WK7A2 What is Assessing Client Family Progress?

Practicum – Assessing Client Family Progress
Objectives: 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 in the uploaded document.
ACTUAL ASSIGNMENT
PLEASE Addressed each of the bullets with a subtopic, use the resources, you can use other references
within last five years only to 2019. Please do not begin a paragraph with author name(s) (PLEASE USE
parenthetical/in-text citations)
Part 1: Progress Note
Using the client family in the uploaded document, 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
Part 2: Privileged Note
Based on the resources/references, prepare a privileged psychotherapy note that you would use to
document your impressions of therapeutic progress/therapy sessions for your client family in the
uploaded document.
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.
References/Resources
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice
(2nd ed.). Washington, DC: Author.
• Standard 5B “Health Teaching and Health Promotion” (pages 55-56)
Nichols, M. (2014). The essentials of family therapy (6th ed.). Boston, MA: Pearson.
• Chapter 8, “Experiential Family Therapy” (pp. 129–147)
• Chapter 13, “Narrative Therapy” (pp. 243–258)
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for
evidence-based practice. New York, NY: Springer.
• “Genograms” pp. 137-142
Cohn, A. S. (2014). Romeo and Julius: A narrative therapy intervention for sexual-minority couples.
Journal of Family Psychotherapy, 25(1), 73–77. doi:10.1080/08975353.2014.881696
Escudero, V., Boogmans, E., Loots, G., & Friedlander, M. L. (2012). Alliance rupture and repair in conjoint
family therapy: An exploratory study. Psychotherapy, 49(1), 26–37. doi:10.1037/a0026747
Freedman, J. (2014). Witnessing and positioning: Structuring narrative therapy with families and
couples. Australian & New Zealand Journal of Family Therapy, 35(1), 20–30. doi:10.1002/anzf.1043
Phipps, W. D., & Vorster, C. (2011). Narrative therapy: A return to the intrapsychic perspective. Journal
of Family Psychotherapy, 22(2), 128–147. doi:10.1080/08975353.2011.578036
Saltzman, W. R., Pynoos, R. S., Lester, P., Layne, C. M., & Beardslee, W. R. (2013). Enhancing family
resilience through family narrative co-construction. Clinical Child and Family Psychology Review, 16(3),
294–310. doi:10.1007/s10567-013-0142-2
Running Head: PRACTICUM – ASSESSING CLIENT FAMILIES
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Part 1: Comprehensive Client Family Assessment
Demographic information
M.H is a 19-year-old, Hispanic female.
And her mother, a middle age Hispanic
Presenting problem
An 18-year-old female who presented with anxiety and depression asked for a family
session with her mother to address her worries she kept to herself, concerning their family
dynamic. The client reported that family issues are the main cause of her mental health problems
and failing grades at school.
History or present illness
Client reports that she started feeling anxious and depressed nine months ago when her
brother and his wife with their two children came to live with them. The client was in a good
mental state when just her and her mother lived in their home.
Past psychiatric history
The client has never seen a psychiatrist or diagnosed with mental health problems. This
was her first time in a mental health facility.
Medical history
Client reports seasonal allergies. Client’s mother has thyroid cancer in remission. The
client reported her father suffers from back pain as he is a construction worker.
Substance use history
Client denied substance use. Client’s mother reported alcohol use occasionally. The client
reported that her brother and his wife drink alcohol daily which affects their ability to work and
efficiently take care of their two children.
PRACTICUM – WEEK 3 ASSESSING CLIENT FAMILIES
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Developmental history
None reported. The client was born full term with no problems growing up.
Family psychiatric history:
Mother reported no mental health issues. Client’s father has anger management issues
and anxious most of the time but has never been seen by a psychiatrist or diagnosed with mental
health issues. The client reported that her brother and his wife have alcohol abuse problems but
has never sought help or treatment.
Psychosocial history
The client reported that she had a lot of friends and got along with them until recently.
Client’s mother reported she does not have any friends currently since her best friend dated her
husband and the friendship was dissolved.
History of abuse/trauma
Client denies any abuse/trauma. None reported by the client’s mother.
Review of systems
Gen: Client and her mother denied and recent weight changes, weakness, fatigue or fever.
EENT: Client and her mother denied visual or hearing problems, nasal discharge or
allergies, teeth or sore throat problems.
Neck: Client and her mother denied neck pain, stiffness or history of neck injury.
Respiratory: No breathing difficulties or wheezing observed nor reported
Cardiovascular/Peripheral Vascular: Denied chest pain/chest discomfort. No history of
thrombosis or claudication reported.
Gastrointestinal: Client and her mother denied nausea, vomiting, diarrhea, constipation or
abdominal discomfort. The client reported decreased appetite.
PRACTICUM – WEEK 3 ASSESSING CLIENT FAMILIES
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Genitourinary: Client and her mother denied any urinary or sexual problems.
Musculoskeletal: No history of arthritis or gout reported by the client and her mother.
Skin: Denied bruising, rashes or itching. Client’s skin and her mother’s skin are intact.
Neuro: Denied seizures, paralysis or muscle weakness.
Psych: Client denied having any suicidal/homicidal ideations and reports anxiety and depression
Allergic/Immunologic: No allergies
Physical assessment
Client’s Vital Signs: BP 108/64, P66, RR18, T97.8, WT 120LBS, Ht 548inches
Appearance: Client and her mother appeared neat, well-groomed and had appropriate clothing
for the weather. The client looked tired and anxious.
Mental status exam
Orientation: Client and her mother are alert and oriented to person, place and time
Appearance: Neatly groomed and steady gait.
Behavior/Attitude: Cooperative, good eye contact, polite, sometimes yawning and rubbing
fingers together
Speech: Clear, normal rate, rhythm, and spontaneous
Mood: Anxious and depressed
Affect: Appropriate to the situation, congruent
Thought Process: Logical and goal-directed
Thought Content: No delusions or paranoia noted
Suicidal/Homicidal Ideation: No suicidal or homicidal ideation noted
Cognitive/Concentration: grossly intact
Memory: grossly intact
PRACTICUM – WEEK 3 ASSESSING CLIENT FAMILIES
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Insight/Judgment: Good
Impulse control: Good
Differential Diagnoses
Generalized Anxiety Disorder, 300.02 (F41.1)
Major Depressive Disorder (MDD) 296.33 (F33.2)
M.H. reported that since his brother moved in to live them, she feels anxious and has
difficulties concentrating on house chores or school work, she feels restless at night and hardly
sleeps well nor feels rested, which are signs of anxiety (American Psychiatric Association,
2013). The client was also observed rubbing fingers together during a family therapy session and
sometimes taking deep breaths. In addition, M.H. also suffers from depression as she revealed
having crying spells, decreased appetite, decreased sleep, mostly isolated in her room and have
no interest to visit with friends like she used to do before her brother and his family moved in to
live with them (Wheeler, 2014). M.H. reports that she always feels sad on daily basis at home
and school 9 months ago.
Case formulation
The client is an 18-year-old female who presented with a panic attack because of being
overwhelmed with family problems and failing school grades. Client lives with her mother,
brother, and wife with two kids in a tiny family house, takes care of the two kids and picks them
from school because she is the only one driving and their parents are always drunk. She feels
depressed, anxious on a daily basis since her brother and his family moved in to live with them.
She reports less concentration, less appetite, less sleep, crying most times, has no friends and
isolates herself. The client does not have the courage to explain how she feels to her mother.
Client’s mother often tells her to “be strong and snap out of it” every time a client tries to talk to
PRACTICUM – WEEK 3 ASSESSING CLIENT FAMILIES
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her. The last trigger was when the client saw her failing grade and realized her inability to
function well. Generalized anxiety disorder and major depressive disorder are given for
individuals with prolonging symptoms affecting their functional levels and their daily lives like
the case of M.H. Most clients with depressive symptoms also experience anxiety symptoms
(Möller, Bandelow, Volz, Barnikol, Seifritz, & Kasper, 2016).
Treatment plan
With process therapy, M.H will address her problems and fears with her mother during
and at home as needs arise. M.H. will, identifying her emotions, express her thoughts and
feelings in relation to her expected duties of caring for her brother’s children and be able to set
her boundaries with what she can and cannot do. Her progress will be measured through her
feelings, her mother’s feedbacks and therapist observations. Journaling and psychotherapy will
be offered to M.H. to assist her through the process.
M.H. will be encouraged to continue with psychotherapy to explore her feelings, hygienic
ways to improve sleep, her experiences and how they affect relationships. Supportive
psychotherapy, cognitive-behavioral, and interpersonal conceptual models will be used by the
therapist for the treatment of anxiety and depression (Margolies, 2016). Supportive reflection,
interactive feedback, and symptom management will be also used. Moreover, the therapist will
assist the client to develop diverse helpful coping skills to use during stressful times to include
relaxation and deep breathing exercises.
PRACTICUM – WEEK 3 ASSESSING CLIENT FAMILIES
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Part 2: Family Genogram
Levi
Mary
Mathew
Sarah
Great Grand Parents
x
Thomas (Father)
Esther (aunt)
John
Camila (Mother)
Parents
Grandchildren
Married
Myra (Client)
Jorge (Brother)
Jane (sister-in-law)
Great-grandchildren
Mia
Ryan
PRACTICUM – WEEK 3 ASSESSING CLIENT FAMILIES
Reference
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Margolies, L. (2016). Understanding Different Approaches to Psychotherapy. Psych Central.
Möller, H.-J., Bandelow, B., Volz, H.-P., Barnikol, U. B., Seifritz, E., & Kasper, S. (2016). The
relevance of “mixed anxiety and depression” as a diagnostic category in clinical
practice. European Archives of Psychiatry and Clinical Neuroscience, 266(8), 725–736.
http://doi.org/10.1007/s00406-016-0684-7
Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A howto guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing
Company.
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