NURS 6640 Comprehensive Client Family Assessment and Family Genogram

NURS 6640 Comprehensive Client Family Assessment and Family GenogramLearning Resources

Week 3 Psychodynamic Psychotherapy Resources Readings

  • American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
  • Standard 2 “Diagnosis” (pages 46-47)
  • Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
  • Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 225–238 and pp. 245–258)
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Note: You will access this text from the Walden Library databases.
  • Young, J. M., & Solomon, M. J. (2009). How to critically appraise an article. Nature Clinical Practice. Gastroenterology & Hepatology, 6(2), 82–91. NURS 6640 Comprehensive Client Family Assessment and Family Genogram

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Learning Objectives

Students will:

  • Evaluate the application of current literature to clinical practice

Assignment 2: Practicum – Assessing Clients

PART 1

Learning Objectives

Students will:

  • Assess clients presenting for psychotherapy
  • Develop genograms for clients presenting for psychotherapy

To prepare:

  • Select a client whom you have observed or counseled at your practicum site.
  • Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.

The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):

  • 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/trauma
  • Review of systems
  • Physical assessment
  • Mental status exam
  • Differential diagnosis
  • Case formulation
  • Treatment plan

Assignment 2: Practicum – Assessing Clients

 

Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

 

 

Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6640_Week3_Assignment2_Rubric

  Satisfactory Unsatisfactory
Quality of Work Submitted: The extent of which work meets the assignned criteria and work reflects graduate level critical and analytic thinking. 26 (26%) – 30 (30%)

Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.

0 (0%) – 25 (25%)

Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.

Quality of Work Submitted: The purpose of the paper is clear. 4 (4%) – 5 (5%)

Purpose of the assignment is stated, yet is brief and not descriptive.

0 (0%) – 3 (3%)

No purpose statement was provided.

Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:
Understand and interpret the assignment’s key concepts.
8 (8%) – 10 (10%)

Demonstrates a clear understanding of key concepts.

0 (0%) – 7 (7%)

Shows a lack of understanding of key concepts, deviates from topics.

Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:

Apply and integrate material in course rsources (i.e. video, required readings, and textook) and credible outside resources.

16 (16%) – 20 (20%)

Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view.

0 (0%) – 15 (15%)

Includes and integrates specific information from 0 to 1 resource to support major points and point of view.

Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:
Synthesize (combines various components or different ideas into a new whole) material in course resources (i.e. video, required readings, textbook) and outside, credible resources by comparing different points of view and highlighting similarities, differences, and connections.
16 (16%) – 20 (20%)

Summarizes information gleaned from sources to support major points, but does not synthesize.

0 (0%) – 15 (15%)

Rarely or does not interpret, apply, and synthesize concepts, and/or strategies.

Written Expression and Formatting
Paragraph and Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.
4 (4%) – 5 (5%)

Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity 80% of the time.

0 (0%) – 3 (3%)

Paragraphs and sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time.

“Written Expression and Formatting
English writing standards: Correct grammar, mechanics, and proper punctuation”
3 (3%) – 5 (5%)

Contains a few (1-2) grammar, spelling, and punctuation errors.

0 (0%) – 2 (2%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

“Written Expression and Formatting
The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.”
3 (3%) – 5 (5%)

Contains a few (1-2) APA format errors.

0 (0%) – 2 (2%)

Contains many (≥ 5) APA format errors.

Total Points: 100

Name: NURS_6640_Week3_Assignment2_Rubric

 

Patient’a Name: G. M., DOB 3/27/1959

Primary Insurance: CareFirst BlueCross BlueShield MD Region, TER83480955

Presenting Problem

Glenice is an employed married 60 yr. old African American female who has been married for 17 years to her husband who is 48 yrs old. She has 3 sons and one was murdered. Glenice is referred by her employer’s EAP doctor for stress related concerns.

Current Mental Status

General Appearance: Appropriate
Dress: Appropriate
Motor Activity: Unremarkable
Insight: Good
Judgment: Good
Affect: Appropriate
Mood: Euthymic
Orientation: X3: Oriented to Person, Place, and Time
Memory: Intact
Attention/Concentration: Good
Thought Content: Appropriate
Perception: Unremarkable
Flow of Thought: Unremarkable
Interview Behavior: Appropriate
Speech: Normal

Safety Issues

Patient has intent to act:not specified

Patient has plan to act:not specified

Patient has means to act:not specified

Background Information

Identification:Glenice is a Christian and attends church.

History of Present Problem:Glenice reports feeling like she needs help w/trying to figure out why she is always being taken advantage of. As a result she has been feeling angry and wonders is she a piece of crap. She cries about 5 days a week for various compiled reasons. The stress also drains her to the point of feeling tired and wants to sleep. Glenice feels like she does not have anyone. She also over thinks a lot about her health issues and her husband’s drama. He cheated on her and she still struggles w/his issues of infidelity and being unable to get past the pain. In addition, he snorts heroin and she is currently responsible for all the household’s finances. Glenice also asked her husband to leave in March 2019 and is now able to get at least 6 hrs of continuous sleep. Prior to him leaving she was getting about 4 hrs of sleep. Glenice also reports being a stress eater and gains weight during the winter months.

Past Psychiatric History:Glenice was last seen by a therapist about 3 months ago for marital issues and stress related concerns.

Trauma History:Glenice was raped around the age of 7. In addition, she grew up in a household w/an alcoholic mother and was exposed to different instances of potentially being molested.

Family Psychiatric History:Alcoholism runs on mother side and father injected heroin.

Medical Conditions & History:-Thyroid problems affecting esophagus.
-Neck disc problems
-Back surgery in 2015
-Total knee replacement on 1 knee in 2016
-Diagnosed w/stage one breast cancer on 2/2018 and had a lumpnectomy in May and June 2018.
-Diagnosed w/tendinitis in right foot
-Stomach ulcer

Current Medications:-Lisinipril – high blood pressure
-Linzess
-Gabapentin (nerve pain)
-Oxycodone 10mg as needed for pain

Substance Use:-Alcohol- age of 1st use reports as 12 and last use reports as 6/6/19. Typically drinks about a half red cup of Coconut Rum Cream about 1-2 days a week.
-Marijuana- experimental as a child. NURS 6640 Comprehensive Client Family Assessment and Family Genogram
-Cocaine and Crack- age of 1st use reports as mid 20s and last use reports as 2012.

Family History:Raised by her mother in New York who was an alcoholic and father was not present due to drug use. Both parents are deceased. Her father passed away from a heroin overdose. Glenice has 3 siblings and one is deceased. In addition, Glenice has 2 sons who are 39 and 43. Her youngest son was murdered on November 9, 2002.

Social History:Glenice reports her oldest son does not talk to her and her middle son is no longer speaking to her. She has not spoken to her oldest son since some time 2018 because she does not agree w/how he treats women. In addition, she has a great relationship w/her brothers. NURS 6640 Comprehensive Client Family Assessment and Family Genogram

Developmental History:Glenice has issues w/spelling.

Educational / Occupational History:Highest grade completed in high-school is the 10th and received GED around 1984. Currently employed by the DC metro system for the past year and 3 months. Prior to she was working w/the City Wide Transportation for a yr. Glenice also worked for Kennedy Krieger for 7 yrs. as a patient care tech.

Legal History:Arrested in 1999 for a drug related offense and was incarcerated for 1 yr.

Strengths / Liabilities:S- determined
N- genuine love
A- good at encouraging people
P- None

Other Information:-Family hx of high blood pressure that contributed to the deaths of her mother and brother.
-Glenice moved to Maryland in 1997.

Diagnosis

F41.1 Generalized Anxiety Disorder NURS 6640 Comprehensive Client Family Assessment and Family Genogram
F43.21 Adjustment Disorder, With depressed mood

 

 

Psychotherapy of individuals

Part 1: Comprehensive client family assessment

Demographic information

Patient’s Name: Glenice ‘G.M.’

Sex: Female

Date of birth: 1959

Age: 60 years

Religion: Christian

Ethnicity: African American

Marital status: Married for 17 years

Children: Three sons with one deceased

Work Status: Employed

Preferred Language: English

Presenting problem

Glenice is a 60 year old woman who is married to a 48 year old man. She has been married for 17 years. She has three sons of which one is deceased. She has been referred by her employer for stress related concerns.

History or present illness

Glenice indicates that she feels used by the people around her who always take advantage of her. She feels that they do not appreciate her and this has made her feel angry as well as her perception of her self-worth. In addition, this has caused her to become very emotion with the result that she cries about five days every week for different compiled reasons. NURS 6640 Comprehensive Client Family Assessment and Family Genogram. Besides that, the stress associated with her feelings of being used and anger have left her tired most times, causing her to require much sleep. She feels that she does not receive adequate social support since her husband who should support her has added to her stress through infidelity and emotional traumas. Also, her husband has a heroin drug habit that precludes him from managing the household finances, causing her to take on this responsibility. She has since separated from her husband although they are not divorced. Prior to separating from her husband, she would get an average of four hours of sleep every night. Her sleep hours have since increased to an average of six hours every night following the separation. Additionally, she reports that she is a stress eater and has gained weight during the times when she is stressed. NURS 6640 Comprehensive Client Family Assessment and Family Genogram.

Past psychiatric history

She last visited a therapist three months ago to address marital issues and stress related concerns.

Medical history

She is currently taking Lisinipril to manage high blood pressure, Gabapentin for nerve pain, and Oxycodone for pain.

Substance use history

She first drank alcohol at 12 years of age, and is currently a social drinker who ingests an average of half a red cup of coconut rum cream in one or two days every week. She experimented with marijuana as a child. She first used cocaine and crack in her mid-twenties, and last used these substances in 2012. NURS 6640 Comprehensive Client Family Assessment and Family Genogram.

Developmental history

She has issues with spelling.

Family psychiatric history

She was raised in New York by her mother who was an alcoholic. Her father was absent as a result of drug use. Her parents are deceased with her father dying from a drug overdose. She has three siblings with one of them deceased. She had three sons, but one of them died in 2002 while the other two sons are 39 and 43 years of age respectively.

Family history of high blood pressure that contributed to the death of her mother and brother.

Psychosocial history

She reports that her children do not talk to her. On the other hand, she has a good relationship with her siblings.

History of abuse/trauma

She was raped when she was seven years of age. She was raised by an alcoholic mother and absentee father thus exposing her to many situations that exposed her to potential abuse NURS 6640 Comprehensive Client Family Assessment and Family Genogram.

Review of systems

General: Has a straight posture.

Skin: Pallid skin tone.

Head: No history of headaches.

Eyes: Uses prescription glasses to correct vision.

Ears: No vertigo.

Nose: No running nose.

Mouth and Throat: No pain or sores.

Neck: No pain or masses.

Respiratory: No hemoptysis, sputum, wheezing, or cough.

Gatrointenstinal: No black stools, diarrhea, vomiting or nausea.

Genitourinary: No urination urgency or frequency.

Neurologic: No paralysis.

Musculoskeletal: Occasionally joint and muscle pain following extensive activity.

Hematologic: No history of anemia or bleeding disorder. NURS 6640 Comprehensive Client Family Assessment and Family Genogram

Emotional: Depression immediately following her husband’s death.

Physical assessment

Vital signs completed: 1:38

B/P: 138/88

Pulse: 82 BPM

RR: 18 BP

Temp: 37oC

Pulse Ox: 96%

Weight: 67 kg

General appearance: Alert appearance.

Skin: No abnormal lesions or moles.

Neck: No masses.

Cardiovascular: Regular rhythm and rate. No gallops, rubs or murmurs.

Lungs: No crackles or wheezes.

Mental status exam

Has an appropriate general appearance, dress, affect, thought content, and interview behavior. She has good insight, judgment, and attention/concentration. She has normal speech. She has unremarkable motor activity, perception, and flow of thought. She has euthymic mood. She has X3 orientation, and is oriented to person, place and time.

Differential diagnosis

The diagnosis is presented that the patient suffers from general anxiety disorder (F41.1). The presented symptoms supporting this diagnosis are persistent worry, restlessness, fatigue, nervousness, and irritability. The differential diagnosis is that the patient suffers from adjustment disorder, with depressed mood (F43.21). The symptoms supporting this diagnosis include hopelessness, tearfulness, and feeling sad (American Nurses Association, 2014; American Psychiatric Association, 2013) NURS 6640 Comprehensive Client Family Assessment and Family Genogram.

Case formulation

The patient attended the psychiatric assessment to determine an appropriate diagnosis and seek treatment.

Treatment plan

The patient will be subjected to medication and psychotherapy to manage the general anxiety disorder symptoms. In addition, there is a need for applying relaxation techniques, learning coping skills, and making lifestyle changes. Treatment for adjustment disorder, with depressed mood, would involve psychotherapy and medication that manage the symptoms. The psychotherapy offers coping and stress management skills, facilitates early return to normal routine, and offers emotional support (Sperry, 2016; Wheeler, 2014). NURS 6640 Comprehensive Client Family Assessment and Family Genogram.

 

Part 2: Family genogram

References

American Nurses Association. (2014). Psychiatric-mental health nursing: scope and standards of practice (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. NURS 6640 Comprehensive Client Family Assessment and Family Genogram

Sperry, L. (2016). Handbook of diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment (3rd ed.). New York, NY: Routledge.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: a how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company. NURS 6640 Comprehensive Client Family Assessment and Family Genogram