Assignment 2: Practicum – Assessing Client Family Progress

Learning Objectives

Students will:

· Create progress notes

· Create privileged notes

· Justify the inclusion or exclusion of information in progress and privileged notes

· Evaluate preceptor notes

To prepare:

· Reflect on the client family you selected for the Week 3 Practicum Assignment.

The Assignment

Part 1: Progress Note

Using the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:

· Treatment modality used and efficacy of approach

· Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)

· Modification(s) of the treatment plan that were made based on progress/lack of progress

· Clinical impressions regarding diagnosis and or symptoms

· Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)

· Safety issues

· Clinical emergencies/actions taken

· Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them

· Treatment compliance/lack of compliance

· Clinical consultations

· Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)

· The therapist’s recommendations, including whether the client agreed to the recommendations

· Referrals made/reasons for making referrals

· Termination/issues that are relevant to the termination process (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)

· Issues related to consent and/or informed consent for treatment

· Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

· Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family from the Week 3 Practicum Assignment.

In your progress note, address the following:

· Include items that you would not typically include in a note as part of the clinical record.

· Explain why the items you included in the privileged note would not be included in the client family’s progress note.

· Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.

By Day 7

 

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Please fill in the boxes at the 3rd page of this topic (Resilience – Strength of Social Support Network). Thank you!

 

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Write 100-word Reflective Journal on how this clinical scenario enhanced your understanding of important communication techniques and what would be incorporated into your individual communication style to improve the nurse-patient/family relationship. 

 

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Write 100-word Reflective Journal on how this clinical scenario enhanced your understanding of important communication techniques and what would be incorporated into your individual communication style to improve the nurse-patient/family relationship. 

 

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 Write a brief Introduction why you chose these decisions .

  

Decision 1

The PMHNP will administer 10 mg of zyprexa orally at bed time and initiate 230mg of invega sustenna through intramuscular, in addition to 156 mg via the same route on day four. A similar dose will be administered within one months’ time. In addition the PMHNP will administer 10mg of Abfility orally at bed time. Expected outcome for this decision is a 25% decrease in the PANSS score (Stahl, 2013). This decision is also expected to alleviate the patient’s psychotic symptoms and achieve normalcy within one month. A slight weight gain is also expected as the drugs are known to increase weight in patients. Because I don’t select the other decisions, the patient is expected to have faster and noticeable changes in psychotic behavior within two weeks of treatment commencement. 

Decision 2

At this point the PMHNP will decide to continue with use of medications selected in decision 1 (Stahl, 2013). However the PMHNP will instruct the administering nurse to begin intramuscular injections of 300mg of Abfility and continue with 10 mg of the same drug in the morning. At this point, PANSS is expected to decrease by 50 % although the patient will also have noticeable weight gain due to use of invega sustenna (Stahl 2014). Because I don’t select other decisions, the patient is expected to have less cardiovascular drug toxicities and experience reduced risks for adverse drug reactions between Invega sustenna and Haldol Deaconoate. 

Decision 3

The decision at this point is to have the patient continue with Invega Sustenna and provide psychological counseling on the effects of the drugs associated with weight gain. It will be essential to explain to the patient that the weight gain from this drug is minimal in comparison with other drugs (Stahl, 2013). The PMHNP will set an appointment follow up date with the patient after one month duration and refer to the nutritionist and physical activity instructor. The difference between expected outcome in decision 3 and results of the decision is Abfility may not be efficacious for more than a period of 6 months given that it does not bind to D 2 receptors in a similar manner as Invega Sustenna. This will necessitate the PMHNP to change to Abfility Maintena because it is easily tolerated by patients on Abfility. 

Because I don’t select the other decisions, the patent will be able to utilize the same drug for the longest possible duration and optimize on their efficacy prior to switching to other types of medication (Stahl, 2013). Since the patient may not have the mental capacity to participate in the decision making process or make autonomous mental health decisions, it is essential to discuss treatment options with the spouse and explain the importance of adherence to treatment (Stein & Giordano, 2015). In addition, the mental health nurse is required to make those decisions which will benefit the patient and also outweigh the risk for adverse health outcomes. 

References

 

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