NRNP PRAC 6635 Week 8: Assessing & Diagnosing Patients with Substance-Related & Addictive Disorders

NRNP PRAC 6635 Week 8: Assessing & Diagnosing Patients with Substance-Related & Addictive Disorders

NRNP PRAC 6635 Week 8: Assessing & Diagnosing Patients with Substance-Related & Addictive Disorders

Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
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.

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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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Assessing & Diagnosing Patients with Substance-Related & Addictive Disorders

Subjective:

CC (chief complaint): The client has been referred for complaints of excessive drinking of alcohol that is interfering with her occupational duties as a teacher. She is dysfunctional with complaints from parents nd students that she comes and sleeps in the classroom. 

HPI: The client is a 48 year-old female of Caucasian descent who presents with a history of excessive etoh consumption. She narrates a previous history of etoh taking as well as accets a family history of the same in her father. The onset of the symptoms was in her early adulthood and all is located in her mind as she feels that for her to cope with her daily stresses she has to drink alcohol. The duration of the symptoms has been more than one year (12 months) and they are characteristically persisietnt and compulsive in nature. They are aggravated by solitude but somewhat alleviated by physical activity. The timing of the symptoms is mostly in the evenings whereby she sleeps drunk and wakes up still under the influence. She rates the severity of her symptoms at 7/10. 

Past Psychiatric History:

• General Statement: She has a history of alcohol consumption but has never been treated for alcohol dependence.
• Caregivers (if applicable): She can take care of herself and does not need any caregivers.
• Hospitalizations: She has never been hospitalized for alcohol treatment or any other psychiatric illness.
• Medication trials: No medication has been attempeted to treat her alcohol dependence.
• Psychotherapy or Previous Psychiatric Diagnosis: She has never been diagnosed with a psychiatric condition or given any form of psychotherapy.

Substance Current Use and History: She admits to current excessive etoh consumption and has a past history of using the same too. She started in her teenage years and the habit continued into her freshman years. She denies the use of any other substances.  

Family Psychiatric/Substance Use History: There is no significant family history of psychiatric illnesses or substance use except for her father. He was an alcoholic who ended up requiring treatment and joned te self-help 12 step group Alcoholic Anonymous or AA (Capuzzi & Stauffer, 2016). He ended up being sober after the AA meetings.

Psychosocial History: The client is an only child brought up by both parents. She is well learned and has a PhD in Biology as well as a masters in  high school education. She is not married but has many friends with whom she frequently goes out to drink. She does not reveak anuy other activity that she is fond of doing in her free time.

Medical History:

• Current Medications: She is not on any current medication.
• Allergies: She denies having any known allergies.

• Reproductive Hx: She states that she is heterosexual but des not have any children.

ROS:

• GENERAL: Denies fatigue, fever, malaise, or weight loss.
• HEENT: Denies photophobia, double vision, otorrhea, tinnitus, rhinorrhea, sneezing, or sore throat.
• SKIN: Negative for urticaria, pruritus, eczema, or rashes.
• CARDIOVASCULAR: Denies chest pains or discomfort as well as palpitations.
• RESPIRATORY: Denies difficulty in breathing, coughing, or producing sputum.
• GASTROINTESTINAL: Negative for diarrhea, nausea, vomiting, or a change in bowel movements.
• GENITOURINARY: Denies excessive urination, burning sensation, or suprapubic pain.
• NEUROLOGICAL: Denies feeling pins and needles in the extremities, weakness, syncope, dizziness, or loss of bladder/ bowel control.
• MUSCULOSKELETAL: Negative for arthralgia, myalgia, and joint stiffness.
• HEMATOLOGIC: Negtive for blood disorders as well as clotting disorders.
• LYMPHATICS: Denies having lymphadenopathy or a history of havng spelenectomy.
• ENDOCRINOLOGIC: She is negative for excessive sweating, thirst, or water intake. She denies previous hormonal therapy.

Objective:

Physical exam: All he laboratory tests and physical examination findings show no abnormalities.

Diagnostic results: Normal chest radiograph. WBC 6.3 x 10⁹; Hb 13.8 g/dL.

Assessment:

Mental Status Examination: The client is a 48 year-old Caucasian female who appears well dressed for the occasion and time of the day. She is well-groomed and does not appear unkempt. Her speech sounds coherent and it is also goal-oriented. She is alert and oriented in place, space, person, time, and event. She is cooperative with the interviewer and maintains good eye contact throughout.  No mannerisms or tics could be observed. She reprted her mood as “fantastic” but her affect was observed to be dysphoric denoting incongruence. There were no obvious hallucinations or delusions noted. There was also no homicidal or suicidal ideation noted. Her insight was good as well as her judgment. The diagnosis that was made was alcohol use disorder or AUD (APA, 2013; Sadock et al., 2015). The diagnostic code for this in the DSM-5 is 303.90 (F10.20). 

Differential Diagnoses

1. 303.90 (F10.20) Alcohol Use Disorder (AUD): This client fulfills most of the DSM-5 diagnostic criteria for the diagnosis of this disorder. For instance, she feels an irresistible urge to take alcohol even when she knows that it will affect her performance at work. She also cannot bring herself to stop taking alcohol even when she tries to. She takes the alcohol in increasingly larger quantities than she intetnded to and has become dependent on it. Any attempts at stopping elicit withdrawal symptoms on her part. These are important diagnostic criteria for AUD and she meets all of them (APA, 2013; Sadock et al., 2015).
2. 296.22 (F32.1) Major Depressive Disorder (MDD): This client also fulfills some of the DSM-5 diagnostic criteria for MDD in that she may be consuming alcohol as a result of her melancholy mood, which she experiences practically every day. She is powerless, melancholy, and dejected, and she has lost her ability to enjoy pleasure activities. Taking etoh is the only method to get rid of these feelings and forget about them. Her sleeping patterns have clearly been interrupted (which explains why she sleeps in class), and she isolates herself. As a result, she has become dysfunctional in the areas of self-care, employment, and interpersonal connection (APA, 2013; Sadock et al., 2015). According to the American Psychiatric Association (APA, 2013), MDD is known to co-exist together with AUD and so it is not far-fetched to say that MDD is a viable differential diagnosis.

• 296.52 (F31.32) Bipolar Disorder: Bipolar mania is marked by a period of continual heightened arousal. These symptoms include distractibility, sleeplessness, and inflated self-esteem. Irresponsible activities such as unlimited alcohol use and immorality can be engaged in during the manic phase. The mood disorder, which is not caused by drug addiction or any medical condition, causes significant dysfunction (APA, 2013; Sadock et al., 2015). This is therefore another possible differential diagnosis for the 48 year-old teacher.

Reflections: I did the assessment of this client as per laid down recommendations for initial psycgiatric interviews (Carlat, 2017). If given another chance I would still do the same. Informed consent was obtained and the client consulted in her care. This is respect for autonomy as a buoethical principle (Haswell, 2019). The choice of quseions and general assessment was meant to strengthen her resolve and not to make her feel inadequate. This is beneficence and nonmaleficence together. Health education was given and the clint advised to take up the offer of group cognitibe behavioral therapy or CBT for cognitive restructuring (Corey, 2017). She was also asked to joing the local chapter of the Alcoholics Anonymous (AA) that is a self-help group based on the 12-step approach (Smith, 2015). These modalities would help her regain functionality and become sober in the long run.

References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Capuzzi, D., & Stauffer, M.D. (2016). Foundations of addictions counseling, 3rd ed. Pearson Education Inc.

Carlat, D.J. (2017). The psychiatric interview, 4^th ed. Wolters Kluwer. 

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Smith, R.L. (2015). Treatment strategies for substance and process addictions. American Counseling Association.