PRAC 6665 Assignment 2: Focused SOAP Note and Patient Case Presentation

Walden University PRAC 6665 Assignment 2: Focused SOAP Note and Patient Case PresentationStep-By-Step Guide

This guide will demonstrate how to complete the Walden University NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment 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 NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment

Whether one passes or fails an academic assignment such as the Walden University NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment 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 NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment

The introduction for the Walden University NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment 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 NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment

After the introduction, move into the main part of the NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment 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 NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment

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 NRNP 6665 Week 1 Discussion: Comprehensive Integrated Psychiatric Assessment

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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Assignment 2: Focused SOAP Note and Patient Case Presentation

Photo Credit: Pexels

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP 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 three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:
- All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
- When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
- You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment

Record yourself presenting the complex case study for your clinical patient. In your presentation:

Dress professionally with a lab coat 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 complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
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. Specifically address the following for the patient, using your SOAP note as a guide:
- 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 their mental status examination results. What were your differential diagnoses?
  PRAC 6665 Assignment 2 Focused SOAP Note and Patient Case Presentation
  
  Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
- Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
- Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

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By Day 7 of Week 3

Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.

Submission and Grading Information

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

Please save your Assignment using the naming convention “WK3Assgn2+last name+first initial.(extension)” as the name.
Click the Week 3 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
Click the Week 3 Assignment 2 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 “WK3Assgn2+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 3 Assignment 2 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 3 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 3

To participate in this Assignment:

Week 3 Assignment 2

Sample Answer for PRAC 6665 Assignment 2: Focused SOAP Note and Patient Case Presentation

Subjective:

CC (chief complaint): “My friends always abandon me.”

HPI: W.R. is a 31-year-old female who reported for psychiatric evaluation with reports of her friends always abandoning her. She was worried about her social relationships because they never seemed to last, and she blamed herself for not being a better friend. The patient reported a history of self-image problems and a pervasive pattern of unstable interpersonal relationships. Besides, she admitted to having impulsive behavior, which led to recurring self-mutilating behaviors, such as cutting and burning herself and risk-taking behaviors. The client reported that she tried to avoid being abandoned, which made her frequently enter into sexual liaisons. She reported feeling empty for a long time and would get angry in a crisis. The client was obsessed with her self-image and her intimate relationships.

Substance Current Use: Drinks alcohol when hanging out with friends; Admits to often drinking more than she can handle. She smokes 2PPD and smokes recreational marijuana.

Medical History: No medical illnesses.

Current Medications: None
Allergies: NKDA

Reproductive Hx: Para 1+0; G0. Positive for Chlamydia infection eight months ago.

ROS:

GENERAL: No weight changes or fatigue.
HEENT: No visual changes, hearing loss, nasal congestion, sneezing, or sore throat.
SKIN: Positive for cuts, bruises, and healing burn wounds.
CARDIOVASCULAR: No edema, chest pain, or palpitations.
RESPIRATORY: No cough or SOB.
GASTROINTESTINAL: No abdominal tenderness or bowel changes.
GENITOURINARY: No urinary symptoms or vaginal discharge.
NEUROLOGICAL: No headaches, dizziness, or muscle weakness.
MUSCULOSKELETAL: No muscle pain or joint discomfort.
HEMATOLOGIC: No hx of bleeding or anemia.
LYMPHATICS: No swollen lymph nodes.
ENDOCRINOLOGIC: No increased urination or intolerance to cold or heat.

Objective:

Diagnostic results: No tests were requested.

Assessment:

Mental Status Examination:

The patient is neat but inappropriately dressed with a mini-skirt, a revealing top, and heavy makeup. She has a clear and goal-directed speech. She maintains minimal eye contact and is somewhat uncooperative and uneasy during the session. Her self-reported mood is nervous, and her affect is constricted. The concentration and attention span are varied. She is oriented to person, place, and time. She demonstrates good judgment and abstract thought.

Diagnostic Impression:

Borderline Personality Disorder (BPD): BPD is characterized by extraordinarily unstable mood, behavior, affect, object relations, and self-image. Individuals with BPD have temperamental instability in relationships and self-concept (Leichsenring et al., 2024). Clinical features include unstable interpersonal relationships, Trying too much to avoid being abandoned, Impulsive behavior and actions, Recurrent self-mutilating behavior, Chronic feelings of emptiness, Regular sexual liaisons, Substance abuse, and Reckless behavior (Mishra et al., 2023). The patient has unstable interpersonal relationships, impulsive behavior, self-harm behavior, abuses alcohol and substances, and gets into sexual liaisons

Attention-deficit/hyperactivity disorder (ADHD): ADHD presents with Inattention, Hyperactivity, or Impulsivity. The common features in adults include disorganization, relationship concerns, restlessness, anxiety, lack of focus, negative self-image, substance misuse, impulsivity, and emotional concerns (Williams et al., 2023). The patient has self-image problems, a pervasive pattern of unstable interpersonal relationships, feelings of emptiness, impulsive behavior, and substance misuse, which align with ADHD.

Histrionic Personality Disorder: Patients with this personality disorder have flamboyant, dramatic, excitable, and overreactive behavior and aim to gain attention. They exhibit inappropriate sexually seductive behavior, have rapid shifts of emotions, and use physical appearance to draw attention to themselves (D’Huart et al., 2023). This differential diagnosis is based on the patient’s history of getting into sexual liaisons, using her physical appearance to seek attention, like wearing revealing clothes and heavy makeup, and being obsessed with her self-image and her intimate relationships.

Reflections: If I were to redo the assessment, I would assess the patient for suicide risk owing to her history of self-harm behaviors. If I were to follow up on the patient, I would assess the patient’s risk for self-directed violence and other-directed violence. Besides, I would assess her coping strategies and for improvements in her self-image.

Case Formulation and Treatment Plan:

The patient presented with a marked instability in mood, affect, functioning, and interpersonal relationships.

Psychotherapy: Weekly Individual psychotherapy sessions, insight-oriented or supportive, based on the patient’s ego strength. This was recommended because it focuses on the patient’s deeper feelings and uses superficial drama as a defense mechanism (Leichsenring et al., 2024).

Psychopharmacologic agents: No medications were prescribed at this point since psychotherapy is the treatment of choice. There are no FDA-approved medications for BPD.

Alternative treatments: SSRIs like Zoloft if the patient has depression and somatic symptoms. Anxiolytics like Alprazolam for anxiety (Pascual et al., 2023).

Follow-up: Follow up in four weeks.

Referrals: Refer to a psychotherapist for counseling.

SDOH: BPD, similar to other mental health disorders, is linked with socioeconomic disadvantage. Kirkbride et al. (2024) explain that social stratification leads to disproportionate access to resources like wealth and knowledge. These resources help people avoid exposure and deal with harmful stressors that contribute to mental health disorders. Thus, the patient’s BPD could have been attributed to life stressors created by inadequate access to resources.

Health Promotion & Patient Education: The patient can be educated about the available support networks for persons with personality disorders, where she can learn to create effective social relationships (Leichsenring et al., 2024).

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

References

D’Huart, D., Seker, S., Bürgin, D., Birkhölzer, M., Boonmann, C., Schmid, M., Schmeck, K., & Bach, B. (2023). Key insights from studies on the stability of personality disorders in different age groups. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1109336

Kirkbride, J. B., Anglin, D. M., Colman, I., Dykxhoorn, J., Jones, P. B., Patalay, P., Pitman, A., Soneson, E., Steare, T., Wright, T., & Griffiths, S. L. (2024). The social determinants of mental health and disorder: evidence, prevention, and recommendations. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 23(1), 58–90. https://doi.org/10.1002/wps.21160

Leichsenring, F., Fonagy, P., Heim, N., Kernberg, O. F., Leweke, F., Luyten, P., Salzer, S., Spitzer, C., & Steinert, C. (2024). Borderline personality disorder: A comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry, 23(1), 4-25. https://doi.org/10.1002/wps.21156

Mishra, S., Rawekar, A., & Sapkale, B. (2023). A comprehensive literature review of borderline personality disorder: Unraveling complexity from diagnosis to treatment. Cureus. https://doi.org/10.7759/cureus.49293

Pascual, J. C., Arias, L., & Soler, J. (2023). Pharmacological management of borderline personality disorder and common comorbidities. CNS Drugs, 37(6), 489-497. https://doi.org/10.1007/s40263-023-01015-6

Williams, O. C., Prasad, S., McCrary, A., Jordan, E., Sachdeva, V., Deva, S., … & Gupta, A. (2023). Adult attention deficit hyperactivity disorder: a comprehensive review. Annals of Medicine and Surgery, 85(5), 1802-1810. https://doi.org/10.1097/MS9.0000000000000631

Sample Answer 2 for PRAC 6665 Assignment 2: Focused SOAP Note and Patient Case Presentation

Patient Information:

Initials: D.B

Ages: 16 years old

Gender: Female

Subjective:

CC (chief complaint): Psychiatric evaluation- Addiction to heroin

HPI: D.B is a 16-year-old female patient who came to the clinic accompanied by her mother with a chief complaint of heroin addiction. She has been taking heroin for the past 2 years, 10-14 stamp bags daily. The patient was recommended to rehab, but she refused. She confirms low self-esteem, low self-worth, depression, hopelessness, helpless and poor insight. She has a history of sexual abuse by her uncle from the age of 5 to 12 years. She started taking marijuana to counter the experience, then pain pills before she started taking heroin. She confirms having self-injurious behavior like cutting herself, with a history of PTSD. She also sells sex for drugs and is positive for hep C test. The mother is an alcoholic, while the father died at the age of 30 years from an opioid overdose.

Substance Current Use: Two years active user of heroin, 10-14 stamp bags per day. The patient has a history of marijuana and pain pills. She denies the use of alcohol or any other drug of abuse. She has a history of sexual abuse by her uncle, from the age of 5 to 12 years. She sells sex for drugs, with a history of self-injurious activities and PTSD.

Family History of Substance Use: Her mother is an alcoholic, and has been in and out of rehab a couple of times. Father died at the age of 30 from an opioid overdose.

Medical History: PTSD and self-injurious behaviors

Current Medications: None
Allergies: No known drug, food, or environmental allergies.

Reproductive Hx: Regular menstrual cycles. Sexually active, and even sells sex for drugs. Positive for Hep C test.

ROS:

GENERAL: Appears well-groomed in age-appropriate clothes. No changes recent changes in body weight, fever, fatigue, or chills.
HEENT: Head: No headache, trauma, or changes in hair distribution. Eyes: No double vision, excessive tearing, discharge, itchiness, or history of visual disorders. Ears: No pain, discharge, itchiness, tinnitus, or hearing problems. Nose: No congestions, running nose, or inflammation. Mouth/Throat: No bleeding gums, toothache, sore throat, or difficulties in swallowing.
SKIN: warm with no rashes, bruises, eczema, lumps, or adenopathy.
CARDIOVASCULAR: No chest pressure, pain, heart murmurs, or cyanosis.
RESPIRATORY: No chest discomfort, breathing problems, cough, sneezing, or wheezing.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation, changes in bowel movement, or hernia.
GENITOURINARY: No changes in urine frequency, dysuria, polyuria, or pyuria. No abnormal discharge or painful sex.
NEUROLOGICAL: No ataxia, headache, dizziness, or paresthesia.
MUSCULOSKELETAL: No muscle or joint pain.
HEMATOLOGIC: No history of nose bleeding, anemia, or any other blood disorder.
LYMPHATICS: No history of splenectomy or lymphadenopathy.
ENDOCRINOLOGIC: No polyphagia, disturbances in growth, or history of thyroid disease.

Objective:

Diagnostic results: Positive for Hep C test. As a result of sexual behavior, it is necessary to order HIV and STD tests. Urine drug tests are necessary if the patient is taking any other drugs apart from the ones mentioned. Other routine tests include complete blood count, lipid profile tests, liver function tests, and A1C tests (Elman, & Borsook, 2019). X-ray and CT scan of the head are necessary to rule out physical trauma as the reason behind the patient’s symptoms. Other screening tools that were utilized include SPRINT, SPAN, and trauma screening questionnaire (TSQ) among others.

Assessment:

Mental Status Examination: The patient is well-groomed in age-appropriate clothes. She is well oriented in person, place, and time. She has a sad facial expression. She avoids eye contact and gazes around the room when talking about something that makes her uncomfortable like being sexually abused by her uncle. Her thought process is intact and answers questions in a quite tremulous speech. She confirms the feeling of worthless, helplessness, hopeless and low self-esteem (Elman, & Borsook, 2019). She displays poor insight and confirms a history of PTSD and self-injurious behaviors. She however denies hallucination or suicidal ideation.

Differential Diagnosis:

Substance Use Disorder/PTSD: The patient in the provided case study is most likely suffering from PTSD and SUD. She has a previous history of PTSD diagnosis, as a result of being sexually abused by her uncle. She currently confirms taking IV heroin, for the past two years. According to the DSM-5 diagnostic criteria, a patient can be diagnosed with SUD when they display impaired control, social problems, risky use, and physical disturbance as a result of drug use (Hassan et al., 2017).
Substance-Induced Depressive Disorder: This disorder is characterized by persistent depression which results from substance intoxication or withdrawal. According to DSM-V, a patient can qualify for this diagnosis when they display prominent and persistent mood disturbance which presents with markedly diminished interest in physical activities or things that were interesting before (Elman, & Borsook, 2019). The patient complained of depression and feeling worthless, and lack of interest.
Major Depressive Disorder (MDD): This disorder is characterized by a persistent feeling of sadness and loss of interest in routine daily activities. According to DSM-V diagnostic criteria, a patient must present at least five of the following symptoms for more than two weeks to qualify for MDD diagnosis, depressed mood, diminished interest, sleep disturbances, significant recent weight changes, loss of energy, and worthless feeling (Hassan et al., 2017). The patient displayed most of these symptoms.

Reflections: The information gathered by the PMHNP is quite limited in making appropriate diagnoses and formulating the most appropriate treatment plan for the patient. However, it is quite evident that the patient is suffering from PTSD and substance use disorder. The clinician thus has to find more information regarding past psychotropic agents used by the patient and their effectiveness (Back et al., 2019). Consequently, it is important to inform the child service protection about the case of the patient such as her mother being an alcoholic and living with her abusive uncle whenever her mother was in rehab.

Case Formulation and Treatment Plan:

Pharmacological Intervention: Initiate SC injection (Sublocade) monthly for heroin addiction (Back et al., 2019). For management of PTSD symptoms, start the patient on sertraline (Zoloft) 25mg/day, which may be increased by 25 mg weekly, to a maximum dose of 200mg/day depending on the treatment outcome.

Non-Pharmacological Intervention: Detoxification, and group therapy since the patient denied the idea of rehab (Williams et al., 2020). Alternative therapy includes self-help groups and cognitive behavioral therapy.

Health Promotion: Engage in physical activity to promote your energy levels and avoid idleness, to reduce craving. Seep adequately with a well-balanced diet.

Patient Education: The patient must exhibit high compliance for positive treatment outcomes (Williams et al., 2020).

Follow-up: The patient should report back for treatment evaluation and adjustments after every four weeks.

References

Hassan, A. N., Le Foll, B., Imtiaz, S., & Rehm, J. (2017). The effect of post-traumatic stress disorder on the risk of developing prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. Drug and alcohol dependence, 179, 260-266. https://doi.org/10.1016/j.drugalcdep.2017.07.012

Back, S. E., Killeen, T., Badour, C. L., Flanagan, J. C., Allan, N. P., Santa Ana, E., … & Brady, K. T. (2019). Concurrent treatment of substance use disorders and PTSD using prolonged exposure: a randomized clinical trial in military veterans. Addictive behaviors, 90, 369-377. https://doi.org/10.1016/j.addbeh.2018.11.032

Elman, I., & Borsook, D. (2019). The failing cascade: comorbid post-traumatic stress and opioid use disorders. Neuroscience & Biobehavioral Reviews, 103, 374-383. https://doi.org/10.1016/j.neubiorev.2019.04.023

Williams, J. R., Cole, V., Girdler, S., & Cromeens, M. G. (2020). Exploring stress, cognitive, and affective mechanisms of the relationship between interpersonal trauma and opioid misuse. PloS one, 15(5), e0233185. https://doi.org/10.1371/journal.pone.0233185