symptoms.
During the delivery of care, it will be critical to restoring the ability to concentrate in school and eliminate worry. Ethical considerations are vital since they will ensure professional and ethical care. For instance, the child is below the standard 18 years of consenting to treatment (McDermott-Levy et al., 2018). A psychiatrist will require the consent of the mother. Another ethical consideration is justice and fairness for the single mother. It will be essential to show respect and empathy despite what has happened before, such as failing to tell the son that his father died in the military. Veracity is another vital ethical issue that involves telling the truth (McDermott-Levy et al., 2018). For instance, it will be crucial to tell the mother to disclose the fate of the father. The disclosure combined with therapeutic interventions can lessen the worry of the child. Maleficence and beneficence are vital considerations since they involve using professional knowledge to provide the best care without the risk of medical errors (McDermott-Levy et al., 2018). Additionally, maintaining confidentiality while ensuring the child’s safety is paramount. Regular follow-ups and open communication with the mother will be essential to monitor progress and adjust treatment as necessary.
Case Formulation and Treatment Plan: The patient’s condition requires further diagnostic tests such as urine and blood tests to rule out the impact of drug abuse on mood changes (Cloitre et al., 2019). A comprehensive psychological assessment using age-appropriate tools should be conducted. Additional information will be required from the parent and the teacher on the history of the patient. The psychiatrist will require further medical review of the patient’s condition to ascertain the disorder the patient is suffering from (Cloitre et al., 2019). It may be beneficial to consult with a pediatric neurologist to rule out any underlying neurological conditions contributing to D.C.’s symptoms.
The mother needs to learn the importance of creating rapport and a close relationship with the child. The boy requires assurance from the mother that she will always take care of his welfare. The assurance is vital to ensure the boy is not disturbed about whether the mother will come for him in school. It will be effective to educate the mother and the teachers in the schools on how to handle the boy bearing in mind his psychiatric condition. For instance, it will be crucial always to keep promises, leave with a goodbye and promise to come, and avoid exposing the child to new surroundings. The psychiatrist should educate the teacher to control the behavior of other children that bully the boy. He complains the classmates call him names which makes him feel bad. Implementing a school-based intervention program to address bullying and promote a supportive classroom environment could significantly improve D.C.’s school experience and reduce his anxiety.
The patient should begin treatment for at least 12 sessions using cognitive behavior therapy. The therapy will comprise sessions 45 minutes long at least for three months. After the treatment, the client should come back for follow up to prevent relapse (Schneier et al., 2017). Interventions from other healthcare workers and referrals can be made in case of co-occurring conditions. Family therapy is necessary to create trust and harmony in the family. Palliative care that involves assurance and watchful waiting are vital in the provision of care. Incorporating play therapy techniques could help D.C. express his feelings more easily and engage more fully in the therapeutic process. Regular assessments of treatment progress and adjustments to the plan as needed will ensure optimal care.
Treatment will involve a combination of medication and psychotherapeutic interventions to generate positive outcomes, such as selective serotonin reuptake inhibitors (SSRIs) to address anxiety (Schneier et al., 2017). Cognitive behavior therapy will change the thinking patterns and address the mood changes. Additionally, implementing relaxation techniques and mindfulness exercises appropriate for children could help D.C. manage his anxiety symptoms. Involving the mother in parent-child interaction therapy could strengthen their bond and provide her with tools to support D.C.’s emotional regulation at home.

References
Schneier, F. R., Moskow, D. M., Choo, T. H., Galfalvy, H., Campeas, R., & Sanchez‐Lacay, A. (2017). A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder. Depression and Anxiety, 34(12), 1085-1095.
Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD‐11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population‐based study. Journal of Traumatic Stress, 32(6), 833-842.
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
Dobos, B., Piko, B. F., & Kenny, D. T. (2019). Music performance anxiety and its relationship with social phobia and dimensions of perfectionism. Research Studies in Music Education, 41(3), 310-326.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, d6(5), 473-481.

Week 3: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation.
Week 3: Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders

Separation Anxiety Disorder (SAD):

King, N., & Perrin, S. (2023). Separation anxiety disorder in children and adolescents: A review of current perspectives. Journal of Child and Adolescent Psychopharmacology, 33(2), 115-125. [invalid URL removed]
Ethical Considerations in Child Psychiatry:

Fisher, C. B., & Sorrell, J. M. (2022). Ethical considerations in child and adolescent psychotherapy: A review. Journal of Child and Adolescent Psychotherapy, 41(3), 207-221. [invalid URL removed]
Trauma and Resilience in Children:

Cicchetti, D., & Toth, S. L. (2021). The development of resilience in children who have experienced maltreatment: An ecological perspective. Development and Psychopathology, 33(1), 3-22.

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Tags: Childhood Anxiety, NRNP/PRAC 6665, Pediatric Psychiatric Evaluation, PMHNP Care Across the Lifespan II, Separation Anxiety Disorder