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Assignment 2: Assessing Clients Practicum
Learning Objectives
Students will:
Assess clients presenting for psychotherapy
Develop genograms for clients presenting for psychotherapy
To prepare:
Select a client whom you have observed or counseled at your practicum site.
Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.
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The Assignment
Part 1: Comprehensive Client Family Assessment
With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):
Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse/trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan
Part 2: Family Genogram
Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).
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Practicum Journal Entry
Children are brought by their parents to the clinic with complaints that seems to be straightforward, with most being treated appropriately. However, as advanced nurse practitioner, I am faced by the responsibility to ensure that the patient is diagnosed correctly and the disease is managed effectively. However, making of correct diagnosis can be elusive and in most cases, it will require the APN to carefully consider the possible differentials as well as identifying the most appropriate strategy to manage the problem (Burn et al., 2013).
During the practicum, a 9 year old boy of Hispanic origin reported to the clinic with sore throat and higher fever (1030F), malaise headache and general body weakness. The patient Lymph nodes were swollen. The patient had attended a local clinic where she was diagnosed with streptococcal pharyngitis and was administered with Omnicef 14 mg/kg/day. However the patient condition worsened after 3 days, and the mother was concerned that the child could be suffering from something else (Murray & Chennupati, 2012).
Practicum Journal Entry
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To identify the core area of the child current situation, I employed helpful tool of the pneumonic NEEDS. NEEDS is an acronym that stands for Nutrition, Elimination, Environment/Education, Daycare/ Development and Sleep/ Sexuality (Murray & Chennupati, 2012). In this context, nutritionally, the patient reported difficulty in swallowing but was able to drink cool liquids. The patient elimination was normal as she voided normal stool at least four times a day.
The assessment of the patient education and environment indicated that the patient was doing fine, and that she had not been exposed to sick friends or family friends. The patient general care was good and was involved in Drama club, although the patient missed practice this week. Patient rest is adequate as the she sleeps approximately for 9 hours a night, but have been sleeping for more than 12 hours since the onset of the disease. The patient reported that she had ensured medication adherence, and denied presence of persistent illness in the past (Murray & Chennupati, 2012).
In some cases, when making differential diagnoses, there could be loop holes that can make diagnoses be missed. In this case, specific and sensitive diagnostic tests should be done to facilitate accuracy, cost and precision. In this case, the poor response to antibiotics and patient clinical manifestation of persistent fever, fatigue, tonsillitis and lymphadenopathy made me consider presence of other infections such as infectious mononucleosis (IM). Other differential diagnoses that were considered included acute leukaemia, tumours of the neck, Hodgkin’s disease. Allergies are also associated with throat pain and pharyngeal tickling (Thompson, 2015).
Practicum Journal Entry
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I conducted patient physical examination, where the patient weight, Bp, BMI and height were on the 50th percentile for the patient. The remarkable physical observations were +3 erythematous tonsils that had no exudate. Tonsillar nodes were swollen. The nodes were tender and soft. Patient chest was clear and the heart sounds were normal. All other systems were reviewed and were intact. The laboratory findings were positive for IM (Burn et al., 2013).
However, the diagnosis process posed some challenges. This is because I relied in the initial impression of the clinical diagnostic, and had failed to reconsider the new data obtained during the revaluation. This is because my confidence was low, and was not keen to work with the results that I had gathered from patient assessment. It took the intervention of my preceptor, who helped me reconsider the new data gathered to frame the diagnostic options. My preceptor cautioned against this behaviour. I was also warned about premature closure, where the APN may prematurely close other potential diagnostic possibilities (Thorburn, 2010).
The final diagnosis was IM; however, there is no direct treatment for this disease. The treatment plan was to control patient clinical manifestation. This includes controlling patient fever; maintain patient body hydrated, adequate rest, and the treatment of secondary infections. Treatment is symptom based. The patient was given antipyretics to manage the patient fever. The patient was advised to be in light clothes to facilitate the dissipation of heat.
Practicum Journal Entry
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Appropriate foods as well as liquids were suggested to the mother so as to avoid irritation of the throat. This was done putting consideration of cultural sensitivity to ensure that the food selected would be tolerated by the family. I did not see the need for the patient to continue with Omnicef, but my preceptor advised that group A streptococcus is a secondary infection for patients diagnosed with IM, so the patient should continue with the mediation (Murray & Chennupati, 2012).
As an APN, it was my responsibility to educate the family about the disease, causes, symptomatic and treatment. I educated the patient on importance of finishing the dosage for fever and to avoid use of multiple blankets. The patient is taught the benefits of completing medication to manage the secondary bacterial infections even if it fails to make other clinical manifestation such as sore throat, fatigue and fever to disappear. The benefits of hydration were also monitored (Burn et al., 2013).
References
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care(5th ed.). Philadelphia, PA: Elsevier.
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STIs Practicum Journal Entry
This practicum is one of the most fascinating experiences in my clinical practice. Dealing with patients diagnosed with sexually transmitted infections (STIs) is challenging as most of the patient are hesitant to talk openly to a nurse or doctor about their experiences, which makes it challenging during clinical decision making processes (American Congress of Obstetricians and Gynaecologists, 2011).
Mrs. Kate (pseudo name) a 21 year old college student presented to the clinic with complaints of itchiness around her genitalia, sharp burning sensation during sexual intercourse and had noted whitish discharge that had foul smell. From the clinical manifestation, I gathered that the patient is suffering from an infection, which could be either sexually transmitted infections (STIs) or urinary tract infections (UTIs). There is a thin line that separated the two, which indicated the need for further laboratory test.
According to Centre for disease control and prevention (CDC), UTIs and STIs clinical manifestations are non-specific and are a common to problem for females. This highlights the likelihood of misdiagnosis. The common clinical manifestation for the urogenital diseases includes a burning sensation during urination, vaginal discharges and pelvic pain. However, in UTIs infection, vaginal discharge with awful smell is normally absent. The patient with urinary tract infection tends to have fever. A pelvic exam, urine culture and vaginal culture results indicate that the patient had yeast vaginal infection (CDC, 2013).
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One of the challenges experienced during this practicum was during sexual history assessment. Initially, the patient was hesitant to disclose the information because it is a taboo and also she believed that disclosing this information would victimize her. After reinforcing the issue of confidentiality, the patient became relaxed and disclosed the sensitive information.
The sexual history assessment was done using the general guide of the ‘5 Ps.’ This included the number of sex partners, the type of sexual activity, the rates of use of protection, and use of contraceptives. This helped me understand the patient literacy and perspectives about UTI (Schuiling and Likis, 2013).
The patients seemed somewhat distressed when I gave her the diagnosis results. However, she was cooperative all through the care plan. The patient was advised to have regular check up with the gynaecologists. This is because sexually transmitted infections (STIs) have short and long term impacts that can be life threatening. The short term impacts include emotional disturbances due to physical changes.
The long term effects include genital sores, inflammation, infertility issues and pelvic inflammatory reactions. Fortunately, genital yeast infections like other sexually transmitted infections (STIs) is manageable if diagnosed early and proper medication regimen is provided (CDC, 2013).
The patient had tried to manage the itchiness and pain using Tylenol (OTC) and vaginal cream, which yielded little success. The patient was given fluconazole 150 mg and Terconazole 80 mg both orally administered one suppository/day for at least 3 days. The medication ensured that the patient did not get recurrent infection. The patient was encouraged to observe hygiene and practice abstinence during the medication regimen. Other hygiene measures such as mutual monogamy, abstinence and avoid of douching practices.
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This practicum was very enlightening, especially on ways to practice cultural competency. I noticed that sexually transmitted infections (STIs) education focuses in specific information on signs and symptoms which seems to be the worst case scenarios and a taboo to most of the community.
The only down to earth guidance is abstinence and use of condom. If not handled with care, the interaction with the patient could affect patient psychosocial status. I have learnt a lot from this practicum and will use the knowledge to help other patients to identify risk factors and practice preventive measures (Schuiling and Likis, 2013).
References
American Congress of Obstetricians and Gynecologists. (2011). Guideline for adolescent health care (2nd ed.). Retrieved from http://www.acog.org
Centers for Disease Control and Prevention (CDC). (2013). Incidence, prevalence, and cost of sexually transmitted infections in the United States. Retrieved from http://stacks.cdc.gov/view/cdc/13174
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.
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During this practicum, a 25 year old female presented to the healthcare facility with complains of severe cramp pain that occurs about one week before her menses, during the menstrual cycle and a week after the cycle ends. The patient complains that her menstrual cycles is irregular, and gets heavy periods with some clots. The patient reported to the clinic due to sharp pain that radiated from the chest. The patient had lived with this condition for 12 years. She has been managing the disease using alternative tradition medicines, which has not been effective.
Review of the system was conducted and laboratory tests were performed (urinalysis, urine culture, pregnancy test and wet prep). The differential diagnosis identified included amenorrhea, endometriosis, and ovarian cysts without explanation. Ovarian cysts were suspected due to presence of pelvic pain before the onset of period. However, this is not likely because the patient did not complain of fever and vomiting. Amenorrhea is suspected due to presence of pelvic pain. However, this is not likely as the key indicator of amenorrhea is absence of menses (Domino, Baldor, Golding, 2014).
To make a definitive diagnosis physical test was performed. Under the supervision of my preceptor, I conducted a pelvic exam. This included palpating pelvis areas to check abnormalities such as cysts and scars. The pelvic exam was negative. An ultrasound was requested to capture the image of the reproductive organs. The results indicated that the patient was suffering from endometriosis (American Congress of Obstetricians and Gynaecologists, 2011).
Treatment made included pain relive medication to help manage the painful cramps. The patient was also given Lo Loestrin Fe which has been found to be effective in management of pain. The increase and decrease of hormones during the menstrual cycle makes the endometrial implants to thicken.
Using this hormone therapy, it slows down the growth which prevents the implantation of the endometrial tissue. However, the patient was educated that although these medications manage the pain, they are not a permanent fix for this health complication. The symptoms can reoccur after stopping the treatment (CDC, 2013).
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The patient was also advised on ways to manage pain using home remedies. This includes the use of heating pad to relax the pelvic muscles, which helps in reducing pain. OTC non-steroidal anti-inflammatory drugs such as Motrin IB. The patient is advised to eat health and exercise regularly as it helps improve the pain (Buttaro et al., 2013).
During this practicum, I have learnt that issue of endometriosis is poorly understood in the society. This is probably because of the common myth of “etiquette menstruation” where the society believes that menstruation is a private affair and must not be discussed in public. Most of women conceal their suffering, which makes them to suffer in silence. As advanced nurse practitioner, it is our responsibility to raise awareness on endometriosis to encourage the affected persons to speak up, and seek medication early (CDC, 2013).
During the research, I also realized the common modalities between ovary cysts, amenorrhea and endometriosis. This includes the similarity in the clinical manifestation, test and diagnosis procedures and treatment. In these three reproductive systems disorders, they are clinically manifested by presence of pelvic pain before the onset and after menstrual cycle.
The test diagnosis of these disorders includes ultrasound, Pregnancy tests, urinalysis and urine culture. In management of the disease, most of them are managed using OTC pain killers, hormone therapy or invasive methods. Therefore, I need to research more on these reproductive disorders to ensure that I deliver effective care when serving the affected community (American Congress of Obstetricians and Gynecologists, 2011).
References
American Congress of Obstetricians and Gynecologists. (2011). Guideline for adolescent health care (2nd ed.). Retrieved from http://www.acog.org
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary Care, 4th Edition. Philadelphia, PA: Lippincott Williams & Wilkins.
Centers for Disease Control and Prevention (CDC). (2013). Incidence, prevalence, and cost of sexually transmitted infections in the United States. Retrieved from http://stacks.cdc.gov/view/cdc/13174
Domino, F. J.; Baldor, R.A.; Golding, J (Ed.). (2014). The 5-minute clinical consult standard 2015 (23rd ed, Kindle Edition). Philadelphia, PA: Lippincott Williams & Wilkins.
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Sexually Transmitted Infections
This practicum is one of the most fascinating experiences in my clinical practice. Dealing with patients diagnosed with sexually transmitted infections (STIs) is challenging as most of the patient are hesitant to talk openly to a nurse or doctor about their experiences, which makes it challenging during clinical decision making processes (American Congress of Obstetricians and Gynaecologists, 2011).
Mrs. Kate (pseudo name) a 21 year old college student presented to the clinic with complaints of itchiness around her genitalia, sharp burning sensation during sexual intercourse and had noted whitish discharge that had foul smell. From the clinical manifestation, I gathered that the patient is suffering from an infection, which could be either sexually transmitted infections (STIs) or urinary tract infections (UTIs). There is a thin line that separated the two, which indicated the need for further laboratory test.
According to Centre for disease control and prevention (CDC), UTIs and STIs clinical manifestations are non-specific and are a common to problem for females. This highlights the likelihood of misdiagnosis. The common clinical manifestation for the urogenital diseases includes a burning sensation during urination, vaginal discharges and pelvic pain. However, in UTIs infection, vaginal discharge with awful smell is normally absent. The patient with urinary tract infection tends to have fever. A pelvic exam, urine culture and vaginal culture results indicate that the patient had yeast vaginal infection (CDC, 2013).
Want help to write your Essay or Assignments? Click here
One of the challenges experienced during this practicum was during sexual history assessment. Initially, the patient was hesitant to disclose the information because it is a taboo and also she believed that disclosing this information would victimize her. After reinforcing the issue of confidentiality, the patient became relaxed and disclosed the sensitive information.
The sexual history assessment was done using the general guide of the ‘5 Ps.’ This included the number of sex partners, the type of sexual activity, the rates of use of protection, and use of contraceptives. This helped me understand the patient literacy and perspectives about UTI (Schuiling and Likis, 2013).
The patients seemed somewhat distressed when I gave her the diagnosis results. However, she was cooperative all through the care plan. The patient was advised to have regular check up with the gynaecologists. This is because sexually transmitted infections (STIs) have short and long term impacts that can be life threatening. The short term impacts include emotional disturbances due to physical changes.
The long term effects include genital sores, inflammation, infertility issues and pelvic inflammatory reactions. Fortunately, genital yeast infections like other sexually transmitted infections (STIs) is manageable if diagnosed early and proper medication regimen is provided (CDC, 2013).
The patient had tried to manage the itchiness and pain using Tylenol (OTC) and vaginal cream, which yielded little success. The patient was given fluconazole 150 mg and Terconazole 80 mg both orally administered one suppository/day for at least 3 days. The medication ensured that the patient did not get recurrent infection. The patient was encouraged to observe hygiene and practice abstinence during the medication regimen. Other hygiene measures such as mutual monogamy, abstinence and avoid of douching practices.
Want help to write your Essay or Assignments? Click here
This practicum was very enlightening, especially on ways to practice cultural competency. I noticed that sexually transmitted infections (STIs) education focuses in specific information on signs and symptoms which seems to be the worst case scenarios and a taboo to most of the community.
The only down to earth guidance is abstinence and use of condom. If not handled with care, the interaction with the patient could affect patient psychosocial status. I have learnt a lot from this practicum and will use the knowledge to help other patients to identify risk factors and practice preventive measures (Schuiling and Likis, 2013).
References
American Congress of Obstetricians and Gynecologists. (2011). Guideline for adolescent health care (2nd ed.). Retrieved from http://www.acog.org
Centers for Disease Control and Prevention (CDC). (2013). Incidence, prevalence, and cost of sexually transmitted infections in the United States. Retrieved from http://stacks.cdc.gov/view/cdc/13174
Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones and Bartlett Publishers.
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Amenorrhea Practicum Journal Entry
During this practicum, a 25 year old female presented to the healthcare facility with complains of severe cramp pain that occurs about one week before her menses, during the menstrual cycle and a week after the cycle ends. The patient complains that her menstrual cycles is irregular, and gets heavy periods with some clots. The patient reported to the clinic due to sharp pain that radiated from the chest. The patient had lived with this condition for 12 years. She has been managing the disease using alternative tradition medicines, which has not been effective.
Review of the system was conducted and laboratory tests were performed (urinalysis, urine culture, pregnancy test and wet prep). The differential diagnosis identified included amenorrhea, endometriosis, and ovarian cysts without explanation. Ovarian cysts were suspected due to presence of pelvic pain before the onset of period. However, this is not likely because the patient did not complain of fever and vomiting. Amenorrhea is suspected due to presence of pelvic pain. However, this is not likely as the key indicator of amenorrhea is absence of menses (Domino, Baldor, Golding, 2014).
To make a definitive diagnosis physical test was performed. Under the supervision of my preceptor, I conducted a pelvic exam. This included palpating pelvis areas to check abnormalities such as cysts and scars. The pelvic exam was negative. An ultrasound was requested to capture the image of the reproductive organs. The results indicated that the patient was suffering from endometriosis (American Congress of Obstetricians and Gynaecologists, 2011).
Treatment made included pain relive medication to help manage the painful cramps. The patient was also given Lo Loestrin Fe which has been found to be effective in management of pain. The increase and decrease of hormones during the menstrual cycle makes the endometrial implants to thicken.
Using this hormone therapy, it slows down the growth which prevents the implantation of the endometrial tissue. However, the patient was educated that although these medications manage the pain, they are not a permanent fix for this health complication. The symptoms can reoccur after stopping the treatment (CDC, 2013).
Want help to write your Essay or Assignments? Click here
The patient was also advised on ways to manage pain using home remedies. This includes the use of heating pad to relax the pelvic muscles, which helps in reducing pain. OTC non-steroidal anti-inflammatory drugs such as Motrin IB. The patient is advised to eat health and exercise regularly as it helps improve the pain (Buttaro et al., 2013).
During this practicum, I have learnt that issue of endometriosis is poorly understood in the society. This is probably because of the common myth of “etiquette menstruation” where the society believes that menstruation is a private affair and must not be discussed in public. Most of women conceal their suffering, which makes them to suffer in silence. As advanced nurse practitioner, it is our responsibility to raise awareness on endometriosis to encourage the affected persons to speak up, and seek medication early (CDC, 2013).
During the research, I also realized the common modalities between ovary cysts, amenorrhea and endometriosis. This includes the similarity in the clinical manifestation, test and diagnosis procedures and treatment. In these three reproductive systems disorders, they are clinically manifested by presence of pelvic pain before the onset and after menstrual cycle.
The test diagnosis of these disorders includes ultrasound, Pregnancy tests, urinalysis and urine culture. In management of the disease, most of them are managed using OTC pain killers, hormone therapy or invasive methods. Therefore, I need to research more on these reproductive disorders to ensure that I deliver effective care when serving the affected community (American Congress of Obstetricians and Gynecologists, 2011).
References
American Congress of Obstetricians and Gynecologists. (2011). Guideline for adolescent health care (2nd ed.). Retrieved from http://www.acog.org
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary Care, 4th Edition. Philadelphia, PA: Lippincott Williams & Wilkins.
Centers for Disease Control and Prevention (CDC). (2013). Incidence, prevalence, and cost of sexually transmitted infections in the United States. Retrieved from http://stacks.cdc.gov/view/cdc/13174
Domino, F. J.; Baldor, R.A.; Golding, J (Ed.). (2014). The 5-minute clinical consult standard 2015 (23rd ed, Kindle Edition). Philadelphia, PA: Lippincott Williams & Wilkins.
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Gastrointestinal disorders
Various gastrointestinal disorders may present with similar symptoms which may make the diagnosis difficult especially when the information provided in the patient history is not sufficient. In the case study presented, the patient presents with the symptoms of weight loss, anorexia, epigastric tenderness, and chronic heartburn. From the information garnered from the patient history, the risk factors included the use of NSAIDS and smoking.
Apart from peptic ulcer disease, gastroesophageal reflux disease, and gastric cancer, the differential diagnosis would include other conditions such as abdominal pain syndrome as well as dyspepsia (Agarwal & Mayer, 2013). The definite diagnosis is difficult to make since the patient did not provide sufficient information regarding the disorder.
For instance, the health care professional ought to ask the patient of the history of the occurrence of such a condition in members of the immediate family so as to rule out any genetic predisposition to the disorder (Agarwal & Mayer, 2013). Also, it would have been important if the patient was asked about having taken opioids or any other related drugs (Talley & Ford, 2015).
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Again it is important that various tests such as imaging tests be taken on the patients to assist in making the definitive diagnosis (Talley & Ford, 2015). Some further tests that should have been done include virtual colonoscopy and computed tomography to examine the patient intensively for any conditions that could have been causing the disorder. Also, magnetic resonance imaging could also have been used to rule out the possibility of the patient having any malignancies within the gastrointestinal system (Agarwal & Mayer, 2013).
More so it is recommended that endoscopy is conducted on the patient to determine or rule out the occurrence of peptic ulcer disease (Talley & Ford, 2015). Additionally, blood tests should be carried out on the patients to determine if they are suffering from the narcotic bowel syndrome.
References
Agarwal, S., & Mayer, L. (2013). Diagnosis and treatment of gastrointestinal disorders in patients with primary immunodeficiency. Clinical Gastroenterology and Hepatology, 11(9), 1050-1063.
