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): The client presents accompanied by her mother. The chief complaint, as reported by the mother, is that the clients meds do not seem to be working. Her grades have been on a consistent downward trend, from As, to Bs, and currently Ds. Conflicts with her sister and mother at home have escalated to the point that her mother describes her as mean and nasty, and she has lost many of her long-standing friends. The client, on her part, says she has no particular complaints and that her mother is exaggerating.

HPI: The client is a 15-year-old white female who is referred by her PCP due to worsening difficulties at school and at home. The client first saw a psychiatrist at the age of 7, when she was evaluated for attention-deficit hyperactivity disorder (ADHD) because of instractibility, impulsivity, and restlessness. After a series of failed behavioral interventions, the client was placed on Methylphenidate-based medication at the age of 8. For the next six years, her social life and scores in school improved, and she was pretty much like ay other kid her age as long as she took her medication. Over the past year, however, the client has stopped being a bubbly teenager and is moody most of the time. She spends days by herself, locked up in her room, and hardly speaks to anyone. During these days, she is uninterested in everything, is constantly complaining that her family and friends do not like her, and sleeps most of the day. Her mother reports that for a week or two, she would be bubbly, laugh at anything and enthusiastically help with the house chores. Then she would again sink into a week or so of persistent sadness and irritability, where she is constantly yelling at her sister and mother to the point that everyone is walking on eggshells.

At around age 14, her therapist increased her dosage of ADHD medication. The clients family history is pertinent of bipolar disorder or manic depressive illness, with the mother indicating that the clients father, whom she has never met, was treated with lithium when they were together.

Substance Current Use: The client denies use of any illicit substances or alcohol

Medical History:

Current Medications: Concerta 36mg once daily. Client denies taking any OTC drugs or any medication other than her ADHD medication.

Allergies: No known allergies

Reproductive Hx: Client denies contraceptive use or engagement in any form of sexual activity. Client claims to be on the second day of her periods.

ROS:

GENERAL: Denies chills, fever, weight loss, or recent illnesses

HEENT: Eyes: no visual loss, double vision, blurred vision, or yellow sclerae; Ears, Nose, and Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat

SKIN: No itching or rash

CARDIOVASCULAR: No chest pain or discomfort; paltpitations or edema

RESPIRATORY: No cough, sputum, or shortness of breath

GASTROINTESTINAL: No abdominal pain or blood, No nausea, vomiting, diarrhea, or anorexia

GENITOURINARY: No burning on urination, odd color, or hesitancy

NEUROLOGICAL: Slight headache from time to time, dizziness, ataxia, syncope, or numbness/tingling in the extremities, no changes in bladder or bowel control

MUSCULOSKELETAL: No joint pain, back pain, muscle pain, or stiffness

HEMATOLOGIC: No signs of bleeding, anemia, or bruises

LYMPHATICS: Nodes are of normal size and client has no history of splenectomy

ENDOCRINOLOGIC: Client denies experiencing cold, profuse sweating or heat intolerance. No polydysmia or polyuria.

Objective:

Diagnostic results: In conjunction with the physical examination, the clinician ordered...

The client was advised not to stop taking the medication abruptly as this increases the risk of mood instability and a relapse of mania. She was also taught that medication adherence is key because bipolar disorder, if left untreated, increases the risk of suicide or homicidal actions. At the same time, overdosing or failure to take the medication as prescribed could lead to lithium toxicity, whose symptoms include increased reflexes, trouyble walking, and kidney problems (FDA, 2018).

Discussed Risks of Mixing Medication: Lithium has been shown to increase the risk of adverse effects of Methylphenidate-based medication in combination therapy (FDA, 2018). In light of this, the client is to carefully monitor for adverse effects of Concerta such as trouble sleeping, appetite loss, weight loss, vomiting, or headache, and to notify the clinician to reduce the dosage in case any of these effects persist or worsen.

Client has emergency numbers: Emergency Services 911. Client instructed to call 911 or present at the nearest ER if they become actively homicidal or suicidal

Time Allowed for Questions and Answers: Given the clients age, both the client and her mother were granted an opportunity to ask questions regrading the treatment plan, to which the clinician responded and concluded that they had understood the discussion. To assess their understanding, the clinician asked random questions and informed them of their right to informed consent.

Follow up with PCP: No follow-up with PCP was scheduled at this point

Labs Ordered or Reviewed: pregnancy test to ascertain the information provided by the client on LMP date. Renal function test was also ordered to test the baseline performance of the clients kidneys before commencing the treatment with lithium because the medication is associated with a high risk of renal dysfunction (FDA, 2018).

Return to Clinic: Client…