Psychosocial Assessment (written – Maximum 15 pages including title page,
reference list and appendices). 20%
a. Introduction
In the introduction provide an account of the patient and his/her illness from his/her perspective. Briefly describe how he has dealt with the diagnosis/treatment and how he has lived in the past/ present.
b. Complete a full bio-psychosocial assessment including the mental
status assessment. (See Chapter in Boyd, The Psychiatric Nursing
Process). Include a genogram of family relationships.
c. Present the results of a Mini Mental Status Examination (MMSE) or
any appropriate psychiatric assessment tool (CAGE, MAST, SANS, etc…) conducted during a one-to-one interview with the client.
d. Identify client’s DSM V diagnoses and current treatment including
medication regimen. Describe the observed behaviors that meet the DSM criteria.
e. Identify nursing diagnoses and list in order greatest to least in
priority.
f. Develop a care plan for the top three nursing diagnoses.
g. Perform a literature review that summarizes four to six references:
etiology, S/S, manifestations of the psychiatric diagnosis and nursing
interventions pertaining to nursing diagnoses. One article should be a meta-analysis pertaining to either nursing or psychiatric
diagnosis/treatment. For all research articles, provide a description of the purpose, sample, methodology, findings, implications for
practice, and author’s (s’) conclusions. State rationale for selecting each article, including a statement of how it applies to patient’s
psychiatric diagnosis, nursing diagnoses and/ or treatment. Cite all references in APA format.
Students are advised to submit the paper to Safe Assign in order to avoid incorrect referencing that violates the University policy on plagiarism and that is subject to receiving zero credit for the assignment which represents 20% of the clinical grade.
N/B
Client’s Information
patient is a 26 year old African American Male to Spring Grove Hospital Center on 03/15/2019 on the basis of court order following being found @ IST/D for charges of trespassing, theft and burglary 4th degree.
denies auditory and visual hallucination
denies drug and alcohol use currently. used Cannabis about 2 weeks.
he was diagnosed with psych issues at the age of 18 in 2010 and has been in so many different hospitals because of the psych issues.
he is single, no children, unemployed, veterinary assistant credentials.
allergy: non
he was adopted, but loves the adopted parents
DIAGNOSIS: SCHIZOPRENIA & CANNABIS USE DISORDER
MEDICATIONS: Fluphenazine Decanoate 25mg every 3months, Remeron 30mg PO QHS, Zyprexa 10mg PO QHS, Lisinopril 10mg, Depakote 500mg PO BID
LABS
-urea nitrogen (BUN) 12
-creatinine 0.78
-eGFR NON-AFR. AMERICAN 125
-sodium 139
potassium 4.1
albumin 3.6
bilirubin 0.3
protein 6.3
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