NRNP 6635 Assessing/Diagnosing Patients With Substance-Related and Addictive Disorders
Sample Answer for NRNP 6635 Assessing/Diagnosing Patients With Substance-Related and Addictive Disorders Included After Question
An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.
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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).
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A Sample Answer For the Assignment: NRNP 6635 Assessing/Diagnosing Patients With Substance-Related and Addictive Disorders
Title: NRNP 6635 Assessing/Diagnosing Patients With Substance-Related and Addictive Disorders
Subjective:
CC (chief complaint): “I am scared.”
HPI: Lisa Tremblay is a 33-year-old female in a detox facility. She states that she fears getting into rehab because of what other people will think about her. She fears that people will think of her as a person with an addiction. She also worries about her business, which she says is over after operating for nine months. According to Lisa, the business collapsed because of her boyfriend, Jeremy, who took money from the account. The boyfriend spent the money to pay cocaine debts, and this caused the business to lose $ 80,000. Lisa was introduced to cocaine by her boyfriend, who made her believe it was non-addictive. However, she developed a cocaine addiction. Lisa reports that she feels uneasy if she does not smoke cocaine. Smoking cocaine makes her feel good, and she usually wants to smoke more when the feeling of highness reduces. According to Lisa, she does not need help because Jeremy promised her that she would be okay, and she believes him because she loves him.
Past Psychiatric History:
- General Statement: No psychiatric history.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: None
Substance Current Use and History:
Take opiates worth about $100 daily.
Uses cannabis 1–2 times weekly.
Drinks 1/2 gallon of vodka daily. She reports drinking with her friends but states that she is in control of her alcohol consumption.
Family Psychiatric/Substance Use History: The patient’s mother has a history of agoraphobia and benzodiazepine abuse.
The father was imprisoned due to drug abuse.
The patient’s older brother has a history of opioid use.
Psychosocial History: The patient lives with her boyfriend, Jeremy, whom she reports having a strained relationship with after he cheated on her. She has a daughter with an ex-boyfriend, and the girl lives with her friends. Lisa and her boyfriend had started a web design business, which collapsed after he withdrew money to pay cocaine debts. The patient has a legal history of arrest after being found in possession of drugs. She was sexually abused by her estranged father when she was 6-9 years old. The father was incarcerated for sexual abuse and drug charges. Lisa’s mother lives in Maine. She has not heard from her older brother for ten years. She reports sleeping 5-6 hours/day, and her appetite increases when high.
Medical History: The patient has Hepatitis C. She is considering treatment for Hep C+ but needs detox first.
- Current Medications: None
- Allergies: Allergic to Azithromycin.
- Reproductive Hx: None
ROS:
- GENERAL: Denies fever, chills, weight changes, or malaise.
- HEENT: Denies eye pain, ear pain, discharge, rhinorrhea, or sore throat.
- SKIN: Denies rashes, lesions, or discoloration.
- CARDIOVASCULAR: Denies dyspnea, edema, chest pain, or palpitations.
- RESPIRATORY: Denies wheezing, cough, SOB, or sputum.
- GASTROINTESTINAL: Positive for reduced appetite. Denies abdominal pain or bowel changes.
- GENITOURINARY: Denies dysuria or abnormal PV discharge.
- NEUROLOGICAL: Denies dizziness, paralysis, or tingling sensations.
- MUSCULOSKELETAL: Denies muscle/joint pain or limitations in movement.
- HEMATOLOGIC: Denies bruising or bleeding.
- LYMPHATICS: Denies lymph node swelling.
- ENDOCRINOLOGIC: Denies excessive sweating, increased hunger, acute thirst, or polyuria.
Objective:
Physical exam: if applicable
Vital signs: BP-180/110; T- 100.0; P- 108; R-20; Ht- 5’6; Wt-146lbs
Diagnostic results:
ALT-168
AST-200
ALK-250
Bilirubin-2.5
Albumin-3.0;
GGT-59
Urine drug test positive for opiates, THC, and alcohol
BAL-308
Assessment:
Mental Status Examination:
The patient appears nervous and constantly fidgets and looks out through the window. She is alert and oriented to person, place, and time. Her self-reported mood is ‘worried,’ and her affect is broad. She has clear and coherent speech. Her thought process is coherent and goal-oriented. She exhibits no hallucinations, delusions, or suicidal/homicidal ideations. Memory, abstract thought, and judgment are intact. Insight is present.
Differential Diagnoses:
Substance Use Disorder (SUD): The DSAM-V criteria for diagnosing SUD include four basic categories: Physical dependence, Impaired control, Social problems, and risky use (American Psychiatric Association, 2022; Livne et al., 2021). The patient is physically dependent on cocaine and usually feels terrible when she has not smoked it. She gets high to trigger her appetite and has developed a cocaine addiction. She also has impaired control and cannot stop using cocaine. She continues to use cocaine despite causing social problems like problems with her boyfriend and her business collapsing. Lisa spends lots of money on opiates, about $100 daily. Furthermore, she uses opiates in risky settings and has been arrested for possessing drugs.
Alcohol Use Disorder (AUD): AUD is characterized by a problematic pattern of alcohol use that results in clinically significant impairment or distress (American Psychiatric Association, 2022; Palmer et al., 2019). The patient presents with clinical features of AUD, like taking large amounts of alcohol. She reports taking 1/2 gallon of vodka daily. Besides, her urine drug test is positive for alcohol, making AUD a differential diagnosis.
Generalized Anxiety Disorder (GAD): GAD is diagnosed based on excessive, unjustified anxiety or worry, which interferes with essential activities of daily living (Boland et al., 2022; Szuhany & Simon, 2022). Lisa reports being worried about going to rehab because people will think she has an addiction. This may interfere with her treatment and recovery of opiate addiction and abuse.
Reflections: SUD is the appropriate diagnosis for this patient since she presented with a pattern of symptoms associated with using cocaine. In a different situation, I would inquire if the patient has a history of domestic violence since women who abuse substances face violence in their relationships. Legal considerations related to this patient include privacy and confidentiality. The clinician should assure the patient of confidentiality of what she says and what is recorded. Health promotion should aim to educate the patient on the effects of alcohol, cannabis, and cocaine use on her overall health.
References
American Psychiatric Association. (2022). Substance-related and addictive disorders. In Diagnostic and statistical manual of mental disorders
Boland, R. Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Livne, O., Shmulewitz, D., Stohl, M., Mannes, Z., Aharonovich, E., & Hasin, D. (2021). Agreement between DSM-5 and DSM-IV measures of substance use disorders in a sample of adult substance users. Drug and alcohol dependence, 227, 108958. https://doi.org/10.1016/j.drugalcdep.2021.108958
Palmer, R. H. C., Brick, L. A., Chou, Y. L., Agrawal, A., McGeary, J. E., Heath, A. C., Bierut, L., Keller, M. C., Johnson, E., Hartz, S. M., Schuckit, M. A., & Knopik, V. S. (2019). The etiology of DSM-5 alcohol use disorder: Evidence of shared and non-shared additive genetic effects. Drug and alcohol dependence, pp. 201, 147–154. https://doi.org/10.1016/j.drugalcdep.2018.12.034
Szuhany, K. L., & Simon, N. M. (2022). Anxiety Disorders: A Review. JAMA, 328(24), 2431–2445. https://doi.org/10.1001/jama.2022.22744
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NRNP 6635 Assessing/Diagnosing Patients With Substance-Related and Addictive Disorders Rubric Detail
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Name: NRNP_6635_Week8_Assignment_Rubric
| Excellent | Good | Fair | Poor | |||
| Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.
In the Subjective section, provide: |
18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. |
16 (16%) – 17 (17%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. |
14 (14%) – 15 (15%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. |
0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing. |
||
| In the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. |
18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented. |
16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. |
14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. |
0 (0%) – 13 (13%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing. |
||
| In the Assessment section, provide: • Results of the mental status examination, presented in paragraph form. • At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 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. |
23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected. |
20 (20%) – 22 (22%)
The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected. |
18 (18%) – 19 (19%)
The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy. |
0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing. |
||
| Reflect on this case. Discuss what you learned and what you might do differently. 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.). | 9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking. |
8 (8%) – 8 (8%)
Reflections demonstrate critical thinking. |
7 (7%) – 7 (7%)
Reflections are somewhat general or do not demonstrate critical thinking. |
0 (0%) – 6 (6%)
Reflections are incomplete, inaccurate, or missing. |
||
| Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). | 14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making. |
12 (12%) – 13 (13%)
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study. |
11 (11%) – 11 (11%)
Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification. |
0 (0%) – 10 (10%)
Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based. |
||
| Written Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. |
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. |
3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic. |
0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion were provided. |
||
| Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors |
4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors |
3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors |
0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding |
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| Total Points: 100 | ||||||