Order ID |
53563633773 |
Type |
Essay |
Writer Level |
Masters |
Style |
APA |
Sources/References |
4 |
Perfect Number of Pages to Order |
5-10 Pages |
Description/Paper Instructions
NRNP/PRAC Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): “I have been feeling helpless since my wife past wy two months ago, and I want to commit suicide because im too lonely.”
HPI: William is a 62-year-old male who presents to the facility with complaints of feeling hopeless and suicidal ideations due to loneliness. These symptoms began two months ago after his wife passed away following a tragic road accident. He states that his wife was his only companion, and now he is hopeless and helpless. He claims that he wants to join her in the other world to continue being together.
Substance Current Use: He only smokes five cigars a day. He used to take a bottle of beer twice a week, but since the death of his wife, he has been drinking around three bottles daily to get sleep.
Medical History:
- Current Medications: metformin 500mg BD for type 2 diabetes. (He states that he has been missing some doses)
- Allergies: He has no known allergies
- Reproductive Hx: heterosexual. He is sexually inactive.
ROS:
- GENERAL: he states to have lost weight. No fever or chills were reported.
- HEENT: Head: he denies head trauma or headache; Eyes: he uses reading glasses. Otherwise, his eyes are healthy. No pain or abnormal tearing was reported; Ears: he states that his hearing has reduced. no ringing was reported.; Nose: he denies nose bleeding or postnasal drainage.; Throat: no swallowing difficulties said. There is evidence of missing teeth on the upper jaw.
- SKIN: The skin is wrinkled. There is an erythematous bruising around the neck. The patient says it was a suicide attempt.
- CARDIOVASCULAR: no palpitations and chest discomfort. The heart rate is within normal range, and the rhythm is regular. he reports shortness of breath on exertion only
- RESPIRATORY: respirations are slow, steady, and unlabored. he denies difficulty in breathing
- GASTROINTESTINAL: he reports reduced appetite. bowel sounds are diminished, and the last bowel movements were two days ago
- GENITOURINARY: no concerns reported. prostate exam conducted two weeks ago
- NEUROLOGICAL: he reports reduced sleep but denies headaches, blackout spells, or seizures.
- MUSCULOSKELETAL: reports mild stiffness of joints that began last week. The joints are painless.
- HEMATOLOGIC: he denies uncontrolled bleeding or coagulopathies.
- LYMPHATICS: cervical lymph nodes are swollen and tender.
- ENDOCRINOLOGIC: no extreme hunger or thirst was reported.
Objective:
Diagnostic results: no tests were ordered.
Assessment:
Mental Status Examination:
The patient is a 62 years old male whose appearance corresponds to his stated age. He is alert and oriented to place. Time and person. He is roughly groomed, with uncombed grey hair. He is appropriately dressed for the weather. He speaks in a clear voice with a low tone. His thought process is interfered, logical, and goal-oriented. He does not show any sign of flights of ideas or loose association. His mood is sad, with an effect that corresponds to his mood. He does have alerts of delusional thinking, and he does not report any visual or auditory hallucinations. He reports multiple suicidal ideations and failed suicidal attempts. He reports planning to kill his dog and cat before committing suicide. He has good concentration, and both long-term and short-term memories are intact, with poor insight.
Diagnostic Impression:
Major depressive disorder (MDD): Depression, often referred to as major depressive disorder or clinical depression, is a significant mood condition that affects many people. Depression causes people to feel unhappy and hopeless all of the time, and they lack enthusiasm for things they used to like (WHO, 2020). Apart from the psychological concerns that depression causes, people may also have physical disturbances like persistent pain or gastrointestinal issues. Patients may present with either too much or very low appetite and altered sleeping patterns. In extreme cases, patients can present with suicidal ideations, self-inflicted harm, and homicidal ideations. The patients described in this case study present with all the above complaints. Hence it is considered the primary diagnosis.
Anxiety: Anxiety is a mental problem characterized by a constant and overpowering worry. Anxiety and terror are symptoms. Panic, dread, and discomfort are common symptoms, as are feelings of impending doom or danger (Chand & Marwaha, 2022). They often come with sleep issues and difficulty remaining calm. Although the patient is afraid of living alone, he does not have a great magnitude of fear. most of the patient’s presentations are not characteristics of anxiety, and hence the diagnosis is ruled out
Adjustment disorder: When a person has a traumatic incident or significant shift in their life, they may have an adjustment disorder as a psychological or behavioral response. It is regarded as an abnormal or overwhelming response to an incident or change when it occurs within three months of the incident or transition taking place. Symptoms include, for example, Not liking things you used to appreciate because you’re sad, hopeless, or otherwise unhappy (O’Donnel et al., 2016). Crying on a regular basis. They may also be in attendance. Feeling worried or apprehensive, as well as tense, jittery, or agitated. Although the patient presents with most of these symptoms, it’s ruled out due to the patient’s presentation with suicidal ideations, which is uncommon in a patient with adjustment disorder.
Reflections:
I think this is an emotional case to handle. Past psychiatric history for the patient was not obtained. If we were given a chance to reevaluate the patient, I would inquire about his psychiatric history to know whether he has experienced such symptoms before. This is because some mental disorders may relapse following a long period of recovery when triggered. It is crucial to know whether the patient has ever been treated for depression. This will also help to determine what drugs can be effective in treating the patient.
Case Formulation and Treatment Plan:
- The patient will be initiated on fluoxetine, which will help him to manage the depressive symptoms (Micheli et al., 2018)
- The patient will be referred to a psychiatrist for cognitive behavioral therapy or group therapy (Weck et al., 2015)
- He will be issued an emergency number to call in case of a suicidal emergency.
- He should return for evaluation after two weeks.
RUBRIC
QUALITY OF RESPONSE |
NO RESPONSE |
POOR / UNSATISFACTORY |
SATISFACTORY |
GOOD |
EXCELLENT |
Content (worth a maximum of 50% of the total points) |
Zero points: Student failed to submit the final paper. |
20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. |
30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. |
40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. |
50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. |
Use of Sources (worth a maximum of 20% of the total points). |
Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. |
5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. |
10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. |
15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. |
20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. |
Grammar (worth maximum of 20% of total points) |
Zero points: Student failed to submit the final paper. |
5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors |
10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors |
15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. |
20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. |
Structure of the Paper (worth 10% of total points) |
Zero points: Student failed to submit the final paper. |
3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. |
5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper |
7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. |
10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. |
|
|
GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
Also, you can place the order at www.collegepaper.us/orders/ordernow / www.phdwriters.us/orders/ordernow
|
Do You Have Any Other Essay/Assignment/Class Project/Homework Related to this? Click Here Now [CLICK ME]and Have It Done by Our PhD Qualified Writers!! |
|
|
PLACE THE ORDER WITH US TODAY AND GET A PERFECT SCORE!!!