Practicum – Week 1 Journal Entry

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Practicum Placement Agency’s Name: Ascension Genesys Regional Medical Center

Preceptor’s Name:

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WeekDatesTimesTotal Hours for This Time FrameActivities/CommentsLearning Objective(s) Addressed
12/269:30-10:4040 Mins Counseling session with 53 y/o male dx w/ Depression. Pt admitted for chest pain and positive drug screen for cocaine, alcohol and marijuana. No hx of tx for depression. During therapy session, pt admitted to thoughts of suicidal idealization and financial hardship causing stress as pt is to be evicted for non-payment. Counseled pt on outpt tx centers and ongoing outpt therapy. Pt has no desire at this time to quit drinking, to attend therapy, or take medications. Will follow up with pt as he is still actively withdrawing from alcohol. Sitter in room for safety.Incorporated Eeickson’s Modeling and Role Modeling Theory that emphasizes unconditional acceptance, nurturance, and facilitation as the nurse helps the patient take steps toward a healthy lifestyle. Providing the patient with resources and information of for outpatient psychotherapy sessions, alcohol support groups and financial assistance gives the patient a sense of affiliated individuation. Continuation of therapy is necessary throughout hospital stay to build on this patient drive to be accepted and dependent on support systems. As of today, the patient continues to have basic needs unmet which leads to distress and progressed illness. Petiprin, A. (2016). Psychiatric and mental health nursing. Nursing Theory. Retrieved from http://www.nursing-theory.org/theories-and-models/erickson-modeling-and-role-modeling-theory
12/2610:50-11:3040 Mins Follow-up therapy with 72 y/o male dx with paranoid schizophrenia admitted to the hospital for acute renal failure r/t attempted suicide. Pt admits to not taking his antirejection meds from his renal transplant in 2007 in hopes that his kidneys will fail, and he will die. Pt believes aliens have abducted him and his family 20 yrs ago and by dying is the only escape from them. He believes that the aliens are trying to kidnap him for sex trafficking. Pt also reports feeling hopeless and depressed. Therapy with redirection failed as pt is very paranoid of hospital staff at this time. He does not respond to internal stimuli during the interview and is reluctant to talk about the aliens in depth as he is afraid of being sent back to the psychiatric inpatient hospital. Pt is being maintained on Depakote 375 mg a day at HS, Zyprexa 10 mg at HS, and Seroquel 50 mg once daily at HS. Remeron 7.5mg once daily started to help with sleep and Zyprexa increased to 15mg daily. Will follow up tomorrow. 
12/2611:45-12:4560 Mins 58 y/o female dx w/ Bipolar II came in unresponsive from home. Conducted initial assessment and interview with pt. Noted hallucinations, delusions, and very paranoid. Pt was violent towards the nurse last night, grabbing her by the neck and pulling her to the ground. Pt home meds held that are sedating. Pt in 4-point restraints and being certed to inpatient psychiatric hospital. Restarted home dose of Seroquel XR 400mg at HS. Attempted to calm patient and reorient, but patient was very paranoid stating that staff are “poisoning her”. 
12/261:00-2:0060 Mins 56 y/o Follow up with pt that was admitted for AWA, Depression and needing to be screened for risk of suicide. Pt has depression and reports bursts of anger that he cannot control well. Suicide screen included questions such as “have you ever tried to hurt yourself?”, “have you ever thought of a plan?”, “has anyone in your family committed suicide?”, “do you feel hopeless?”, “do you feel like your life isn’t worth living?”. These questions have ruled the pt out for immediate risk for suicide. Sitter remains in room for one more day to monitor while home medications are restarted, and new medications have time to work. Therapy included utilization of the nursing theory Orlando’s Nursing Process Discipline, in which role of the nurse is to identify immediate needs for help (Petiprin, 2016). Started pt on 300mg of Seroquel daily at bedtime to help with mood. Will follow up with patient tomorrow.Orlando’s Nursing Process Discipline Theory was used to identify the patient who has cried out for help by attempting suicide at home. As pt is feeling helpless with his current health state, he remains depressed and it’s the nurse’s role to provide direct assistance to the patient’s avoidance of the feeling of helplessness. Petiprin, A. (2016). Psychiatric and mental health nursing. Nursing Theory. Retrieved from http://www.nursing-theory.org/theories-and-models/erickson-modeling-and-role-modeling-theory.php
12/2614:30-15:3060 Mins 53 y/o Admitted with Bipolar, Polysubstance Abuse and hx of domestic violence. Initial consult with pt conducted, assessment and interview completed. Pt reports her husband throwing her into a mirror, police being called and him having to leave. She stated that she had much to get done so she “took her friends Adderall, drank alcohol and took her home meds”. Pt has no suicidal idealizations, hallucinations or delusions. Offered domestic violence information and resources. Offered emotional support and encouragement. Pt also referred for outpatient psychiatric services for consistent therapy. Pt would not accept any DV information at this time and is in denial about her husband being abusive. Pt has hx of abuse in her family as her father was emotionally abusive growing up. Will continue to provide inpatient therapy while in the hospital and follow up outpt. Restarted home dose of Depakote, ordered a morning Depakote level and ammonia level. 
12/2615:50-16:4050 Mins 27 y/o Bipolar/ Homeless Initial assessment and intake session performed. Pt was very vulgar and inappropriate throughout session. Did not want to participate in interactive therapy. She did answer questions related to prior history and it is concluded that pt has diagnosis of Bipolar II. Will attempt therapy session daily while patient is admitted to the hospital. 
12/2617:00-17:3030 Mins83 y/o male admitted for UTI and Delirium. Pt has hx of dementia as well. Conducted a follow up assessment of patient’s condition after UTI has been treated and pt was treated for UTI and given Abilify 7.5mg once daily for delirium. Today pt remains confused and combative but hallucinations seem to be gone. Goal is for pt to be without a sitter or restraints, so he can be placed at a long-term care facility that specializes with dementia. 
12/277:00-7:3030 MinsFollowed up with 58 y/o female dx w/ Bipolar II that came in unresponsive from home. After initial assessment conducted yesterday and home dose of XR Seroquel restarted, pt was less aggressive today and not hallucinating. Pt was able to have restraints discontinued today and therapy was much more successful. Doctor signed the inpatient psych cert. Explored pt polysubstance abuse issues and learned that pt was sexually abused as a child leading to her using drugs at a young age as a coping mechanism. 
12/277:50-9:0080 Mins9 y/o male diagnosed with Psychosis/Autism. Initial assessment and intake information gathered. Counseling conducted with mother and outpt therapy suggested. Pt needing proper placement into school program designed for autism rather than defiant disorder. Play therapy conducted in the playroom in the pediatric unit. Therapy will be conducted daily while patient admitted to hospital. 
12/279:15- 10:0045 mins 53 y/o Followed up pt admitted with Bipolar, Polysubstance Abuse and hx of domestic violence. Conducted initial interview yesterday providing therapy, DV resources and restarting home dose of Depakote. Depakote level this morning was a good level of 18 and ammonia was normal. Depakote continued, and therapy conducted to focus on affiliated individualization. Pt has lost her drive to be accepted and basic needs are not being met. Therefore, providing awareness of patient’s individual uniqueness explores Erickson’s Modeling and Role Modeling Theory (Petiprin, 2016).Analyzed and applied Erickson’s Modeling and Role Modeling Theory
12/2710:20-11:3050 mins Conducted initial psychiatric consult with pt admitted for sepsis following a UTI. Pt is a 56 y/o Caucasian make that presented with hallucinations and paranoia. Pt was experiencing auditory hallucinations throughout interview where he would yell out at the wall. Pt would cry when redirected and realized that he was having such bad confusion. Pt is well known to clinic for MDD following multiple medical conditions including a stroke and decline in physical function. Therapy conducted with pt to regarding ongoing depression and redirection of confusion. Pt being maintained on Zyprexa, ability, Remeron HS for sleep and increase appetite.Two nursing theories utilized in therapy. When conducting any initial consult with a patient, King’s Theory of Goal Attainment is considered as it focuses on the interpersonal relationship of an individual’s goals and the specific factors influencing them. This theory also focuses on the specific steps of the nursing process such as assessment, diagnosis, planning, implementations, and evaluation, all included in the initial consult interview with the patient. As the nurse brings knowledge and skills regarding ways to overcome challenges leading to mental health illness, the patient has self-perception of problems and concerns. Together, the nurse and patient can distinguish unmet needs that are leading to distress and illness and come up with interventions that lead to goals being met. This theory that unmet needs lead to distress and illness and a patient need for drive, is based on Erickson’s Modeling and Role Modeling Theory.
12/2712:30-13:3060 minsDebrief with preceptor and reviewed different nursing theories that she typically uses when conducting therapy sessions with patients.Spoke with preceptor regarding the application of Solution-Focused Therapy within the hospital. Since the time in the hospital is acute and limited on time, it is important to reach a solution and begin patient healing process in a timely fashion. Therefore, this method of counseling is quick and to the point of care.
12/2812:10-12:4030 mis56 y/o Follow up with pt that was admitted for AWA, Alcohol withdraw has subsided and no reports of burst of anger today by pt or other nursing staff. Continued therapy session today with education on anti-depressant therapy along with outpt counseling. Pt is apprehensive of starting an anti-depressant but does find that speaking with our team has helped him “find himself”. He wants to continue taking the 300 mg of Seroquel at HS for his mood and states that this also has helped him get more adequate sleep. 
12/281:00-2:00pm60 minsFollow up with pt for therapy on recent suicide attempt. Pt was found with a rope by his mother and was admitted to the hospital for MDD and attempted suicide. After counseling with pt, it was learned that pt is having a very difficult time dealing w/ his multiple physical dx’s including hernia repairs and obstructed bowels. Pt is now unable to work and recently moved in with his mother who he explains to be very controlling and protective. Pt was educated on community resources, outpt services for therapy, and disability information. Pt is maintained on Effexor 150mg 2x/day at home and reports that he recently cut the dose down himself before admission because he wasn’t having any depression symptoms. Pt educated on the importance of maintaining his current dose that was working and to follow up with psychiatric services. 
12/282:00-2:4040 mins 91 y/o male pt. Conducted a follow up therapy session for pt recently readmitted for combative behavior at the nursing home rehab. Pt has a hx of PTSD and recently dx with dementia. Pt is A/O x 3 and aware that he is “hitting the nurses”. Pt suffers from nightmares and recommend output therapy. Pt was recently sent to rehab facility where he was extremely violent and combative. Pt is now placed for inpatient psychiatric treatment as no other nursing homes or rehab centers will accept him. Pt is unable to care for himself at home and needs 24/hr care. Spoke with pt regarding his traumatic experiences in war and he was able to express feelings of being scared and paranoid. He states the staff are going to hurt him. Redirected the patient and educated on health status and treatment. Pt seemed calmer after therapy. Remains in restraints and a sitter at bedside. Will follow up tomorrow. Completed inpatient psychiatric certification paperwork. 
12/283:00-4:0060 mins Initial psychiatric consult conducted. Pt is a 67 y/o female Caucasian admitted for possible drug overdose, suicide attempt. Pt was found unresponsive at home by her husband and drug screen positive for opiates, cocaine, and alcohol. Husband reports that she drinks a fifth a day of vodka. Pt has he of attempted suicide two years ago when she stabbed herself in the neck with a steak knife. Pt is on AWA protocol and very restless, disoriented and combative. Current meds for controlling her mood and withdrawals are not adequate. She has gotten 16mg of Ativan in the past 24 hours. Haldol 5mg PRN Q6h added to POC. Also, home dose of Cymbalta 60mg once daily to avoid additional withdrawal and control her chronic pain. Will continue to follow up with pt and family daily. Once pt is alert and oriented, will continue therapy and determine pt need for inpatient psychiatric placement. 
12/284:00-4:3030 mins 86 y/o female pt follow up visit for pt admitted for UTI HAVING delusions and hallucinations. It was determined that pt has delirium r/t infection and was given Abilify to assist with symptoms. Pt alert and oriented after 4 days on Abilify and antibiotics for urinary tract infection. Pt has hx of MDD and is having complaints of feeling hopeless and lonely. Spoke with pt regarding her feelings and pt expresses that she is sad her children don’t come up to see her and that her health is declining. Explored pts home life and learned that up to admission, pt has become less motivated to get up in the mornings, not interested in activities she previously was interested in and hygiene was poor. Pt reports taking multiple anti-depressants and doesn’t feel they have been working. Wellbutrin started today to help with depression. As Wellbutrin is more of a stimulant antidepressant, this is chosen in hopes to provide the pt with energy and motivation. Also, pt is overweight and Wellbutrin aides in appetite suppressant. Resources given for outpt psychiatric counseling services and reassured pt that I would be returning daily to provide therapy while admitted to hospital. Will follow up with pt tomorrow. 
12/284:30-5:3060 mins Initial psychiatric interview conducted with pt. Pt admitted for alcohol withdrawal after being escorted to hospital by police following his threat at a bank to “give them all his money”. Pt presents in 4-point restraints, alert to person and very argumentative. Therapy was unable to be conducted today but a full history of illness and previous conditions was reviewed with family. Pt has hx of PTSD after service in Vietnam. Educated family on resources for psychiatric services and AA. Mother expresses her concerns with pt being discharged back to her house as she is afraid of pt. Informed her of the inpatient psychiatric placement if she felt he is a danger to himself or others and would not follow up with a psychiatrist post discharge. Mother signed a petition for inpatient placement and paperwork submitted to psychiatrist for review. Will follow up with pt daily during hospital stay and review medications that can help with aggression and restlessness such as Haldol 5mg PRN when alcohol withdrawal protocol meds do not work. 
13/17:30-8:0030 mins Follow up visit for 83 y/o male admitted for UTI and Delirium seen last week. Pt with underlying dementia is now out of restraints, not hallucinating and non-aggressive. Spoke with social work and found a long-term care facility that takes his insurance. Pt is cleared from psychiatric services today as his delirium subsided and dementia symptoms have reverted to his baseline. 
13/18:15-9:1560 mins Initial consult for 77 y/o female admitted for a recent fall and psych consulted for concern for severe depression. Assessment and interview conducted with pt. Pt admits to hx of depression, no suicidal idealization, and no hallucinations. Pt states she is feeling more depressed and feelings of loss of hope since her health has declined. Educated pt on underlying CHF disease process and encouraged support groups. Explored pt availability for attending therapy sessions regularly. Reviewed anti-depressant use history. Continued Prozac and Buspar from home med list and will consider alterations at a later time when more therapy sessions have been conducted. 
13/19:30-10:3060 minsInitial consult 61 y/o male admitted for respiratory failure and consulted for paranoid schizophrenia. Assessment and interview conducted. Pt was initially cooperative and calm and become very paranoid and anxious when psychiatric history questioned. Provided supportive psychotherapy and psychosocial treatment.Utilized supportive psychotherapy which often leads to improvement in adaptive and interpersonal function (Rosenthal, et al., 1999). This method of therapy was chosen as patient was not very expressive and was very closed off toward personal history of mental illness. Rosenthal, R. N., Muran, J. C., Pinsker, H., Hellerstein, D., & Winston, A. (1999). Interpersonal Change in Brief Supportive Psychotherapy. The Journal of Psychotherapy Practice and Research, 8(1), 55–63.
13/110:40-11:2040 mins 9 y/o male diagnosed with Psychosis/Autism. Follow up therapy session with mother and son. Mother has agreed to participate in outpt therapy to help cope with son’s diagnosis. Play therapy continued in the pediatric playroom. 
13/111:50-12:5060 mins 38 y/o female diagnosed with PTSD, Depression and polysubstance abuse referred to psychiatric service for attempted suicide. Initial consult conducted, assessment, diagnosis and interventions planned. Pt being treated for Hepatitis A and severe liver failure. Will follow up with patient when she is more medically stable. At this time, pt is on a ventilator. 
13/11:00-1:3030 minsDebrief with Instructor 
13/11:45-2:4560 mins 86 y/o female dx with MDD. Follow up with patient and supportive therapy conducted. Assessed dose of Lexapro at 10mg PO daily. Pt has continued complaints of feeling hopeless and feels her family doesn’t care about her. Pt concerned that recent Lexapro addition isn’t doing anything. Educated patient that Lexapro usually takes a bit longer to work and if not, increasing next week is a possibility. Will continue to follow up with patient daily while admitted to the hospital. Provided encouragement to pt and allowed pt to reflect on inner strengths.Supportive therapy conducted and education on medication provided. Encouragement provided and strength building.
13/12:45-3:3045 mins 67 y/o female Caucasian admitted for possible drug overdose, suicide attempt. Initial psychiatric consult conducted. Drug screen positive for opiates, cocaine, and alcohol. Pt reports drinking a 5th a day of vodka. Crisis intervention completed with supportive therapy to patient and family. Pt is on AWA protocol and remains combative and restless. 16 mg of Ativan in the past 24 hours. Medication review completed. Haldol 5mg Q6h added to POC. Continued on home dose of Cymbalta. Daily follow up will be completed. Inpatient psychiatric placement may be needed but will re-evaluate when patient is alert and oriented.CIWA alcohol withdrawal scale utilized. Initial intake assessment completed with supportive therapy to family.
13/13:30-4:3060 mins 65 y/o male dx with MDD, CVA. Follow up therapy session completed. Assessed patient’s anti-depressant medication. No change. Pt in much better spirits today. Plans for discharge home with home health aides. Set up outpt follow up appointment with psychiatric service. 
13/48:00-9:0060 mins50 y/o female diagnosed with schizophrenia and personality disorder. Pt admitted for colitis and abdominal pain. Initial consult to psychiatric service as pt has reported hallucinations, voices in her head that won’t leave her alone “called the pleasure”. Pt stated that the pleasure was trying to take away her “spirit” that God placed within her to spread to the world. She is very delusional and paranoid that the pleasures take over her body and “do things” so that others believe they are her. Redirection of thoughts lead to agitation. Seroquel dose is currently at 25mg 2x/day and 100mg at bedtime. Will consider increasing this dose or switching to Zyprexa. Inpatient psychiatric placement advice and caseworker is working on initial paperwork with husband to place. Underlying medical issues being ruled out as patient reports the pleasures entering her body after they moved into a new home. Assessment and interview conducted. Therapy was not very successful today. Will follow up tomorrow. 
13/49:15-10:0045 mins63 y/o male diagnosed with a malabsorption disorder that is consulted to psychiatric service for Major Depressive disorder. Conducted initial assessment of patient and therapeutic therapy. Increased dose of Celera and will remain conducting therapy throughout hospital stay. Pt is very discouraged due to the rarity of the disease process he has. He reports being financially strained and now physically as his health has declined. Will continue to monitor pt daily while at the hospital. Suicide screening conducted and pt is cleared for acute risk of suicide. 
13/410:15-11:0045 minsDebrief with Instructor 
13/411:30-12:3060 minsfollow up with 61 y/o male admitted for respiratory failure and consulted for paranoid schizophrenia. Pt is more expressive with his experiences this therapy session although, does not want outpt follow up or anti-psychotics. Pt still remains agitated and paranoid with staff. Haldol 5mg IV IM injection as needed. Continued supportive therapy and will continue to follow while in hospital. 
23/58:00-8:3030 mins Follow up therapy session with 77 y/o female admitted for a recent fall and Major Depressive Disorder. Pt cheerful today and in good spirits. Pt has hope for improvement in ability to care for herself with the help of home health care. Current dose of Prozac and Buspar working well for pt and will continue dose. Pt agreed to outpt therapy with the clinic and agrees that she is doing much better after expressing her feelings and exploring her inner strength. 
23/59:00-10:0060 mins 74 y/o male admitted for GI bleed. Initial consult to psychiatric service for concern for suicidal idealization and depression. Assessment conducted. Pt reports no hx of psychiatric origin in himself or family history. Pt reports just having a hard time dealing with his health problems but now that he has a diagnosis and is able to be treated, “there’s hope”. Pt diagnosed with Adjustment disorder with both anxiety and depression. Pt reports being anxious at times and has feelings of hopelessness. Will continue therapy and recommended outpt therapy sessions as well. Will not start any medications at this time until more therapy conducted. Giving pt insight on strengths and ability to heal has seemed to give the patient more hope. Will follow up with patient tomorrow. 
23/510:15-11:0045 mins 50 y/o female diagnosed with schizophrenia and personality disorder follow up for delusional behavior. Psychiatric certification filed today and awaiting placement. Pt refusing to take any additional medication beside her Seroquel dose already prescribed. Therapy attempted with patient but wasn’t very successful. Pt stated, “I put a gun to my sister’s head to shoot out her pleasures as she is trying to steal my spirit”. Concern for pt safety and safety for others. Sitter placed in room to monitor. Will follow up with pt daily as she is in hospital. 
23/511:15-12:0045 mins Initial consult 61 y/o male admitted for respiratory failure and consulted for paranoid schizophrenia. Follow up therapy conducted. Pt not very receptive of care. Allowed pt to lead conversations and conclude his diagnosis. Pt remained on meds and will consider changing things at next visit if pt remains paranoid and delusional. Pt not delusional today. 
23/512:15-12:4530 mins 65 y/o male dx with MDD, CVA. Initial intake assessment conducted, and interview completed. Supportive therapy session attempted but patient was not very interactive. No change in medications at this time. Will follow up daily with patient to assess willingness to participate in therapy and work on strength and self-confidence building.Supportive therapy attempted but patient would not interact much. In order to provide adequate supportive therapy, feelings, life stressors, and problem solving should be reviewed with the patient and worked through (Wheeler, 2013). Rather, safety and suggestions on coping skills were provided to the patient. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
23/51:00-2:0060 mins86 y/o female dx with MDD. Follow up with patient regarding her feelings of hopelessness. Assessed dose of Lexapro at 10mg and increased to 20mg PO daily. Will continue to follow up with patient daily while admitted to the hospital. Provided encouragement to pt and allowed pt to reflect on inner strengths.Supportive therapy conducted to patient and resources provided. Encouragement and strength building provided.
23/52:15-3:0045 mins 38 y/o female follow up for PTSD, Depression and Polysubstance abuse. Pt still intubated. Spoke with mother regarding pt history and provided her with resources. 
23/53:30-4:0030 mins 74 y/o male follow up for adjustment disorder w/ anxiety and depression underlying. Pt very cheerful today throughout therapy session. He states that he has hope and knows that his diagnosis of a GI bleed is treatable. Pt will go home with in home health care for a period of time to help with adjustment. Will continue to follow up with pt as he is in the hospital. 
23/68:00-8:3030 mins71 y/o male dx with PTSD and Dementia. Follow up supportive therapy visit conducted. Pt reports flash backs and nightmares continuously and his mood is aggressive and impulsive. Will add Zoloft at 50 mg/daily for depression and PTSD treatment. Will continue to monitor and pt may benefit from low dose Seroquel to control mood. Will follow up and reassess.Assessment tool: Hamilton Anxiety Rating Scale used to assess the extent of patient’s anxiety. Pt rated 19/56 indicating mild anxiety (Thompson, 2015). Pt was diagnosed with dysthymia as his anxiety has been chronic and not too severe (American Psychiatric Association, 2013). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.Thompson, E. (2015). Hamilton Rating Scale for Anxiety (HAM-A). Occupational Medicine (Oxford, England), 65(7), 601. doi:10.1093/comedy/kqv054
23/68:45-9:4560 mins74 y/o female dx w/ MDD. Initial intake assessment conducted. Depression severity screened using the Zung self-rating depression scale. Pt reports severe feelings of hopelessness, worthlessness and suicidal idealization. Therapy conducted with patient and outpt services educated on.Utilized the Zung self-rating depression scale to assess the severity of depression. Therapy conducted that included Orlando’s Nursing Process Discipline Theory to help pt recognize strength and diminish feelings of helplessness (Petiprin, 2016). Petiprin, A. (2016). Psychiatric and mental health nursing. Nursing Theory. Retrieved from http://www.nursing-theory.org/theories-and-models/erickson-modeling-and-role-modeling-theory.php
23/610:00-11:0060 mins 71 y/o male dx with PTSD and Dementia. Initial consult conducted, and assessment completed. Pt reports flash backs and nightmares. Pt has underlying confusion but is alert and oriented to person, place and time today. PTSD Checklist- civilian version completed. Pt indicated to be atSupportive therapy provided, and Civilian PTSD checklist tool used to assess level of PTSD disorder.
23/611:10-12:0050 mins 62 y/o female consulted to psychiatry for assistance with her MDD. Initial intake assessment completed, and client interviewed. Client very knowledgeable about her disease and is willing to begin in depth therapy to help her cope with past experiences. Explained that psychoanalytic therapy is more in depth and requires at least 1-2 sessions per week. She is willing to dedicate the time but is concerned with her unwillingness to get out of bed in the morning. She feels she has no energy at all and has lost motivation to even care for herself. Completed a medication review and client has an extensive history of antidepressant use. She is currently taking Celexa 40 mg per day. Will add Wellbutrin XL 150mg daily as a dual therapy to give her more energy as Wellbutrin is a stimulant antidepressant. Client has no hx of seizures or alcohol dependence, high anxiety or appetite issues that would contraindicate this therapy. Will follow up daily while she is in the hospital.Provided supportive therapy for MDD and referred to outpt clinic for more expressive therapy options are available. Expressive therapy is more in-depth, involved emotional processing, and more frequent insightful sessions that offer a more consistent support for clients to find their inner self, according to Wheeler (2014). Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
23/612:20-1:1050 minsPt was able to provide history and supportive therapy attempted with pt. Resources and support provided to wife. Will follow up with pt daily while in the hospital and continue to provide supportive therapy. Pt has not been treated pharmacologically for mental health in the past. Will start the patient on Zoloft 50 mg/day based on the initial starting dose recommendations of Stahl (2014b) and assess pt response daily. Will not attempt to increase dose for a couple weeks.Supportive therapy to family. Pt resistant to treatment but did a medication review and added Zoloft to plan of care. According to Stahl (2014b), SSRIs are the first line treatment for depression/ anxiety and PTSD disorders and Zoloft is one of the SSRIs that is indicated for treatment in PTSD. Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
23/61:10-1:4030 mins 86 y/o female dx with MDD. Follow up with patient regarding her feelings of hopelessness. Dose of 20mg Lexapro is reported to be helping her depression. Client is openly conversational today and supportive therapy continued. Provided resources for client to attend outpt therapy and spoke with social work regarding options for a therapist to visit her home. Will continue to monitor.Supportive therapy and collaboration with other providers to set up adequate outpt care.
23/61:40-2:0020 minsDebrief with preceptor 
23/87:30-8:3060 mins 64 y/o male admitted for alcohol withdrawal. Psychiatry consulted to evaluate pt for delusional behavior and current AWA protocol being maxed. Initial assessment completed, and interview conducted. Pt is actively hallucinating and extremely paranoid. Ativan maxed per hospital protocol. Completed a medication review and added Haldol 5mg IM injection every 6 hours and Librium 300mg 2x/day. Will check lithium levels and monitor for lithium toxicity. Educated nursing staff on lithium toxicity signs such as dystonia, hyperreflexia, ataxia and tremulousness. Will follow pt daily while in hospital.Utilized the alcohol withdrawal scale CIWA to assess the severity of withdrawal patient experiencing. Based on scale, was able to determine which medications to utilize for plan of care.
23/88:45-9:3045 mins 74 y/o female dx w/ MDD follow up appointment to conduct therapy for hopelessness and thoughts of suicidal idealization. Assess the patient’s current medication regimen of Prozac at 20 mg PO daily. Increased medication to 30mg daily. 
23/810:00-11:0060 mins 67 y/o female Caucasian admitted for suicide attempt by drug OD. Follow up therapy conducted today. Supportive therapy was successful with patient as we reviewed her feelings, life stressors, and what triggers her depressive episodes. Inpatient psych remains a plan as patient has attempted suicide multiple times resulting in hospital admission. Dose of Haldol added last week has been reported to be successful to assist in patient’s withdrawal symptoms. 
23/811:15-12:0045 mins 71 y/o male dx with PTSD and Dementia. Follow up conducted and supportive therapy completed. Pt is still having some mood issues including impulsiveness and agitation but does indicate it’s a little better. Explained to pt that treatment with Zoloft usually takes weeks to see improvement but Seroquel should be indicating improvement with mood within a week (Stahl, 2014b). Will follow up as pt is in the hospital. Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.Supportive therapy for PTSD and follow up on medication changes.
23/97:30-8:3030 mins 67 y/o female Caucasian admitted suicide attempt by drug OD. Seen yesterday and follow up therapy conducted today. Pt vert calm today with use of Haldol and only required 6 mg of Ativan over the past 24 hours. Continued on home dose of Cymbalta. Inpatient psychiatric placement is confirmed, and patient will be discharged to facility today.CIWA alcohol withdrawal scale utilized. Inpatient psychiatric placement considered, and paperwork filed.
23/99:00-10:0060 mins 54 y/o female admitted for pneumonia and consulted to psychiatry for Bipolar disorder. Initial intake assessment completed, and home medications reviewed. Pt home Depakote was not restarted upon admission to the hospital last week which led to pt having mania. Depakote level ordered and will review in the am. Home dose Depakote 1000mg/day PO was restarted. Will follow up with patient daily to assess mood and provide therapy. 
23/910:15-11:0045 mins68 y/o male admitted for alcohol withdrawal after being escorted to hospital by police following his threat at a bank to “give them all his money”. Pt has hx of PTSD after service in Vietnam. Follow up visit conducted to assess pt willingness to accept therapy and assess orientation. Mental status exam conducted along with the civilian version checklist for PTSD. Haldol 5mg PRN q6hrs along with AWA protocol for alcohol withdrawal has been sufficient. Pt very apprehensive to talk to me today and very mad about the inpatient placement to psychiatric hospital. Pt family feels it’s the best option as he has been a danger to himself and others. Will continue to follow.CIWA protocol tool completed along with civilian version checklist for PTSD. Previous scoring was 68/80 indicating a high level of traumatic disorder. Today the screen indicated a good clinical change with a point deduction of 10 points to a score of 58/80 (Weathers et al., 2013). Weathers, F.W., Lutz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnarr, P.P. (2013). The PTSD Checklist for DSM-5 (PCL-5).
23/911:15-12:0045 mins49 y/o male admitted for MDD and alcohol withdrawal. Initial consult to psychiatric services provided today with a full assessment and interview for patient reporting suicidal idealization. When meeting with pt a suicide screen was completed along with Zung-self rating depression scale. Patient scored a 70 on the depression scale indicating severe depression present (Zung, 1965). Sitter placed in patient’s room as he is considered a danger to himself or others. Supportive therapy conducted, rehab suggested to patient after inpatient psych placement completed. Pt is agreeable to all help and wants to participate in AA treatment and outpt counseling service. Will continue to follow up daily on pt. Zung, WW (1965) A self-rating depression scale. Arch Gen Psychiatry 12, 63-70. 
33/169:00-9:4545 mins49 y/o male admitted for MDD and alcohol withdrawal. Follow up session completed today with supportive treatment conducted. Pt is requesting pharmacological agent to assist with depression. Will start patient on Prozac 20 mg/day in the morning. Will reassess pt daily. Psychiatric placement confirmed and pt will be discharged tomorrow to facility nearby.This week I focused on supportive therapy vs expressive therapy with my patients. I created a case formulation based on each individual’s personality organization level, their primary defenses and their attachment style. I then decided based on these results whether the patient would benefit from supportive or expressive therapy. If a patient was avoidant, aggressive, had high anxiety, or was unable to elaborate on experiences, I chose supportive therapy as a starting point as this therapy requires more focus on feelings, life stressors, and problem solving, according to Wheeler (2014). If the patient was insightful, voluntarily expressive, and able to communicate with coherence and emotional genuineness regarding difficulties throughout childhood I considered using psychodynamic therapy. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
33/1610:00- 10:4545 mins 50 y/o female admitted for exacerbation of chromes disease. Psychiatry consulted for pt hx of schizophrenia and current behavior including hallucinations, delusions and paranoia. Initial consult conducted, and assessment completed. Interview with pt was completed and pt reported having commanding hallucinations for the past 5 years. Husband indicates that pt has refused psychiatric medication and will only attend church group for support. During interview, pt indicated her body has been taken over by “demons’ that want her to withdraw the spirit the Lord put in her to spread around the world. Pt was not accepting of pharmacological therapy. Supportive therapy conducted and was not very successful as patient became more agitated throughout session. Allowed pt to express her feelings and actively listened. Inpatient psychiatric placement recommended, and husband agrees as he expressed being afraid of her at times. Husband is very concerned about her behavior. Will continue to follow pt while at the hospital. Psychiatric to be around to sign inpatient certification.Supportive therapy attempted to lead to decreased anxiety and provide resource building.
33/1611:00-12:0060 mins 43 y/o female admitted for hip transplant. Psych consulted for self-harm crisis. Pt has hx of MDD and recently diagnosed with adjustment disorder. Pt verbalized want to harm herself. Crisis intervention with initial intake assessment. Supportive therapy provided. Inpatient psych certification filled and pt to go to facility for treatment. Sitter at bedside for safety and will continue to follow up daily.Crisis intervention, Supportive therapy including external resources, Inpatient psych cert. As patient was diagnosed with adjustment disorder, supportive therapy was necessary to sort out issues the patient was experiencing with management of disease, discuss situations and express feelings (Wheeler, 2014). Educating the patient on his medical diagnosis so he has a better understanding of his disease process and reviewing coping mechanisms was the focus of our session.
33/1612:15– 12:4530 mins 82 y/o female admitted for delirium and depression. Session for therapy was not very effective as pt was extremely sleepy. decreased dose of Seroquel from 300mg PO to 100mg PO daily. Added Wellbutrin 75 mg 2x/day for reports of severe depression, not wanting to get out of bed at home, not bathing, dressing or having any energy to take care of herself. Pt reports having the feelings of depression for the past 5 years but has had no psych history and has not been seen by a psychiatrist or treated in the past. Pt has been very delirious and combative to staff and is why Seroquel was started originally. 
33/161:00-1:4545 mins64 y/o male needing psychiatric consult for active episode of depression. Hx of PTSD, anxiety and depression. Currently has no suicidal idealization at this time but reports history of feeling like he doesn’t want to live anymore after he recently became very weak in his legs and nursing home bound. Resources given to patient regarding outpt therapy sessions. Encouragement provided and will follow up tomorrow with patient. Home dose of Cymbalta increased for depression and pain control. other home medications discontinued per pt request Nd risk for serotonin syndrome, Elavil, Lexapro and Trazadone. Will evaluate medications again daily as patient is in the hospital.Supportive therapy consisted of reviewing disease process and management, discussing issues the patient needs to overcome when returning home and providing encouragement to the patient (Wheeler, 2014). Pt could benefit from Psychodynamic therapy to overcome trauma and associated depression from his PTSD. Will continue to evaluate pt readiness for expressive therapy. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
33/162:00-3:0060 mins 60 y/o admitted for nausea and vomiting. Psych consult ordered for pt Bipolar disease management. Pt on 600 mg PO Seroquel and 2,000 mg of Depakote at home. Initial intake assessment completed with patient.   
33/163:15-4:0045 mins 63 y/o follow up for Adjustment disorder and MDD related to disease process. Pt is becoming more familiar with treatment management and adjustment disorder to recent disease process is improving. Pt is cleared from being suicidal and will follow up with our office outpatient. Supportive therapy successful and pt wants to continue with more in-depth therapy through the outpt office.Supportive therapy began today by reviewing coping mechanisms, expressing feelings, and reviewing patient’s life stressors. As psychodynamic therapy requires more intensive teaching and longer therapy sessions, supportive therapy was the alternative for today (Wheeler, 2014). Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
33/178:00-9:0060 mins63 y/o follow up appointment for Adjustment disorder. Psychoanalytic therapy done today and pt was able to dig deep into his childhood issues leading to depression. Pt discharged today so he will follow up in office in 4 days for another therapy session.Psychoanalytic therapy conducted as we spoke about his troublesome childhood experiences and dug deeper into
33/179:30-10:10:3060 mins 32 y/o female seen for attempted overdose with hx of major depressive disorder. Pt reports suicidal idealization and took bottle of Wellbutrin attempting to commit suicide. Was found down in garage and hypothermic. Complete assessment performed and pt will be certified to inpatient psychiatric hospital. Sitter remains in room for patient safety. Pt also has a history of seizure disorder and 300mg PO Wellbutrin is discontinued as it can provoke seizures. CT of brain completed. EEG indicates no seizure activity. medication review with pt to evaluate the options for anti-depressants. Will follow up with patient tomorrow and provide further therapy with pt and mother.Therapy was not very successful. Supportive therapy attempted, as expressive therapy would be inappropriate with this patient based on her hx of molestation leading to a decrease in ability to connect with others and build a trusting relationship (Wheeler, 2014). Typically, these patients thrive off support from others including encouragement, safety, coping mechanisms, and strength building. Intake assessment performed and will continue to build trust and rapport with patient to build more efficient support system. Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
33/17/201810:45-11:4560 mins 50 y/o female admitted for exacerbation of chrons disease. Follow up appointment conducted with patient regarding schizophrenia, commanding hallucinations and paranoia. Inpatient psych certification renewed today and facility accepting to take patient this afternoon. Pt still unwilling to accept any psychotropic medications. Family counseling provided for husband and one son. Resources for outpt therapy for them was offered and husband is accepting of help. Will follow up with pt after inpatient placement completed.Family counseling, Inpatient psych certification
33/17/201812:00-1:0060 mins 43 y/o female admitted for hip transplant, Adjustment disorder and MDD. Follow up appointment completed. Pt denying self-harm and very agitated that she is to leave for inpatient psychiatric facility today. Supportive therapy conducted which was not very successful. Pt refusing to take any of her current medications. Sitter remains in room until EMS arrives for transport to inpatient placement center. Offered outpt services for patient when she is out of center.Supportive therapy attempted but patient was not very interactive. Did provide resources for her to review on her own time. Inpatient psych cert completed.
33/17/20181:15-2:0045 mins 82 y/o female admitted for delirium and depression. Session for therapy was not very effective as pt was extremely sleepy. decreased dose of Seroquel from 300mg PO to 100mg PO daily. Added Wellbutrin 75 mg 2x/day for reports of severe depression, not wanting to get out of bed at home, not bathing, dressing or having any energy to take care of herself. Pt reports having the feelings of depression for the past 5 years but has had no psych history and has not been seen by a psychiatrist or treated in the past. Pt has been very delirious and combative to staff and is why Seroquel was started originally. 
33/18/20188:00-9:0060 mins 64 y/o male needing psychiatric consult for active episode of depression. Hx of PTSD, anxiety and depression. Currently has no suicidal idealization at this time but reports history of feeling like he doesn’t want to live anymore after he recently became very weak in his legs and nursing home bound. Resources given to patient regarding outpt therapy sessions. Encouragement provided and will follow up tomorrow with patient. Home dose of Cymbalta increased for depression and pain control. Home medications discontinued to decrease risk for serotonin syndrome, Elavil, Lexapro and Trazadone. Will evaluate medications again daily as patient is in the hospital.Supportive therapy conducted today. Will attempt psychodynamic therapy during outpt sessions as patient is securely attached and has a neurotic to healthy personality organization.
33/18/20189:15-10:0045 mins60 y/o admitted for nausea and vomiting. Psych consult ordered for pt Bipolar disease management and recent mania episode. Follow up supportive therapy conducted and pt is doing much better after home doses of Seroquel and Depakote were restarted. Educated patient on the importance of not missing any doses of these medications, abruptly stopping them and ensuring that the hospital is aware he takes them if future admission occurs. Pt is being discharged today and he will follow up in the office outpt for continued therapy of his Bipolar disorder. 
33/18/201810:15-11:1560 mins32 y/o female admitted for OD following a suicide attempt. Follow up therapy session conducted today and pt is looking much better. She is eager to go to the inpatient psychiatric facility to receive help and requested information regarding group therapy sessions at our outpt clinic. EMS will be to pick patient up within 2 hours. Follow up appointment scheduled for the day after discharge from psych facility.Patient has benefited from supportive therapy. I believe we have a strong trust relationship and great rapport leading to an environment that feels safe and non-judgmental where the patient was able to express her feelings adequately (Wheeler, 2014). Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
33/18/201811:15-12:0045 minsDebrief with preceptor 
33/18/201812:00-12:3030 mins 82 y/o female admitted for delirium and depression. Follow up therapy conducted and medication review. Pt much more alert today after Seroquel was decreased from 300 to 100mg from the initial assessment. Pt reports that she has had much more energy this past week and that the Wellbutrin she was started on seems to be working well. Supportive therapy provided and outpt therapy scheduled after discharge. Pt is being discharged home today. 
43/22/20188:00-12:304.5 hrsGroup counseling session conducted at the outpt counseling center. 32 y/o female suffering from severe nightmares and flashbacks. Dx with PTSD and has been seeing her therapist weekly for cognitive behavioral therapy. Recently, she reports increased anxiety and panic attacks and decided to come to 5 days per week of group counseling to assist with her symptom management. Also, in the session was a 29 y/o female dx with MDD and sleep disorder who has recently lost her job in Vegas, moved back to MI and is now homeless. She reports having trouble completing her job responsibilities due to her depressive state and now she’s lost. Reports coming to therapy for support and treatment for her disease. Session consisted of education on anxiety/depression disorders and treatment options including CBT and pharmacological therapy.Cognitive behavioral therapy is one of the first line treatments for anxiety or depression according to Wheeler (2014). Therapy aims to recognize dysfunctional thinking and change it based on thoughts, feelings and behaviors. As cognition drives anxious or depressed thoughts, patients can use CBT to recognize these maladaptive thoughts and re-label them (Beck, 1994). Beck, A. (1994). Aaron Beck on cognitive therapy [Video file]. Mill Valley, CA: Psychotherapy.net.Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
43/23/20188:00-12:304.5 hoursGroup session completed. 32 y/o female suffering from PTSD, severe nightmares and flashbacks, pt openly expressed her resentment against her mother for not stepping in when her father would rape her from the age of 4 to 15 yrs old. 29 y/o female dx with MDD and sleep disorder, today reports she has been staying from one person’s house to the next and has severe anxiety driving after recent car accident. Group reviewed exposure therapy and how exposing yourself to stressors, fears, and phobias more regularly rather than avoiding them decreases anxiety. New pt at group today for panic attacks and depression following recent son’s attempted overdose. Stress management activity conducted in cognitive behavioral therapy. expressive therapy conducted with all members of the group.Exposure therapy for anxiety disorder, CBT, supportive therapy, expressive and psychodynamic therapy. Stress management activity.

Practicum Week 1 Journal Entry

Erikson’s Modeling and Role Modeling Theory is a great model of nursing that enables the patient to become aware of their uniqueness and gain respect for their needs while building internal drive according to Petiprin, (2016). Understanding that each person has basic needs that must be met and when the need is not met, distress and illness will occur, can help the practitioner and patient come to a consensus on interventions to meet the goal. By mending the

needs of the patient through nurturing, support, and comfort, the patient will gain affiliated individualization (Petiprin, 2016). The key to this theory is that the nurse and patient work together to set mutual health-directed goals by building on patient strengths.

I chose Solution-focused therapy for this week’s journal as many of my patients had a diagnosis of depression. Typically, this type of counseling therapy is utilized in patients with depression and indicate a higher success in patients with less number of sessions (Reddy, et al., 2015). Being that our therapy takes place in an acute hospital setting where the sessions are typically limited to 30 minutes to an hour, utilizing the solution-focused therapy is a great way to influence the patient population in a short period of time. Specific questions are used to facilitate thought processes that lead to changes in patients by increasing positive emotion, and outcomes, according to Franklin, et al., (2017). Along with utilizing specific questions, co-construction focuses on interactive communication with the patient, allowing them to negotiate meanings to come to a positive solution. A difficult aspect of interviewing patients in an acute hospital setting is the limited time and familiarization of the patient. Using specific questions to pinpoint an issue to come to a solution more efficiently in very important in finding adequate treatment measures for these patients.

Goals and Objectives

Goal 1: Conduct a comprehensive interview with a new consult psychiatric patient.

Goal 2: Adequately diagnose a patient after conducting the initial interview, assessment and finally planning interventions.  

Goal 3: Be familiar with different nursing theories and counseling theories that will help aide me in my therapy sessions.

Objective 1: Understand culture, religion and socioeconomics and their influence on psychotherapy.

Objective 2: Analyze therapeutic approaches for different mental health disorders.

Objective 3: Incorporate individuals and families within psychotherapeutic treatments.  

Practicum Timeline

Week 1-Week4: familiarize myself with all the nursing theories and counseling theories. Apply as many to my patient’s therapy sessions in the hospital. Correlate theories to group therapy sessions.

Week 5- Week 6: Focus on PTSD, approaches for treatment and nursing theories that apply to this patient population. In group therapy, many individuals suffer from addiction and PTSD.  Typically, many patients seen in the hospital have polysubstance abuse as a self-coping mechanism to their underlying mental health disorder.

Week 7- Week 8: understand the difference of supportive and interpersonal psychotherapy with individuals on an acute psychiatric basis. Also, apply existential-humanistic therapy options to these patients and those in the group sessions at the outpatient therapy center.

Week 9- This week I will focus on patients in the pediatric unit of the hospital.

Week 10: This week will focus on elderly populations. A lot of patients seen for psychiatric evaluations as an elderly patient are those with delirium from the underlying infections. This population can be sensitive to treatment options and ruling out other reasoning for psych is key.

Week 11: Focus on diagnosing and assessing patient with personality disorder and applying all therapy techniques learned to the psychotherapeutic treatment in the hospital.  

References

Franklin, C., Zhang, A., Froerer, A., & Johnson, S. (2017). Solution Focused Brief Therapy: A

Systematic Review and Meta-Summary of Process Research. Journal of Marital And

Family Therapy, 43(1), 16-30. doi:10.1111/jmft.12193

Petiprin, A. (2016). Psychiatric and mental health nursing. Nursing Theory. Retrieved

from http://www.nursing-theory.org/theories-and-models/erickson-modeling-and-

role-modeling-theory.php

Reddy, P. D., Thirumoorthy, A., Vijayalakshmi, P., & Hamza, M. A. (2015). Effectiveness of

Solution-Focused Brief Therapy for an Adolescent Girl with Moderate

Depression. Indian Journal of Psychological Medicine, 37(1), 87–89.

http://doi.org/10.4103/0253-7176.150849

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories

in context and practice [Video file]. Mill Valley, CA: Psychotherapy.net.

Practicum Week 2 Journal Entry

Demographics: The client is a 42-year-old, Caucasian female who is unemployed and homeless. Patient claims to make money by prostitution and has no place to live. She has not worked in years, has been feeling hopeless and useless she claims.

Presenting Problems: The client states, “I am having severe depression, have no one to turn to and nowhere to go”

History of Present Illness: The client is alert and oriented to person, place and time. She expressed suicidal idealization and reports being addicted to crack cocaine. She also admits to drinking as much alcohol as she can get every day to cover up her feelings. The client current alcohol level is less then 15, urine drug screen positive for cocaine and opiates. During interview patient was very cooperative and expressed her concerns openly. The client reports that the drugs have taken over her life, destroyed relationships, and has caused her to feel worthless. She complains of chills, tremors, anxiety, and burning pain. She admits to having suicidal idealization and stating that she “does not want to live anymore”. Patient also reports poor seep, poor appetite, and irritability. She denies any periods of hyperactivity, euphoric mood, hallucinations, outside of withdrawal and paranoia. Patient tells me she has a poor relationship with her sister and her parents.

Past Psychiatric History: Patient reports being sexually abused by her uncle from the age of 6 until 10 years of age. She has been seen by a psychiatrist through her teenage years but reports stopping therapy at the age of 25. She was diagnosed with post-traumatic stress disorder and major depressive disorder. Pt does not have a family physician, a current psychiatrist as she has no insurance. No report of hallucinations or paranoia but does report severe nightmares and flashbacks from childhood.

Medical History: Patient has no allergies to medications or food. UTD on all immunizations. Patient has a known history of hypertension and high cholesterol. No other known medical history. Patient has not been seen by a physician in many years and has no medical insurance.

Substance Abuse History: Client admits to using crack/cocaine for the past 10 years. Reports to have started drinking alcohol at the age of 12 and has been an ongoing problem. Reports drinking as much as she can find for the day. Patient has been to rehab several times and agrees to go to whatever treatment program the psychiatrist has planned. Patient smokes a pack of cigarettes a day. Father and mother both have history of alcoholism and mother has MDD.

Differential Diagnosis:

Severe episode of recurrent major depressive disorder- The patient has a history of depression, and reports a current feeling of hopelessness, worthlessness, and suicidal idealization. The patient reported that she is feeling depressed and does not want to live anymore. As the patient has reported having chronic depression throughout most of her life and a current episode of suicidal idealization and feelings of hopelessness, I would consider this patient to be having a severe episode of recurrent major depressive disorder, according to the Diagnostic and Statistical Manual (DSM), (2013).

Post-traumatic Stress Disorder- The patient has a history of being sexually abused by her uncle from the age of 6 to 10 years old. She reports frequent flashbacks and severe nightmares of the trauma caused in her childhood. Patient reported not being capable of having relationships in her past as she has problems with trust. Patient became irritable when speaking about the past events of her childhood and has exposed reckless and self-destructive behavior.

Substance/medication-induced depressive disorder-The client has a previous substance abuse history that includes crack/cocaine and alcohol. According to Stahl (2013), depressive symptoms are associated with the ingestion or injection of a substance, and this particular client reports symptoms of depression throughout adolescence. Also, this disorder must be used only when evidence of an independent depressive disorder is not present, and this client has reported use of substances secondary to her mood disorder.

DSM-5 Diagnosis:

Major Depressive Disorder 296.31

Post- Traumatic Stress Disorder 309.81

According to Diagnostic and Statistical Manual (DSM) criteria for major depressive disorder is the presence of five or more symptoms and a change from previous functioning; at least one of the symptoms must be either depressed mood or loss of interest or pleasure (2013). This patient has reported feelings of suicidal idealization, feelings of worthlessness, hopelessness and not wanting to live. The patient has also had reports of insomnia, and irritability. The patient also has been diagnosed with post-traumatic stress disorder and according to the DSM, criteria the patient has to verify this disorder is having directly experienced a traumatic event such as being sexually abused from the age of 6 to 10 years of age (2013). She has also experienced at least one intrusion symptom including recurrent, involuntary and intrusive distressing memories and also, having negative alterations in cognitions such as estrangement from her sister, mother and father. Patient has marked alterations in arousal and reactivity with the associated with the traumatic event evidenced by both reckless/self-destructive behavior and sleep disturbance. All of these alterations have lasted over 1 month and has caused significant distress in occupational and social impairment, all of which are criteria met for diagnosis of post-traumatic stress disorder according to the DSM (2013).

INDIVIDUALIZED TREATMENT PLAN

Medications:

Zoloft50mg1tab PO DailyDepression and PTSD treatment

The dosage of 50 mg is chosen as this is the starting dose for major depressive disorder and PTSD treatment (Stahl, 2014b). Since the patient has suicidal idealization, a sitter will remain at bedside and the patient will be followed by psychiatry daily while admitted to the hospital. According to Stahl, Zoloft is considered a first line medication in treating PTSD and any serotonin reuptake inhibitor is the first line treatment for depression (2013). Since the patient is diagnosed with both disorders, I thought it would benefit the patient to be prescribed Zoloft.

Therapy with rationales: Patient is receptive of being admitted to an inpatient psychiatric hospital. Patient also willing to have participate in outpatient therapy and rehabilitation center after being discharged from the psychiatric facility. According to Magellan Health Inc., there is a 70% response rate in patients diagnosed with major depressive disorder who receive treatment with an SSRI Prozac and cognitive behavioral therapy (2013). Social work is working on securing a family physician and department of human services aid in housing and insurance. According to Wheeler, cognitive behavioral therapy is a great source of therapy for depression and post-traumatic stress disorder (2013).

Legal and Ethical Implications of Counseling these Clients

Maintaining patient confidentiality is important in psychotherapy and is an ethical expectation of the client. It is the providers responsibility to do good by the patient and recommend and prescribe treatment that is evidence-based and essential for patient beneficence (Benfield, 2018). It is the patient’s autonomy to decide for themselves and support their own healthcare but in the case of self-harm or harm of other such as this case, some interventions such as certification to an inpatient psychiatric facility is necessary. Some patients are considered vulnerable and it is the providers responsibility to not subject the patient to harmful intervention and study group and rather be a patient advocate (Kurpad, 2018).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, DC: Author.

Benfield, J. (2018). PROFESSIONAL PRACTICE IN COUNSELLING AND

PSYCHOTHERAPY: ETHICS AND THE LAW. Healthcare Counselling &

Psychotherapy Journal, 18(1), 30.

Magellan Health, Inc. (2013). Appropriate use of psychotropic drugs in children and adolescents:

A clinical monograph. Retrieved from

http://new.dhh.louisiana.gov/assets/docs/BehavioralHealth/publications/ChildrenSummitt

2014/DrRichardDalton.pdf

Kurpad, S. S. (2018). Ethics in psychosocial interventions. Indian Journal Of

Psychiatry, 60S571-S574. doi:10.4103/psychiatry.IndianJPsychiatry_26_18

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University

Press.