Nursing History of Psychosis Paper

50 years old female with past psychiatric history of psychosis who presents to the clinic complaining of erratic behavior (as per patient). Patient presents with the following: disorganized thought process and behavior, hyperverbal speech, religious preoccupation and grandiose delusions. Patient denies suicidal/homicidal ideation. This presentation could be explained by acute exacerbation of chronic mental illness or non compliance with medication. Tx: Risperdal 1 mg BID Follow up appointment in 2 weeks.

Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last 2 weeks, using the Comprehensive Psychiatric Evaluation Template provided. You will then use this note to develop and record a case presentation for this patient.

RESOURCES

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

WEEKLY RESOURCE

TO PREPARE

• Review this week’s Learning Resources and consider the insights they provide about assessment and diagnosis. Also review the Kaltura Media resource in the Classroom Support Center (accessed via the Help button).
• Select a patient that you examined during the last 2 weeks who presented with a disorder other than the one present in your selected case for Week 5.
• Conduct a Comprehensive Psychiatric Evaluation on this patient using the template provided in the Learning Resources. There is also a completed exemplar document in the Learning Resources so that you can see an example of the types of information a completed evaluation document should contain. All psychiatric evaluations must be signed by your Preceptor. When you submit your document, you should include the complete Comprehensive Psychiatric Evaluation as a Word document and the completed assignment signed by your Preceptor. You must submit your document using Turn It In.
  Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
• Develop a video case presentation, based on your evaluation of this patient, that includes chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
• Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

ASSIGNMENT

Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. 

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full case. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis including differentials that were ruled out.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Be succinct in your presentation, and do not exceed 8 minutes. Address the following:

• Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
• Objective: What observations did you make during the interview and review of systems? 
• Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why? 
• Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.