• 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

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).

Required Readings

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.

Required Media

Laureate Education (Producer). (2013b). Hernandez family genogram [Video file]. Baltimore, MD: Author.

1

Comprehensive Client Family Assessment

Student Name

Psychotherapy with Individuals

Practicum Experience Time Log and Journal Template

Student Name: Student Name

E-mail Address:

Practicum Placement Agency’s Name:

Preceptor’s Name

Preceptor’s Telephone:

Preceptor’s E-mail Address:

Demographics Information:

The client is a 91-year-old Caucasian female who resides at home by herself with home health care. Her primary language is English. The client is a retired widow who has one son that lives nearby. The client has Medicare for insurance and her religious preference is Presbyterian.

Presenting Problem:

“My heart was beating fast and my pacemaker is set at 60. I got really dizzy and did not feel well. I was taken to the hospital where my heart was in tachycardia. I stayed in the hospital for several days, so now I am weak and need therapy.”

History of Present Illness:

The client has a history of atrial fibrillation and presented to Baylor Hospital of McKinney with palpitations on 12/06/2018. The client was found to have a urinary tract infection and started on oral antibiotics. The client was seen by Electrophysiology and was found to be in an AV nodal re-entry tachycardia and was treated. While in the hospital, the client complained of right hip pain radiating around to the back. Due to this, the client was referred to rehabilitation. Currently the pain is extending to the left leg.

Past Psychiatric History

The client has had long term issues with anxiety and was diagnosed with generalized anxiety by her general practitioner in her 50’s. The client’s current regime consists of Ativan 0.5mg p.o. BID. The client states this medication and dosage works well for her. The client also has insomnia and takes Ambien 5mg p.o. at night. Client denies any other psychiatric disorders at this time and has not received any psychotherapy or counseling for her anxiety.

Medical History:

The client presents at this time with stable vital signs and is afebrile. Client is 5 ft tall and weighs 130lbs with a BMI of 25.3. Client has a normal weight and height for her age and gender. Vitals are normal. Client is allergic to Bactrim, Imodium, Tetracycline, Doxycycline, and Cipro. Client has no history of falls and her pneumonia and flu vaccines are up to date. Client wears glasses and has had a recent eye examination. The client’s other comorbidities include: CAD, hypertension, tricuspid valve stenosis, arthritis, anemia, peptic ulcer disease, and macular degeneration.

Developmental History:

Developmental Stages: The client states to her knowledge her birth was normal and there were no issues during her mother’s pregnancy. The client states she was active as a small child and participated in sports from a young age. The client states she was “very independent” as a child and wanted to do everything herself, i.e. picking out her own clothes and dressing herself. Client states she progressed through school without any difficulty and made A’s in most of her subjects. Client states she was closest to her sister, but had several friends which were both male and female in which she interacted well with. These facts support the client having appropriate gross and fine motor achievements as well as speech, language, and social achievements throughout her lifetime (Parry, 2005). The client’s sister is deceased and there are no other family members to interview for her developmental progress. The client states her mom did not smoke and did not drink alcohol during her pregnancy and stated it was the time of the prohibition era.

Psychosocial History

The psychosocial history is an important part of an assessment. It evaluates an individual’s mental health and social well-being as well as assessing the individual’s self-perception and how they function in their community (Lengel, 2017).

The client has a son who lives 10 minutes from her home and is her primary support system. Prior to her hospitalization, the client lived by herself and was self-sufficient except for someone who cleaned her house every other week. Additionally, the client has a daughter who lives in Austin which she sees approximately four times per year. The client’s oldest son lived in Flagstaff, AZ, but died approximately one year ago from gastric cancer. The client’s parents are deceased as well. The client has one friend she is contact with via telephone which she has known for 70+ years. The client is retired, but worked as a teacher for many years while raising her children. The client has been a vigorous reader throughout her lifetime and continues to read regularly. The client states she was married twice during her life and has surpassed both husbands. The client was married to her first husband for 50 years before he expired. The client later married her second husband when she was 72 years old, and had known him since first grade. The client was married to her second spouse for 14 years before his passing.

Family Psychiatric History

The client states her mother had issues with insomnia as an older adult; however, there were no other known psychiatric illness she was aware of in with her parents. The client states she believes her grandfather may have had depression, but it was never diagnosed.

History of Abuse/Trauma

Client denies any history of abuse or trauma during her life time.

Review of Systems

Client’s last physical exam was performed by her general practitioner in August, 2018. Last eye exam was in October and a dental exam is pending in January.

Constitution: Client states she normally sleeps well and gets 7-8 hours of sleep at night, but due to her recent hospitalization she has had some sleep disturbances due to interruptions by hospital staff during the night. No history of chills, fever, night sweats, or weight loss.

Eyes: Wears glasses, Macular Degeneration.

Ears: Wears hearing aids bilaterally.

Nose: Denies problems with sense of smell or nose bleeds. Occasional congestion from mild seasonal allergies.

Throat and Mouth: Partial bottom dentures only. No adverse dysfunction noted.

Head and Neck: Denies history of head injury or loss of consciousness. The head is symmetrical with no bumps to the scalp. No JVD, lymphadenopathy, or thyromegaly noted.

Respiratory: Lung sounds clear with no adventitious breath sounds heard. No cough or hemoptysis noted.

Cardiovascular: Significant for coronary artery disease, chronic atrial fibrillation, status post cardiac pacemaker, and recent re-entry tachycardia.

Gastrointestinal: Appetite disturbance since hospital admission, but is improving. Bowel movements every two to three days. Negative for nausea, vomiting, diarrhea, or hematochezia. Significant for peptic ulcer disease.

Genitourinary: Significant for urinary tract infection with frequent urination.

Musculoskeletal: Positive for osteoarthritis. Client can move all extremities, but has pain to hips, knee, and left foot. Generalized weakness.

Psychiatric and Neurologic: History of general anxiety disorder (GAD). No history of brain injury.

Mental Status Exam:

Appearance: Clients appearance is appropriate for age; patient is neat and well fed.

Attitude and Behavior: Client is cooperative and pleasant during the interview. Eye contact readily made. Attitude and behavior appropriate.

Speech: The client is talkative with normal rate, volume, and tone. Speech coherent with no latency noted.

Motor Activity: Client sitting up in bed, no tremors, lip smacking, or repetitive behaviors visualized.

Affect and mood: Mood anxious with underlying depressive symptom. Client initially appeared happy; however, became tearful during further interview. Affect congruent with mood.

Temperament: Pleasant temperament. Client has appropriate concentration and attention.

Perception: Client denies hallucinations or illusions.

Thought Processes: The client’s thought processes are organized and logical with good insight.

Thought Content: The client denies delusions, and there are no obsessions or preoccupations.

Sensorium and Cognition: Client is alert and oriented to person, place, time, and situation.

Memory. Short-term and long-term memory grossly intact.

Abstract thought: Not tested at this facility.

Intelligence: Client is very astute for her age and education level.

Insight: The client’s insight was appropriate.

Judgement: The client’s judgement is appropriate. Her thought processes are well planned with no impulsivity noted.

Physical Assessment and Neurological Examination

Vital Signs: BP-116/63, HR-60, RR-18, T-97.7

Height/Weight: Ht: 5’0”, Wt: 130lbs.

BMI: 25.3

Neurological Exam

Mental Exam: Client is alert and oriented to person, place, time, and situation. Client is calm and cooperative.

Lab/Diagnostic Testing

Psychiatric diagnosis, such as Generalized Anxiety Disorder (GAD) or Adjustment Disorder (AjD), do not have specific laboratory work which can be used to diagnose them. Due to the age of the client and her recent hospitalization for AV nodal re-entry tachycardia, it is of importance to order basic blood work, such as: a chemistry and complete blood count to monitor her electrolytes for cardiac function and monitor blood levels for possible infectious processes. These lab test may indicate an organic illness which may be causing and/or increasing symptoms of her anxiety or causing depressive symptoms which may be related to AjD.

Overall, the client’s lab work results were not profoundly out of range. Her sodium level is one point under the normal reference range. The client is not on diuretics nor does she have issues with vomiting or diarrhea. However, one complaint is weakness, and hyponatremia does contribute to weakness. In addition, the client’s H/H is slightly low, which can also contribute to weakness. Within a hospital setting, the H/H values are not typically treated with a blood transfusion. These values will be monitored for symptoms of anemia or any abnormal bleeding. The prealbumin is also low; however, the client did state she was not eating well while in the hospital, and she had a UTI which is resolved with antibiotics. Both of these circumstances could contribute to a lower prealbumin in a 91-year-old-woman (Acute Academy of Acute Care Physical Therapy, 2017).

Test	Result	Unit	Reference Range
WBC	9.7	K/mm3	3.8-10.1
RBC	3.62	M/mm3	3.90-5.20
HGB	10.8 L	g/dL	12.0-15.6
HCT	32.3 L	%	35.0-46.0
MCV	89.2	fL	81.0-99.0
MCH	29.8	pg	27.0-33.0
MCHC	33.4	g/dL	32.0-36.0
RDWCV	13.1	%	11.5-14.5
PLT	190	K/mm3	130-400
COLOR	Yellow		Yellow
CLARITY	Clear		Clear
SG	1.010		1.0-1.030
PH	5		5.0-8.5
PROTEIN	1+		Negative-Trace
GLUCOSE-u	NEGATIVE		Negative
KETONE	NEGATIVE		Negative
UROBIL	0.2-1.0		.02-8.0
BILI	NEGATIVE		Negative
NITRITE	NEGATIVE		Negative
LEUKO	3+		Negative
BLOOD	1+		Negative
ASCORBIC ACID	NEGATIVE		Negative
UWBC	25-49		None Seen
URBC	3-5		None Seen
SEPI	FEW		None Seen
UBACT	FEW		None Seen
CULTURE	Yes
Non-Squamous Epithelial	FEW		None Seen
SODIUM	134 L	mmo/L	136-145
POTASSIUM	3.9	mmo/L	3.5-5.0
CHLORIDE	101	mmo/L	95-108
CO2	23	mmo/L	23-32
GLUCOSE	105	mg/dL	70-110
BUN	22	mg/dL	6-25
CREATININE	.85	mg/dL	.30-1.20
CALCIUM	8.9	mg/dL	8.2-10.1
BUN/CREAT	26	Ratio	9-30
eGFR AM	>60.00	mL/min/1.73m2
eGFR NAM	>60.00	mL/min/1.73m2
PREALBUMIN	14.1	mg/dL	17.0-34.0

Differential Diagnosis:

Differential diagnosis should be ruled out for insurance of a proper diagnosis. The DSM-5 is the source in which diagnosis are compared. The following differential diagnosis were ruled out:

1. Major Depressive Disorder (MDD): If the criteria for MDD is met in response to a stressor, the diagnosis of AjD is not applicable (The American Psychiatric Association, 2013).

2. Posttraumatic stress disorder and acute stress disorder: To distinguish between PTSD, acute stress disorder and AjD, there are time and symptom profile considerations. AjD can be diagnosed immediately and last up to six months after a traumatic event. Acute stress disorder can only occur between 3 days and 1 month of exposure. PTSD can not be diagnosed until after 1 month after an event (APA, 2013).

3. Personality disorder: Some personality disorders may be associated with a vulnerability to situational stress which may appear to be AjD. If symptoms of Ajd is met and stress-related disturbances exceed what is attributable to a maladaptive personality disorder, then AjD can be made (APA, 2013).

4. Normative Stress Reaction: This diagnosis is made when there is a normal reaction to a bad event (APA, 2013).

Case Formulation

The client reports she has had atrial fibrillation and a permanent pacemaker in the past and is aware of her physical symptoms. The client states she knew her pacemaker was set at 60 and her heart was beating faster than 60, indicating something was wrong. The client knows her medication regime. She can verbalize her medications by the generic and brand names and is able to state what each of her medications are used for. The client was diagnosed in her 50’s with having anxiety and this history was discussed. The client denies any history of depression; however, she becomes tearful when talking about the death of her oldest son to colon cancer a year ago. The client states, “it was the wrong order of things.” Coping mechanisms and normal grief processes were reviewed with the client. The client verbalizes she has handled the death well due to her religious faith; however, after the current hospitalization and the admittance to the rehabilitation facility, it reminds her of his death and she is upset. Based on the clinical interview conducted and diagnostic criteria from the Diagnostic Manual for Mental Disorder-5 (DSM-V), the client meets the diagnosis for Adjustment Disorder and Generalized Anxiety Disorder. Although major depressive disorder was considered, recent events seem to be a trigger for her current mental status.

Treatment Plan

This client is a 91-year-old female who is acutely aware of herself and her situation including her mental, physical, and emotional health. Anxiety disorders are commonplace in the elderly and often accompany other comorbid psychiatric diagnosis, most commonly depression. Both anxiety and depression can lead to worsening physical, cognitive, and functional impairments in the elderly (Crocco, Jaramillo, Cruz-Ortiz, & Camfield, 2017).

Anxiety disorders tend to be a chronic problem with fluctuations in symptoms. Generalized anxiety disorder (GAD) is the only disorder which remains a common disorder in people over the age of 50 (Bandelow, Michaelis, & Wedekind, 2017). Research and/or evidence for the treatment of anxiety in the elderly is limited; therefore, treatment approaches are made by combining available guidelines on treating the younger adult generation. Anti-depressants are normally the first line treatment with SSRIs and SNRIs because they work well for this population due to their tolerability and safety profiles (Crocco, Jaramillo, Cruz-Ortiz, & Camfield, 2017).

Adjustment disorder (AjD) is classified in the DSM-5 as a stress-related disorder. It is widely recognized as a stress-response syndrome to an identifiable stressor. Research has found AjD is often diagnosed as major depression (Zelvience & Kazlauskas, 2018). Due to the change in the client’s condition and admission into a hospital and current rehabilitation stay, the client is diagnosed with AjD with mixed anxiety and depression.

The goal of treatment is to decrease the client’s anxiety and depression. The client states her Ativan works for her anxiety; however, the administration times in the hospital are not consistent with her home regime. The client states the hospital administers the Ativan with the Ambien at night, and it causes her difficulty in waking as well as being fatigued during the day. This change in medication regime could affect her mental state.

Medication/Medication Adjustment:

There are many pharmacological agents used to treat GAD. However, the client is currently taking Ativan which is a benzodiazepine. Typically, benzodiazepines are used for short time use due to risks of addiction; therefore, they are not considered a first line treatment (Bandelow, Michaelis, & Wedekind, 2017). The client has taken Ativan for sometime and states it is effective for her anxiety. Due to the longevity of this regime, it will not be discontinued; however, the timing of administration will be changed to the client’s home regime. Adjustment disorder and its anxiety and depressive symptoms were reviewed with the client. A suggestion of starting a new medication, Lexapro 10mg p.o. daily, to decrease the client’s anxiety and depressive symptoms was made. Lexapro was chosen because of the client’s cardiac history, and this medication has less effect on cardiac impairments than other SSRI’s (Crocco, Jaramillo, Cruz-Ortiz, & Camfield). The client wishes to try changing her Ativan back to her regular regime before she starts another medication. A follow-up assessment will be made next week.

Assessment Tools with Rationale:

The PHQ-9 and the GAD-7 are the two assessment tools used by the Neuro Psychologist at the clinical facility. Each patient is assessed with these two tools upon an intake interview and during follow-up visits. The PHQ-9 contains nine questions based on the criteria in the DSM-5 for major depression. It is a tool which is useful for identifying and diagnosing problem symptoms (Williams, 2014). The GAD-7 is a seven-question assessment tool based on the criteria in the DSM-5 developed to diagnose generalized anxiety disorders. Its sensitivity is 89% with a specificity of 82%. In addition, it is moderately good at diagnosing panic, social anxiety, and posttraumatic stress disorder (Psychiatric Times, 2013). The client has a previous diagnosis of GAD, but the GAD-7 can evaluate the severity she is experiencing at this time and the PHQ-9 can assess depressive symptoms the client is experiencing either due to past experiences or due to recent life changes experienced in AjD.

Referrals and Rationale:

The client’s current medication regime for GAD is Ativan and the client may potentially be started on Lexapro within the next week. For the psychopharmacological management of the client’s medications, it is ideal for the client to seek a psychiatrist or a PMHNP. In addition, it would be beneficial for the client to seek cognitive behavioral therapy for her GAD from either source.

Many people go to their primary care physicians for psychological symptoms and are prescribed medications which may not work for them. Many physicians are not aware of specific side effects, or aware of other evidence-based treatments which may be beneficial. Such treatments include cognitive behavioral therapy (Smith, 2012).

Therapy and Rationale:

Anxiety and depression commonly occur in the elderly. CBT has been found to be efficacious for late-life depression and anxiety. Essentially CBT is a structured psychotherapy which focuses on specific roles in which cognition and behavior have in the onset and maintenance of mental illness. The elderly are currently at a point in their life they suffer losses and transitions which may trigger thoughts of missed opportunities, unresolved relationships, and reflections of life events (Palazzolo, 2015). The client is 91-years-old and is neurologically intact and would benefit from this type of therapy.

Legal Issues:

The client is an adult and mentally competent to give consent for treatment.

Patient Education:

Research has shown psychoeducation improves life satisfaction in the elderly. Areas such as nutrition, health, self-realization, life satisfaction, stress management, and interpersonal support increase after psychoeducation (Tambag & Oz, 2013). Educating the client on her diagnosis and current regime as well as an additive medication such as Lexapro may improve her symptoms and overall well-being.

GAD is a persistent and excessive worry which interfere with daily activities. The persistent worrying can cause somatic symptoms such as restlessness, feeling on edge, fatigued, muscle tension, insomnia, and difficulty concentrating. These worries focus on common everyday activity such as job responsibilities and family matters which may include chores or appointments. Self-help, coping, and management strategies can be helpful (American Psychiatric Association, 2015).

Adjustment disorder is a stress-related condition which can cause significant issues in life activities and relationships. An adjust disorder affects how an individual think and feels about themselves and the world, which in turn, affects their actions and behaviors. Emotional or behavioral reactions can contribute to feeling anxious or depressed. The GAD-7 and PHQ9 test results can help identify these symptoms (Mayo Clinic, 2018). Recognition of these behaviors as well as education on coping mechanisms can increase the quality of life.

References

Academy of Acute Care Physical Therapy. (2017). Laboratory values interpretation resource. Retrieved from https://cdn.ymaws.com/www.acutept.org/resource/resmgr/docs/2017-Lab-Values-Resource.pdf

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

American Psychiatric Association. (2018). What are anxiety disorders? Retrieved from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience, 19(2), 93-107.

Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological management of anxiety disorders in the elderly. Current Treatment Options in Psychiatry, 4(1), 33-46.

Mayo Clinic. Adjustment disorders. Retrieved from https://www.mayoclinic.org/diseases-conditions/adjustment-disorders/symptoms-causes/syc-20355224

Lengel, R. M. (2017). Psychosocial assessment: A nursing perspective. Retrieved from https://ceufast.com/course/psychosocial-assessment-a-nursing-perspective

Palazzolo, J. (2015). Cognitive-Behavioral therapy for depression and anxiety in the elderly. Annals of Depression and Anxiety, 2(6), 1063.

Parry, T. S. (2005). 12. Assessment of developmental learning and behavioral problems in children and young people. Medical Journal, 183(1), 43-48.

Psychiatric Times. (2013). GAD-7. Retrieved from http://www.psychiatrictimes.com/gad-7-scale/gad-7

Smith, B. L. (2012). Inappropriate prescribing. American Psychological Association, 43(6), 36

Tambag, H. & Oz, F. (2013). Evaluation of the psychoeducation given to the elderly at nursing homes for a healthy lifestyle and developing life satisfaction. Community Mental Health Journal, 49(6), 742-747.

Williams, N. (2014). PHQ-9. Occupational Medicine, 64(2), 139-140.

Zelviene, P., & Kazlauskas, E. (2018). Adjustment disorder: Current perspectives. Neuropsychiatric Disease and Treatment, 14, 375-381