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PRAC 6635 Assignment: Family Assessment

PRAC 6635 Assignment: Family Assessment

Subjective:

CC (chief complaint): There has been a “chaos” in the family since the re-union with daughter and sister Shireen 2 years ago.

HPI: Patti is a 40 years old obese Iranian woman who immigrated to the United States 20 years ago with her 4 children for medical purposes: two daughters Sharleen & Sheela and two sons (names not mentioned). However, Patti’s 3rd daughter Shireen who was 8 years old at that time wasn’t able to leave Iran due to some immigration legalities. Patti worked as a caregiver to support and provide for her children, meanwhile the oldest daughter had to take up the role of a parent. About 2 years ago, Patti was able to bring Shireen to the U.S. However, family has noticed “chaos” in the household since Shireen’s arrival. Shireen was physically, sexually, and emotionally abused by her father in Iran and she blames Patti for leaving her behind in the abusive atmosphere. Patti acknowledges that her husband was an abusive man and the entire family is a trauma survivor. Currently Patti lives with her two sons, while all three girls have moved out. Patti has a bad back and recently had surgery on both feet, which left her disabled due to constant pain. The chaos is reported because Patti lives with her traditional ways and daughters are trying to detach and have their own identity. Patti reports feeling hopeless, helpless, and children are out of her control. She wants daughters to visit more often than they do and spend a night, especially Sharleen because she doesn’t work long hours like the other daughters. Sharleen representing all siblings states, mom is controlling, wants more and more, has no patience, yells, disrespects, and curses, wants people around but is always on phone or watching TV. Children feel suffocated by Patti’s opinions. Children want mom to be positive, & independent. Sheela now is 24 years old, Sharleen 23, Shireen 21, and the boys are ages 18 and 15 years old. Children are grown up and do not want mom to treat them like children.

Past Psychiatric History:

  • General Statement: Patti is an Iranian woman with traditional views and values who is in constant cultural conflict with her children who grew up in the U.S. and are trying to have their own identity.
  • Caregivers (if applicable): 3 daughters and 2 sons
  • Hospitalizations: unknown. However, Patti had bilateral foot surgery recently, which may have required hospitalization
  • Medication trials: Provider should have asked
  • Psychotherapy or Previous Psychiatric Diagnosis: Patti and children currently receiving psychotherapy. Provider should have asked about past psychiatric diagnosis.

Substance Current Use and History: Provider should have asked

Family Psychiatric/Substance Use History: Patti and daughter Shireen have history of physical, sexual, and emotional trauma. Provider should have asked about substance use history.

Psychosocial History: Patti is a 40 years old woman of Iranian decent. She is separated from her husband and migrated to the U.S. 20 years ago. She has 5 children: 3 daughetrs and 2 sons. Patient worked as a caregiver, but is now unemployed due to disability from constant pain from recent bilateral foot surgery and back problem. She currently lives with her 2 sons attending High school. Her 2 daughters work and have moved out, and the oldest daughter is married and living with husband.

Medical History:

 

  • Current Medications: Provider should have asked.
  • Allergies: provider should have asked
  • Reproductive Hx: Patti is separated from husband and has 5 children. Provider should have asked additional information regarding reproductive history such as sexuality, relationship, menstruation, pregnancies, miscarriages, etc.

ROS:

  • GENERAL: Alert, well groomed, obese, in no acute distress
  • HEENT: provider should have assessed
  • SKIN: provider should have assessed
  • CARDIOVASCULAR: provider should have assessed
  • RESPIRATORY: provider should have assessed
  • GASTROINTESTINAL: provider should have assessed
  • GENITOURINARY: provider should have assessed
  • NEUROLOGICAL: provider should have assessed
  • MUSCULOSKELETAL: back pain and provider should have assessed
  • HEMATOLOGIC: provider should have assessed
  • LYMPHATICS: provider should have assessed
  • ENDOCRINOLOGIC: provider should have assessed

Objective:

Physical exam: if applicable

Diagnostic results: N/A

Assessment:

Mental Status Examination: Client is well-kempt and appropriately dressed for age, weather, and occasion.

Appearance:  Client is well-kempt and appropriately dressed for age, weather, and occasion.

Eye contact: good

Speech: Pressured, loud

Behavior: irritable, cooperative

Psychomotor: no involuntary movement

Mood: irritable, depressed, anxious

Affect: congruent with mood

Thought Process: goal directed

Thought Content:  No delusions. Provider should have asked for suicidal, homicidal, or self-harm ideation.

Perception:  No reaction to external or internal stimuli.

Attention/ Concentration: sustained attention and concentration as evidenced by recollection of events.

Cognition:  Alert, oriented X 4.

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

Insight: fair

Judgment: fair

Fund of Knowledge:  Average.

Intelligence:  Average.

 

 

Differential Diagnoses:

Post-traumatic stress disorder (PSTD): The patient has a history of past traumatic encounter considering that she lived with an abusive husband. According to DSM-5, PSTD is a condition that affects people who experiences traumatic events such as rape or sexual violence. The patient in this case appears depressed and with low energy; a symptom that is consistent with PSTD (Murphy et al. 2019).

Depression: The patient could also be having depression. According to Rosebrock, et al. (2018), depression is a condition characterized by diminished quality of life. The patient indicated that she has been in chaos as a family and this means lack of peace and organization. According to DSM-5, People with depression are most likely to have poor concentration abilities, low energy and easily irritated. Besides, depression affects the way an individual thinks and responds to issue. The depressive moods could have been triggered by the traumatic experiences and the poor family relationship exhibited in this case. The patient is currently unemployed after separating from her husband and this could be another factor that could have triggered the onset of depressive symptoms.

The third diagnosis is dysthymic disorder. According to DSM-5, the condition is characterized by loss of interest in life, and feeling hopelessness. Also, the patients are likely to low energy, difficulties in sleeping and poor concentration. The signs are consistent with what the patient presents with (Carta et al., 2019). The patient has low energy and is depressed.

Case Formulation: 

 

  • Referred client to an Intensive Outpatient Program (IOP) that runs 4 hours a day. This program will incorporate individual therapy alongside family therapy at least once a week.
  • Scheduled initial appointment with psychiatrist for medication management and continued psychiatric care.
  • Transportation arranged to and from IOP as well as initial psychiatric appointment. A car will pick Patti up at 9:30 am from her house and drop her off at the IOP for program Monday through Friday. A car will also pick Patti up from the IOP every day from Monday through Friday at 2:15 pm. Patti will be picked up via van on a coming Saturday at 10 am for her initial psychiatric appointment for medication management. The same van will bring her home after the appointment.
  • Call emergency crisis support hotline at 855 521 1317.

 

Treatment plan:

  • Attend IOP daily Monday through Friday.
  • Follow-up with primary care physician within a week for status post foot surgery, weight management due to obesity, and any other related comorbid conditions.

 

Genogram:

Patti is a 40 years old single mother of five grown children: daughters Sheela 24 y.o., Sharleen 23 y.o., and Shireen 21 y.o., and two sons (names and ages not mentioned, in high school. Provider should ask). Patti has been separated from her husband for 20 years. Patti and her 3rd daughter Shireen share history of abuse by husband and father. Patti and Shireen both felt helpless in this situation.

PRAC 6635 Assignment Family Assessment

PRAC 6635 Assignment Family Assessment

While Patti wanted to bring Shireen to America with the rest of her children, she couldn’t due to immigration legalities and fearing risking her life along with the lives of the other four children. This led to Shireen believing that Patti had abandoned her and therefore, allowed the abuse. Patti felt the same way when Shireen and the other daughters moved out. Patti worked very hard to support and provide for her children. And now she feels abandoned because the daughters have moved out and she barely sees them. Daughters feel they have worked very hard as well helping take care of the two younger brothers and playing the role of parents while Patti went to work. Both Patti and her daughters feel their hard work is neighter acknowledged nor paid back as expected.

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The chaos is reported between Patti and children because according to children Patti lives with her traditional ways and daughters are trying to detach and have their own identity. Patti feels hopeless, helpless, and that her children are out of her control. While children feel Patti is very controlling and not giving them room to grow and be independent. Patti depends on her children for emotional and physical support. While children want Patti to be as independent as possible, which allows for their independence also.

Children feel suffocated by Patti’s opinions and wants while Patti feels isolated and abandoned.

All family members show great deal of love and care for each other, however, they are not able to manage it without hurting each others’ feeling. Daughters are trying to set healthy boundaries and feel helpless when it doesn’t work with Patti.

 

Reflections:

The case provides an opportunity to analyze the presentation of the mental health issues in the society. The prevalence of mental health conditions continue to increase and this calls for a serious attention on how to address them and minimize theassociated harmful outcomes. Most of the patients with mental health isues are likely to develop suicidal ideation and the condition progresses. The case analysis provided the opportunity to explore into the patients’presentations and history and come upwith the right diagnosis as outlined by the preceptor. Interacting with the patients and collecting relevant data is significant aspect in the diagnosis and treatment of the patients. The healthcare providers must also be cautious to identy the socio-cultural factors likely to affect the patients present conditions and even the treatment outcomes.

 

 

References

Carta, M. G., Paribello, P., Nardi, A. E., & Preti, A. (2019). Current pharmacotherapeutic approaches for dysthymic disorder and persistent depressive disorder. Expert Opinion on Pharmacotherapy20(14), 1743-1754. https://doi.org/10.1080/14656566.2019.1637419

Murphy, S., Elklit, A., Chen, Y. Y., Ghazali, S. R., & Shevlin, M. (2019). Sex differences in PTSD symptoms: A differential item functioning approach. Psychological Trauma: Theory, Research, Practice, and Policy11(3), 319-327. https://doi.org/10.1037/tra0000355

Rosebrock, L. E., Arditte Hall, K. A., Rando, A., Pineles, S. L., & Liverant, G. I. (2018). Rumination and its relationship with thought suppression in unipolar depression and comorbid PTSD. Cognitive Therapy and Research43(1), 226-235. https://doi.org/10.1007/s10608-018-9935-4

PRAC 6635 Assignment: Family Assessment

Assignment: Family Assessment

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

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To prepare:

  • Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
  • Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
  • View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.

The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

  • Chief complaint
  • History of present illness
  • Past psychiatric history
  • Substance use history
  • Family psychiatric/substance use history
  • Psychosocial history/Developmental history
  • Medical history
  • Review of systems (ROS)
  • Physical assessment (if applicable)
  • Mental status exam
  • Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5 diagnostic criteria
  • Case formulation and treatment plan
  • Include a psychotherapy genogram for the family

Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.

By Day 7

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK2Assgn+last name+first initial.(extension)” as the name.
  • Click the Week 2 Assignment Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 2 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK2Assgn+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.
Grading Criteria

To access your rubric:

Week 2 Assignment Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 2 Assignment draft and review the originality report.

Submit Your Assignment by Day 7

To participate in this Assignment:

Week 2 Assignment

Name: NRNP_6645_Week2_Assignment_Rubric

Excellent

90%–100%

Good

80%–89%

Fair

70%–79%

Poor

0%–69%

Document the following for the family in the video, using the Comprehensive Evaluation Note Template: • Chief complaint • History of present illness • Past psychiatric history • Substance use history • Family psychiatric/substance use history • Psychosocial history/Developmental history • Medical history • Review of systems (ROS) • Physical assessment (if applicable)
Points Range: 18 (18%) – 20 (20%)
The assignment includes an accurate, clear, and complete description of the subjective and objective information for the client family. The response addresses each of the required elements and demonstrates thoughtful consideration of the client family’s situation and culture.
Points Range: 16 (16%) – 17 (17%)
The assignment includes an accurate, clear, and complete description of the subjective and objective information for the client family.
Points Range: 14 (14%) – 15 (15%)
The assignment includes a description of the subjective and objective information for the client family but is somewhat general or contains small inaccuracies.
Points Range: 0 (0%) – 13 (13%)
The assignment includes a description of the subjective and objective information for the client family but is vague or contains many inaccuracies. Or, several of the required elements are missing.
• Mental status exam • Differential diagnoses—Include a minimum of three differential diagnoses and include how you derived at each diagnosis in accordance with DSM-5 diagnostic criteria
Points Range: 18 (18%) – 20 (20%)

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 family in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

Points Range: 16 (16%) – 17 (17%)

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.

Points Range: 14 (14%) – 15 (15%)

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.

Points Range: 0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and/or explanation of the differential diagnoses. Or, assessment documentation is missing.
• Case formulation • Treatment plan that includes psychotherapy interventions
Points Range: 23 (23%) – 25 (25%)

Case formulation is thorough, thoughtful, and demonstrate critical thinking.

The assignment includes an accurate, clear, and complete treatment plan for the client family that includes psychotherapy interventions. The response demonstrates thoughtful consideration of the client family’s situation and culture.

Points Range: 20 (20%) – 22 (22%)

Case formulation demonstrates critical thinking.

The assignment includes an accurate, clear, and complete treatment plan for the client family that includes psychotherapy interventions.

Points Range: 18 (18%) – 19 (19%)

Case formulation is somewhat general or does not demonstrate critical thinking.

The assignment includes a treatment plan for the client family that includes psychotherapy interventions but is somewhat general or contains small inaccuracies.

Points Range: 0 (0%) – 17 (17%)
The assignment provides a vague and/or inaccurate description of the case formulation and treatment plan for the client family. Or, many of the required elements are missing.
• A psychotherapy genogram for the family
Points Range: 18 (18%) – 20 (20%)
The assignment includes an accurate, clear, and complete genogram of the client family. The documentation style is consistent and a key is provided.
Points Range: 16 (16%) – 17 (17%)
The assignment includes an accurate genogram of the client family. The documentation style is consistent and a key is provided.
Points Range: 14 (14%) – 15 (15%)
The assignment includes a genogram of the client family but is somewhat limited or contains factual inaccuracies or inconsistencies in documentation style.
Points Range: 0 (0%) – 13 (13%)
The genogram provided is vague or contains many inaccuracies. Or, the genogram is missing.
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 which delineate all required criteria.
Points Range: 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.

Points Range: 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 are brief and not descriptive.

Points Range: 3 (3%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment are vague or off topic.

Points Range: 0 (0%) – 2 (2%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time.

No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains 1 or 2 grammar, spelling, and punctuation errors.
Points Range: 3 (3%) – 3 (3%)
Contains 3 or 4 grammar, spelling, and punctuation errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains 1 or 2 APA format errors.
Points Range: 3 (3%) – 3 (3%)
Contains 3 or 4 APA format errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥5) APA format errors.
Total Points: 100

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