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NRNP 6635 WEEK 8 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

NRNP 6635 WEEK 8 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

CC (chief complaint):The patient, Lisa, is worried about going to rehab.

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HPI: The patient presents to the clinic worried about going to rehab. She reports that she is scared as she does not want to recognize herself as an addict and also fears people will also refer to her as an addict. She uses alcohol and reports that she sometimes uses with friends, but she is in control. She also reports she fears that her advertising businessis about to close. She reports she found her boyfriend, Jeremy, cheating on her after having moved in together nine months agoand is currently living in a house away from where they lived. She also reports she has emptied their business bank account and says that Jeremy had been using money from the account for four months without her knowledge to pay off his debts. She also says that she recently found out that her boyfriend smokes crack cocaine after she caught him cheating but is aware he drinks a lot and smokes weed. Lisa is also worried about staying in the hospital for detoxification and is unwilling to go to rehab as she associates it with dirt and unemployment. She also says that she recently moved back in with her boyfriend after he apologized and is currently conflicted about leaving him since he had promised to give her back the money they had lost in the business. She also reports that she has also smocked cracked cocaine and that it elevates her mood. She also seems not to have enough of it and fears she will start to feel horrible again. She is also unwilling to accept help as Jeremy promises her everything will be okay.

Past Psychiatric History:

  • General Statement: There is no previous history of a psychiatric evaluation.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis:None

Substance Current Use and History:There is a history of alcohol and cocaine use.

Family Psychiatric/Substance Use History: None

Psychosocial History: She lives with her boyfriend and has an advertising business.

Medical History:

 

  • Current Medications: None
  • Allergies:None
  • Reproductive Hx:She has a daughter called Sarah.

ROS:

  • GENERAL: She reports feeling tired and anxious.
  • HEENT: No nasal discharge, eye redness, and ear pain.
  • SKIN: No bruises, pustules, erythematous lesions, or hyperpigmentation.
  • CARDIOVASCULAR: The patient has had episodes of palpitations but denies orthopnea and paroxysmal nocturnal or exertional dyspnea.
  • RESPIRATORY: No chest pain, dyspnea, and cough.
  • GASTROINTESTINAL: There are changes in appetite and bowel movements but no weight gain or loss and abdominal pain.
  • GENITOURINARY: No dysuria, hematuria, and abnormal vaginal discharge.
  • NEUROLOGICAL: The patient has had episodes of headaches, confusion, and altered levels of consciousness but no vertigo.
  • MUSCULOSKELETAL: No joint pain or stiffness and muscular pain or weakness.
  • HEMATOLOGIC: No abnormal bruising, recurrent infections, or easy fatiguability.
  • LYMPHATICS: No lymph node swelling or pain.
  • ENDOCRINOLOGIC: No polyuria, polydipsia, or changes in menstrual cycle.

Objective:

Physical exam:Not performed.

Diagnostic results:No diagnostic test was done.

Assessment:

Mental Status Examination: The patient was alert, appropriately groomed, and oriented in time, place, and person. She appeared agitated and had a depressed mood. She spoke with a normal rate and rhythm but occasionally used a low tone. She had incoherent thoughts and looseness of associated but had no hallucinations or delusions. She had a reduced attention and concentration span with some selective inattention. She also had some memory gaps and lacked judgment and insight.

Differential Diagnoses:

Substance Use Disorder (SUD): The DSM-V diagnostic criteria for SUD include the use of certain groups of drugs, including alcohol and stimulants like cocaine, as seen in Lisa’s case. Examples of symptoms seen in Lisa that fit in the DSM-V diagnostic criteria include the need for an individual to take the substance in higher amounts and for a longer duration than was originally intended (Volkow et al., 2023). In addition, Lisa has been wanting to regulate her alcohol use but is unable to, has constant urges to smoke cocaine, and currently has relationship problems with her boyfriend. Lisa has also been taking cocaine despite her knowing about the harmful effects it has on her health and is unwilling to seek help or quit her relationship to recover from cocaine use.

 

Major Depressive Disorder (MDD): MDD is an example of DSM-V depressive disorder characterized by a depressed mood that lasts for more than two weeks. In Lisa’s case, she has been feeling hopeless and empty as she fears losing her business and recently found out that her boyfriend cheated on her, and has had significant distress (Christensen et al., 2020). In addition, she appeared tearful and had psychomotor agitation during the interview. She also had difficulties in concentration and was indecisive. However, due to Lisa’s alcohol and cocaine use, most of these symptoms, despite meeting the DSM-V diagnostic criteria, may have occurred due to associated substance use (Aas et al., 2021).

 

Generalized Anxiety Disorder (GAD):GAD is an example of DSM-V anxiety disorder characterized by excessive worry, as seen in Lisa’s case, as she is constantly worried about losing her business, financial, and identity status (Mishra et al., 2023). In addition, she cannot control her worry, is restless, and has concentration difficulties with episodes of blank thought processes. However, she does not meet some aspects of the diagnostic criteria, as some symptoms may have occurred due to substance use(Aas et al., 2021).

 

Reflections:

In my next session, I would wish to ask Lisa about her past before she met her boyfriend to understand her emotional and psychological state before meeting her boyfriend. I would also inquire about her psychosocial support, including friends, family, and community she can rely on when she has personal issues or during recovery (Alsubaie, 2023). I would also educate her on the impact of alcohol and cocaine use on her overall health, inform her importance of rehab for her physical, psychological, and emotional well-being, and encourage her to join one (Frank et al., 2022). I would also educate Lisa about psychotherapy and recommend acceptance and cognitive behavioral therapy to help Lisa understand and accept addiction and also promote behavioral change to help in recovery.

References

Aas, C. F., Vold, J. H., Gjestad, R., Skurtveit, S., Lim, A. G., Gjerde, K. V., Løberg, M., Johansson, K. A., Fadnes, L. T., & Group, H. S. (2021). Substance use and symptoms of mental health disorders: A prospective cohort of patients with severe substance use disorders in Norway. Substance Abuse Treatment, Prevention, and Policy, 16. https://doi.org/10.1186/s13011-021-00354-1

Alsubaie, S. (2023). Psychosocial Life Aspects among Substance Misuse Clients who are at Rehabilitation Phase: A Narrative Review. Health Psychology Research, 11. https://doi.org/10.52965/001c.66174

Christensen, M. C., Johnny Wong, C. M., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ? Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00280

Frank, A. A., Schwartz, A. C., Welsh, J. W., Ruble, A. E., Branch, R., DeMoss, D., & DeJong, S. M. (2022). Enhancing Addictions Education in Patient Care and Medical Knowledge Competencies for General Psychiatry Residents. Academic Psychiatry, 46(3), 375-380. https://doi.org/10.1007/s40596-022-01634-z

Mishra, A. K., & Varma, A. R. (2023). A Comprehensive Review of the Generalized Anxiety Disorder. Cureus, 15(9). https://doi.org/10.7759/cureus.46115

Volkow, N. D., & Blanco, C. (2023). Substance use disorders: A comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention. World Psychiatry, 22(2), 203-229. https://doi.org/10.1002/wps.21073

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Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

 

Learning Resources

Required Readings

Required Media

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Video Case Selections for Assignment

To Prepare:

  • Review this week’s Learning Resources and consider the insights they provide.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

By Day 7 of Week 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What would you do differently with this client if you could conduct the session over??Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK8Assgn_LastName_Firstinitial
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NRNP_6635_Week8_Assignment_Rubric

NRNP_6635_Week8_Assignment_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS
20 to >17.0 ptsExcellent

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

 17 to >15.0 ptsGood

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

 15 to >13.0 ptsFair

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.

 13 to >0 ptsPoor

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
20 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
20 to >17.0 ptsExcellent

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

 17 to >15.0 ptsGood

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

 15 to >13.0 ptsFair

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

 13 to >0 ptsPoor

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
20 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide:• Results of the mental status examination, presented in paragraph form.• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >22.0 ptsExcellent

The response thoroughly and accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

 22 to >19.0 ptsGood

The response accurately documents the results of the mental status exam…. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

 19 to >17.0 ptsFair

The response documents the results of the mental status exam with some vagueness or innacuracy…. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.

 17 to >0 ptsPoor

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.
25 pts
This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
10 to >8.0 ptsExcellent

Reflections are thorough, thoughtful, and demonstrate critical thinking.

 8 to >7.0 ptsGood

Reflections demonstrate critical thinking.

 7 to >6.0 ptsFair

Reflections are somewhat general or do not demonstrate critical thinking.

 6 to >0 ptsPoor

Reflections are incomplete, inaccurate, or missing.
10 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
15 to >13.0 ptsExcellent

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

 13 to >11.0 ptsGood

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

 11 to >10.0 ptsFair

Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

 10 to >0 ptsPoor

Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.
15 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph development and organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. …Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

 4 to >3.5 ptsGood

Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. …Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

 3.5 to >3.0 ptsFair

Purpose, introduction, and conclusion of the assignment is vague or off topic. … Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%-79% of the time.

 3 to >0 ptsPoor

No purpose statement, introduction, or conclusion were provided. … Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation
5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors

 4 to >3.0 ptsGood

Contains a few (one or two) grammar, spelling, and punctuation errors

 3 to >2.0 ptsFair

Contains several (three or four) grammar, spelling, and punctuation errors

 2 to >0 ptsPoor

Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
5 pts
Total Points: 100

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