NRNP 6665 Assessing, Diagnosing, and Treating Adults With Mood Disorders
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
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In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
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Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To Prepare
- Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
- Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
- Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
- Consider what history would be necessary to collect from this patient.
- Consider what interview questions you would need to ask this patient.
- Consider patient diagnostics missing from the video:Provider Review outside of interview:Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)
The Assignment
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
- Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
- Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
By Day 7 of Week 4
Submit your Focused SOAP Note.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK1Assgn+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Assessing, Diagnosing, and Treating Adults With Mood Disorders
In the field of psychiatric mental health nursing, a thorough comprehension of mood disorders is a fundamental prerequisite for psychiatric mental health nurse practitioners (PMHNPs). This understanding empowers them to effectively evaluate, diagnose, and develop appropriate treatment plans for individuals presenting with mood disorders. Mood disorders are characterized by disruptions in a person’s emotional state, and they are typically diagnosed based on specific criteria related to the severity of symptoms, functional impairment, and the duration of these emotional disturbances. For those grappling with mood disorders, these conditions often encroach upon various aspects of their lives, including daily functioning, work, relationships, and overall well-being. Left unaddressed, mood disorders can lead to detrimental consequences such as substance abuse or even thoughts and behaviors related to suicide. However, the good news is that with an effective treatment plan and an understanding of symptom management, individuals with mood disorders can experience substantial improvement in their quality of life.
In this assignment, the primary goal is to assess, diagnose, and devise a treatment plan for a patient who is presented through a case study and is experiencing a mood disorder.
For successful completion of this assignment, it is crucial to thoroughly review the learning resources provided for this week. These resources offer valuable insights into the assessment, diagnosis, and treatment of mood disorders, equipping PMHNPs with the knowledge and skills necessary to provide effective care. Additionally, you will need to familiarize yourself with the Focused SOAP Note template, which will serve as the framework for this assignment. An exemplar of a Focused SOAP Note is also available, offering guidance and illustrating the expected standards for this assignment. Furthermore, you are encouraged to watch the video titled “Case Study: Petunia Park,” where a Walden faculty member engages in an assessment of a simulated patient represented as an avatar. This video serves as the basis for the case study in this assignment and will assist in identifying the crucial patient history that needs to be collected and the vital interview questions to be asked.
To develop a comprehensive Focused SOAP Note, including a differential diagnosis and a well-founded thought process for the primary diagnosis, you should include the following elements in your responses within the provided template:
Subjective: In this section, you will integrate the information provided by the patient concerning their chief complaint and symptomatology. It is essential to elucidate how this information has contributed to the formation of your differential diagnosis. Additionally, you should expound on the duration and severity of the patient’s symptoms and describe how these symptoms are impinging on their daily functioning.
Objective: Document your objective observations made during the psychiatric assessment. This section should present a clear and concise overview of the patient’s current state.
Assessment: Here, you will delve into a comprehensive analysis of the patient’s mental status examination results. You are required to provide a thorough discussion of your differential diagnoses. Include a minimum of three potential diagnoses, listing them in order of priority. To substantiate your diagnostic considerations, it is essential to relate each differential diagnosis to the DSM-5-TR diagnostic criteria. In doing so, you should elucidate how these criteria either support or exclude a particular diagnosis, ultimately leading you to the selection of a primary diagnosis. Your critical-thinking process should be presented in a clear and well-structured manner, encompassing both pertinent positives (information that supports the diagnosis) and pertinent negatives (information that rules out the diagnosis) specific to the patient case.
Rubric
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Create documentation in the Focused SOAP Note Template about the patient in the case study. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS
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In the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
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In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
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In the Plan section, provide:• Your plan for psychotherapy• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. • Incorporate one health promotion activity and one patient education strategy.
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• Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
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Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
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Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.
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Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation
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Total Points: 100
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