NRNP 6675 Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
Walden University Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
Whether one passes or fails an academic assignment such as the Walden University Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
The introduction for the Walden University Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
After the introduction, move into the main part of the Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Sample Answer for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
Subjective:
CC (chief complaint): “My mom said you are going to help me get better.”
HPI:
Dev Cordoba is a 7-year-old boy referred for psychiatric assessment after being referred by the pediatrician for counseling. He comes to the psychiatric clinic alongside his mother, Miss Cordoba. Miss Cordoba mentions that Dev is constantly anxious and expresses worries about ridiculous things like his mother will die or fail to pick him up from school. Dev says that his mother loves his brother more than him. He throws items around the house and has gotten into trouble at school for this. The boy admits that he is anxious most of the time about a lot of things. He states that he gets bad dreams of mostly getting lost and failing to trace his mother and younger brother. Dev also reports losing concent
ration in class and often gets into problems for staring through the window. Miss Cordoba also mentions that Dev has difficulties getting to sleep because he wants the doors open and lights on, and wakes up frequently. Furthermore, Dev usually says he wants to leave school and go home nearly daily, with reports of stomach aches and headaches. He has a poor appetite and has lost three pounds within three weeks. Dev also wets the bed at night, and this has persisted even with a prescription of DDVAP.
Substance Current Use: No history of alcohol or substance use.
Medical History: No medical history of chronic diseases. Immunizations are up to date.
- Current Medications: No current medications
- Allergies: No food or drug allergies.
- Reproductive Hx: Not applicable
ROS:
- GENERAL: Positive for appetite disturbance and weight loss. Negative for fatigue, fever, or chills
- HEENT: Positive for headaches. Negative for a head injury, sinus pain, visual loss, ear pain/discharge, nasal
Assignment Focused SOAP Note for Anxiety, PTSD, and OCD discharge/blockage, or throat pain.
- SKIN: Negative for rashes, itching, or bruises.
- CARDIOVASCULAR: Negative for chest pain, edema, dyspnea, or palpitations.
- RESPIRATORY: Negative for cough, sputum, chest pain, or breathing difficulties.
- GASTROINTESTINAL: Positive for loss of appetite and abdominal pain. Negative for nausea, vomiting, diarrhea, or constipation.
- GENITOURINARY: Negative for dysuria, urinary frequency/urgency, or penile discharge. Positive for enuresis.
- NEUROLOGICAL: Positive for headaches. Negative for dizziness, loss of consciousness, muscle weakness, or tingling sensations.
- MUSCULOSKELETAL: Negative for muscle pain, back pain, or joint stiffness/pain.
- HEMATOLOGIC: Negative for bruises.
- LYMPHATICS: Negative for lymph node swelling.
- ENDOCRINOLOGIC: Negative for cold-heat intolerance, acute thirst, or excessive hunger.
Objective:
Diagnostic results: No lab/imaging tests were ordered.
Assessment:
Mental Status Examination:
The patient is well-groomed and appropriately dressed. He is alert and maintains adequate eye contact in the interview. His speech is clear with normal tone, rate, and volume. The patient has a coherent and logical thought process. He conveys worries about his mother and younger brother being in danger. The client has nyctophobia. No obsessions, compulsions, delusions, or hallucinations were noted. He is oriented to person, place, and time. He demonstrates good abstract thought and judgment. Insight is present.
Assessment
Pediatric Generalized Anxiety Disorder (GAD)
Pediatric GAD is characterized by excessive and uncontainable worry or anxiety about a number of things or events (Bhatia & Goyal, 2018). Excessive worry/anxiety is accompanied by symptoms such as headaches, palpitations, gastrointestinal distress, muscle tension, restlessness, concentration difficulties, and sleep disturbances (APA, 2013). Pediatric GAD is a presumptive diagnosis based on pertinent positive symptoms of excessive and unjustified patient’s worry about his mother and brother being in danger or the mother failing to pick him up from school. The patient also has positive GAD symptoms like constant headaches, stomach aches, poor concentration levels, and sleeping difficulties, which have affected his academic performance.
Separation Anxiety Disorder
Separation anxiety disorder (SAD) manifests with constant and excessive anxiety in children, which is associated with separation or impending separation from the primary caretaker or a family member. Children with SAD present with persistent excessive distress when being separated or anticipating separation from attachment figures (APA, 2013). Children also have persistent and unwarranted worry about losing their primary attachment figures or harm occurring to them. Furthermore, they convey excessive worry about getting into an unpleasant event that may result in separation from their attachment figures (Gittelman & Klein, 2019). The anxiety makes them hesitant about being away from home because of the fear of separation. Besides, children experience recurrent nightmares related to separation and report physical symptoms, like nausea, vomiting, headaches, and stomachaches, when they are separated from an attachment figure (APA, 2013).
SAD is a differential diagnosis based on the patient’s excessive anxiety about being separated from his mother and brother. Besides, he conveys unwarranted worries about losing his mother or the mother failing to show up to school. The patient also has symptoms such as headaches and stomachaches and experiences nightmares about separation from his mother and brother. The worry about being separated from his family makes the patient frequently want to go back home.
Pediatric Obsessive-Compulsive Disorder (OCD)
Pediatric OCD is characterized by constant, recurrent, and unwanted thoughts or urges, which lead to compulsions and interfere with a child’s quality of life (APA 2013; Brezinka et al., 2020). The patient’s recurring obsessions about losing his mother and brother make OCD a differential diagnosis. The obsessions have led to compulsions such as sleeping with doors open and lights on and demanding to go back home when at school. However, this is an unlikely diagnosis owing to the presence of physical symptoms, which are unlikely in OCD.
Plan
Psychotherapy plan: Weekly cognitive-behavioral therapy (CBT) for 12 sessions. The CBT will incorporate sessions with family participation to enhance the therapy process (Panganiban et al., 2019).
Follow-up: The patient will be followed-up after four weeks to assess his progress with psychotherapy and identify any issues requiring interventions.
Reflection notes
If I were to conduct this session again, I would assess for factors that may be contributing to the excessive separation anxiety like bullying in school. I would also obtain a history of any traumatic experiences, stressful life events, or disrupted attachment in the patient’s life since these factors are associated with anxiety disorders in children (Panganiban et al., 2019). If I got a chance to follow up with the patient, I would assess his attitude towards the psychotherapy sessions and inquire about any issues he could be having with the counselor. It is crucial for the PMHNP to identify any issues patients could be having with the counselor and address them to ensure they receive the maximum benefit from psychotherapy. The PMHNP should demonstrate ethical practice when interacting with this patient by seeking consent from the parent before initiating treatment. Besides, the PMHNP should maintain the confidentiality of the patient’s information, and implement interventions backed by evidence-based practice and those linked with the best outcomes and no potential risk to patients (Bipeta, 2019).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Bhatia, M., & Goyal, A. (2018). Anxiety disorders in children and adolescents: Need for early detection. Journal of Postgraduate Medicine, 64(2), 75–76. https://doi.org/10.4103/jpgm.JPGM_65_18
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
Brezinka, V., Mailänder, V., & Walitza, S. (2020). Obsessive-compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC psychiatry, 20(1), 366. https://doi.org/10.1186/s12888-020-02780-0
Gittelman, R., & Klein, D. F. (2019). Childhood Separation Anxiety and Adult Agoraphobia. In Anxiety and the Anxiety Disorders. Routledge.
Panganiban, M., Yeow, M., Zugibe, K., & Geisler, S. L. (2019). Recognizing, diagnosing, and treating pediatric generalized anxiety disorder. JAAPA: official journal of the American Academy of Physician Assistants, 32(2), 17–21. https://doi.org/10.1097/01.JAA.0000552719.98489.75
Sample Answer 2 for Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
Subjective:
CC (chief complaint): Anxious and worried all the time”
HPI: A 7-year-old child and his mother came in for a mental examination at the inpatient psychiatric facility. The patient’s mother says her son has suffered from anxiety and constant worry his mother would die or will inevitably forget to get him from school since he was a little child. There is no identifiable precipitating factor for the patient’s increased concern. His mother states her son often has the impression that she prefers his younger sibling over him. He is often defiant and often causes harm to himself or others by tossing things about the home or even at school. Because of his recurring dreams, he has trouble falling asleep. He often fakes stomachaches and headaches at school to get a pass home. His mother says he hasn’t eaten in days and has dropped roughly three pounds as a result. Even though his physician has prescribed DDVAP, the patient continues to wet the bed on occasion.
Substance Use History:There is no history of mental illness or drug abuse in the family.
Medical History:
Current Medications: For bedwetting, he uses 100 micrograms of DDVAP.
Allergies: No known dietary, environmental, or medication allergies
Surgeries: Denies having ever had surgery.
Chronic Diseases: No established chronic disease
Major traumas: No prior tragic experiences
Hospitalization: No previous hospitalizations
PMH: The pediatrician diagnosed the patient with nocturnal enuresis, and he was given the medication DDVAP 100mg.
Family History: The patient has a close relationship with his mother and younger sibling. His dad was killed in the war. The patient was just five years old when his father was sent overseas with the military.
Social History:The patient enjoys playing with pets. When he is at home, he plays a policeman in his room with his dog. He also likes using his LEGOs to construct things.
ROS:
- GENERAL:There are no night sweats, chills, weariness, or fever. Verifies recent weight decrease of roughly 3 pounds.
HEENT: Head: Headache complaints. There were no head injuries, hair changes, vertigo, or unconsciousness. Eyes: no double vision, blurriness, or alterations in vision. denies wearing glasses or having any unusual vision. Sclera is clean and free of any abnormalities. No indications of discomfort, discharge, dizziness, or ringing in the ears. denies nasal hemorrhage, sinus pressure, post-nasal drip, or congestion are present. Denies having gum disease, a hoarse voice, a sore throat, a toothache, trouble swallowing, bleeding gums, or ulcers.
SKIN: Intact, showing no hives, rashes, itching, or indications of skin problems.
CARDIOVASCULAR: Denies orthopnea, irregular heartbeat, palpitations, rapid or slow heartbeats, edema, or chest discomfort.
RESPIRATORY: Denies persistent coughing, sputum, discomfort, or loud breathing.
GASTROINTESTINAL: Denies experiencing diarrhea, diarrhea, or constipation. confirms lack of appetite and stomach discomfort.
GENITOURINARY: denies painful urination, unusual urine color, hesitation, or urgency.
NEUROLOGICAL: denies fainting, weakness, temporary paralysis, unconsciousness, or the absence of spells. Significant alterations in bowel or bladder control. Reports headache.
MUSCULOSKELETAL: denies discomfort in the joints, muscles, or back. Full ranges of motion are present in both extremities without any stiffness.
HEMATOLOGIC: denies having ever had bleeding issues or injuries.
LYMPHATICS: denies having had an enlarged node or a splenectomy.
ENDOCRINOLOGIC: Denies having polyuria, polydipsia, or a heat or cold sensitivity.
Objective:
Diagnostic results:
Lab Tests: Thyroid issues may cause mood changes, thus a thyroid test should be conducted. Routine Hb and WBC tests. LFTs for liver function and basic metabolic panels are essential to assess hepatic and renal status for dosage titration, particularly with psychotropic drugs (Ayano et al., 2020). Drug and cortisol testing is also done. CT scans and head X-rays for anatomical abnormalities. The optimal psychotropic agent requires echocardiography and ECG.
Pediatric Assessment tools: Record his body temperature, BMI, BP, and RR. Assess the patient’s age-appropriate dental development. Assess the patient’s diet to ensure it contains vitamins, carbs, fibers, and proteins. Examine the patient’s growth and the child’s vaccinations.
Assessment:
Mental Status Examination:The 7-year-old patient entered the examination room dressed appropriately for his age. His orientation in person, place, and time remains intact. He is cooperative and capable of answering all inquiries while easily keeping eye contact. He speaks with fluency and a distinct tone. His mood is melancholy. He is preoccupied, always checking to see whether his mother is around. His cognitive process is logically structured. Both short- and long-term memory are unimpaired. He believes he is about to die. Denies hallucinations, suicidal thoughts, or delirium.
Diagnostic Impression:
- Separation Anxiety Disorder (SAD): Children who have lost a parent or sibling often develop this psychological condition. The case study patient was split from his father at 5 years old. According to DSM-5, SAD patients must show significant concern relative to their developmental stage or age (Krause et al., 2021). In addition, the patient must have at least three of the following symptoms: regular night terrors, a persistent aversion to sleeping alone in the dark, frequent extreme anguish away from family, and bodily symptoms like headache or stomach pain while separated. The patient qualifies for SAD diagnosis.
- Generalized Anxiety Disorder (GAD):GAD patients usually worry excessively, unrealistically, and persistently about nothing in particular (Plaisted et al., 2021). DSM-5 diagnostic criteria require patients to have severe, uncontrollable concern and anxiety for at least six months (Ayano et al., 2020). Sleep troubles, muscular tension, concentration issues, irritability, restlessness, and excessive exhaustion must persist for at least six months. The case study patient had most of these symptoms. His fear of being apart from his mother disqualifies this diagnosis.
- Oppositional Defiant Disorder (ODD):ODD in children is characterized by repeated anger, irritation, vindictiveness, and defiance for more than six months. Similar to the case study, this condition is frequent among kids who have lost a loved one or have been split apart from them (Impey, Gordon, & Baldwin, 2020). Argumentativeness, irritability, decreased energy, lack of interest in routine chores, withdrawal, and depressed mood are among the DSM-5’s diagnostic criteria for OOD (Plaisted et al., 2021). The majority of the above-mentioned symptoms were present in the case study patient, but SAD was already present, making this diagnosis incorrect.
Reflections:The patient’s mental examination is age-appropriate and extremely outstanding since it has all the data needed to reach a diagnosis. The mother of the patient was very helpful in discussing the symptoms the patient had at home. It may also be helpful to speak with the patient’s instructors and peers to get a feel for how they behave in the classroom. The patient is a minor, thus the mother has a legal and ethical obligation to be involved in decisions about his care (Impey et al., 2020). Therefore, the PMHNP is required to tell the mother about the diagnosis and the potential treatments to be taken into account while caring for the patient.
Case Formulation and Treatment Plan:
Primary Diagnosis: Separation Anxiety Disorder (SAD).
Psychotherapy: Psychotherapy is advised as the first-line treatment for SAD in young people (Elmore & Crouch, 2020). Cognitive behavioral therapy is the psychotherapeutic approach that works best for kids (CBT).
Pharmacotherapy: Selected serotonin reuptake inhibitors, including Zoloft, might be taken into consideration for further therapy of the patient’s symptoms. However, this medication is linked to a rise in children’s suicide thoughts (Elmore & Crouch, 2020). As a result, it’s important to adjust the dosage carefully and keep an eye on the patient’s progress.
Health Promotion:The patient’s mother devises a regular eating and sleeping schedule to encourage his sleep cycle (Impey et al., 2020).
Patient Education: The patient’s mother has to be made aware of the importance of her role in supporting her son to take the recommended actions, such as engaging in psychotherapy.
Follow-up: The patient should follow up with the clinic after four weeks to evaluate the efficacy of the therapy and make any necessary adjustments.
References
Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2020). The risk of anxiety disorders in children of parents with severe psychiatric disorders: a systematic review and meta-analysis. Journal of Affective Disorders.https://doi.org/10.1016/j.jad.2020.12.134
Elmore, A. L., & Crouch, E. (2020). The Association of Adverse Childhood Experiences with Anxiety and Depression for Children and Youth, 8 to 17 Years of Age. Academic Pediatrics, 20(5). https://doi.org/10.1016/j.acap.2020.02.012
Impey, B., Gordon, R. P., & Baldwin, D. S. (2020). Anxiety disorders, post-traumatic stress disorder, and obsessive-compulsive disorder. Medicine.https://doi.org/10.1016/j.mpmed.2020.08.005
Krause, K. R., Chung, S., Adewuya, A. O., Albano, A. M., Babins-Wagner, R., Birkinshaw, L., … & Wolpert, M. (2021). International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder. The Lancet Psychiatry, 8(1), 76-86.https://doi.org/10.1016/S2215-0366(20)30356-4
Plaisted, H., Waite, P., Gordon, K., & Creswell, C. (2021). Optimizing exposure for children and adolescents with anxiety, OCD and PTSD: a systematic review. Clinical Child and Family Psychology Review, 1-22.https://doi.org/10.1007/s10567-020-00335-z