Paper Example on Psychiatric Assessment: Finding the Right Treatment Plan

Introduction

Psychiatric assessment is vital in providing clients with the right treatment plan. Different models are applied to address mental disorders. However, nursing practitioners are required to adopt psychiatric mental assessment guidelines in assessing individuals with high risks to mental disorders. An accurate assessment is essential in providing the right treatment. Therefore, any nurse's role is to identify the right approach in identifying and enhancing the client's progress during treatment. Wheeler (2014) explained that a client-centered assessment facilitates quality outcomes in terms of treatment. Such outcomes are only based on the nurse's ability to adopt the right assessment guideline. The primary goal of assessment is to identify the client with a problem and find the right treatment plan. The paper, therefore, seeks to evaluate different symptoms presented by the client with critical mental issues. It further aims to develop a genogram that fits the issues presented by the client and develop the right treatment plan. Interventions applied will be based on the results acquired after the assessment.

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Demographic Information

The client presented in the report was female in 35-years black American from North Carolina. He raises his son single-handedly after a divorce with her husband. She has been going through different challenges relating to the raising and upkeep of their son. However, the recent event exposed her to a more challenging situation that challenged her finances and savings. She lost her job, thus left with no source of income. However, she noted that the husband had some savings, which she transferred from their child's upkeep. From the brief introduction, the client shared many cases of mental wellness programs she has joined in the past but failed to address her primary health crisis.

Presenting Problem

The client presented symptoms linked to personality disorder. Insecurity, fear, and disturbance were common. She was concerned about what people thought about her situation. After divorce, issues with depression have similarly contributed to the frequent cases of anger that she described that she often directs to the son.

History of Present Illness

The medical history of the patient was assessed, and reports highlighted through the American Psychiatric Association (2013) guideline. The patient described a history of the mental and psychiatric problems within their family. This was further noted with what she described as her highly tempered mother. She referred to different incidences and situations where she has had to behave weird and destructive to the son. She often finds herself throwing tantrums on other people. The explosive outburst negatively affected his son, and this explains the reasons for the son's poor performance in school. Furthermore, the client further explains that she aspect most of the time in the house. As a teenager, she was exposed to both physical and sexual abuse due to insecure neighborhoods. She described that the encounter changed her life and affected the way she perceives people and society. The origin of the problem and increasing distrust in people was further attributed to racial segregation she encountered in school (American Psychiatric Association, 2013).

Roque Ferreira et al. (2017) noted that, racial discrimination is one of the primary causes of mental health threats. This client has been similarly noted since she provides an extensive review of how her schooling days affected her current perception of society. Furthermore, the client reported cases of panic attacks. This is sometimes common when a person is exposed to fear (Copeland et al., 2015). On the contrary, it can cause detrimental side effects when left untreated (Silverman et al., 2015). The patient explained different encounters with early employers in her life. In many cases, she was exposed to fear of the consequences of not following instructions and guidelines required at the workplace. As such, she developed panic attacks that further exposed her to increasing mental issues. She reports having sought medication in the healthcare facilities. However, she often relaxed her mind through the consumption of alcohol.

Past Psychiatric History

The client has a history of diverse mood fluctuations that vary based on the exposure to stress and mentally draining activities. The client noted increased alcohol consumption. Her alcohol consumption was meant to relieve her mind from the stressful incidences that directly affected her life. She agreed to the question of encountering depression for more than two consecutive days. She also agreed to have attempted suicide three times after the divorce. However, after the event, she sought to seek medical help where she was prescribed antidepressants, which were to be taken two times a day. Escitalopram had been prescribed along with Fluoxenbtine, which were to be taken at 10 grams per day (Vachon et al., 2015). She admits having had a history of abuse in both childhood and her marriage. Besides, the case of hospitalization was required when she encountered panic attacks. She sought treatment thus recommended to rake bed rest and antidepressant medications

History of Abuse or Trauma

A positive response was provided after an assessment on the history of abuse and trauma. The client reported a case of physical abuse in early childhood. Besides, recent cases of assault were more detrimental. She describes a repeated case of violence from her divorced husband. She described that the husband demeaned her efforts to contribute to the family's upkeep. Although she does not provide a detailed report regarding the extent to which physical abuse affected the child, she explains that she was more disturbed by the fact that their kid had witnessed all the physical abuse and feared for his future' mental wellness. Furthermore, she reported about the latest hob loss. Although this did not seem to bother her as such, she had to describe the different effects of her job loss on her mentality and ability to tackle other daily challenges. The primary cause of traumatic incidences in her life remains that she encountered in high school. She described an incident where other students had to bully and underrate her. Therefore, the issues have often instilled fear in approaching people from other communities.

Medical History

The client reports cases of eye irritation and regular headaches, along with high blood pressure. Her mood, anxiety, and depression primarily determined the rate of occurrences. She states that cases of headache and high blood pressure often occurred whenever she recalled the core incidences of physical abuse. Her physical assessments were good. However, the causes of eye irritation and headaches meant that additional interventions would efficiently promote qualitative recovery. Eye examinations did not, however, reveal any severe issue. She further explained that she often access primary care services in her clinic, and this had offered an opportunity for her to get regular drugs and prescription of special mediation required to reliance her mood.

Substance Use History

Substance use is one of the factors that contribute to significant health issues. Assessment based on this factor showed that the client was not engaged in significant drug and substance abuse. Instead, alcohol consumption was only identified. Additionally, she reported about her reliance on caffeine. She consumed coffee excessively to keep herself awake when she was required to work from home.

Developmental History

The developmental assessment showed a normal and progressive milestone. When asked about her developmental progress, she explained that she reached all her developmental processes on time. Moreover, her schooling days were featured with excellent performance. However, she only quoted a few events when she got ill with flu in high school and had to stay home. Her relationship with the parents and friends was good. Even during her marriage, she had a few friends she would talk to. However, she further reports having completed college-level studies without any developmental issue.

Family Psychiatric History

The client is the last born in a family of 12 children. She reports that two of his brothers are addicted to drug abuse. However, they have been able to seek treatment. She further reported that her uncle is a drug abuse addict, and this has contributed to his mental disorders. Her parents are from an extended family with a healthy social relationship. Moreover, she noted that two of her aunties had a significant problem in relating to people. At one point, one of them was diagnosed with depression while her other one had a personality disorder.

Psychosocial History

The client noted that she was born and raised in North Carolina. However, her grandparents were of African origin. Out of the 12 children, three of her sisters stayed with her parents. The client similarly reported having completed college swiftly and secured a job two months after graduation. Her dream was to see his son grow in the presence of his father. She describes that fatherly presence is vital for the growth and development of any child. Thus, she aspired to be a good mother by keeping the child with his father. The unfortunate event of divorce has, therefore, threatened her social capacity to relate with her friends and manage different questions and issues raised by the child. She also noted that a lack of a supportive social environment had threatened her mental health. Most of her friends intervened in their family matters whenever the husband assaulted her.

Review of Systems

The client explained a major concern about weight loss and lack of sleep. The case of sleep disturbance was attributed to past traumatic events. Assessment of panic and fear was also revealed through the client's report

Evaluation on his head and neck showed a minor case of injury. However, she reports one instance when the husband hit her head with the bottle. The incident did not have any significant threat since the case was minor. Assessment on the head-neck motion similarly showed an efficient movement featured by symmetrical alignment.

Her chest was fine. Assessment questions aimed to find is the patient has ever had disorders related to the region. In response, the client noted that her chest has been healthy throughout her life.

Her vision is excellent. However, cases of irritation were attributed to a minor infection. The client however noted increased levels of such when faced with stressful events.

The client did not have any hearing problems. She denies cases where she has had trouble hearing. Moreover, she had never had any pain in her ears.

Assessment of throat and mouth showed a healthy and proper functioning of the region. Proper chewing and swallowing were noted. The client did not report any major case of throat infection.

The client reported having had a normal nose functioning. Except for a few cases when she had flu, she has never lost her sense of smell. However, cases of nose bleeding occurred when exposed to high temperatures.

The client reports having had tuberculosis when she was in high school. However, respiratory issues, such as difficulty in breathing, have never been featured in her life. Cases of cough and sputum occur when she has coughs and chest-related conditions, which she noted as rare occurrences. Besides, coughs and colds had a minor impact on her health. Assessment of other areas showed proper functioning

Physical Assessment and Neurological Examination

The physical evaluation was conducted from head to toe. The client's height was 4.5'10', with a weight of 100 pounds. Her body's mass index was noted at 21.3. Her blood pressure was recorded at145/105 which revealed a significant issue linked to her...