Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders
Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders
Description
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.
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.).
Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6635: Psychopathology and Diagnostic Reasoning Faculty Name Assignment Due Date NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Subjective: CC (chief complaint): HPI: Past Psychiatric History: • • • • • General Statement: Caregivers (if applicable): Hospitalizations: Medication trials: Psychotherapy or Previous Psychiatric Diagnosis: Substance Current Use and History: Family Psychiatric/Substance Use History: Psychosocial History: Medical History: • • • Current Medications: Allergies: Reproductive Hx: ROS: • • • • • • • • • • • • GENERAL: HEENT: SKIN: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: NEUROLOGICAL: MUSCULOSKELETAL: HEMATOLOGIC: LYMPHATICS: ENDOCRINOLOGIC: Objective: Physical exam: if applicable © 2021 Walden University Page 2 of 3 NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template Diagnostic results: Assessment: Mental Status Examination: Differential Diagnoses: Reflections: References © 2021 Walden University Page 3 of 3
Assessing and Diagnosing Patients with Substance-Related and Addictive Disorders Grid View
| Excellent | Good | Fair | Poor | ||
| Main Postinga | 45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.
Supported by at least three current, credible sources.
Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.
At least 75% of post has exceptional depth and breadth.
Supported by at least three credible sources.
Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
35 (35%) – 39 (39%)
Responds to some of the discussion question(s).
One or two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with two credible sources.
Written somewhat concisely; may contain more than two spelling or grammatical errors.
Contains some APA formatting errors. |
0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible sources.
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style. |
|
| Main Post: Timeliness | 10 (10%) – 10 (10%)
Posts main post by day 3. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not post by day 3. |
|
| First Response | 17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
15 (15%) – 16 (16%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
13 (13%) – 14 (14%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Second Response | 16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
12 (12%) – 13 (13%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Participation | 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days. |
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| Total Points: 100 | |||||