Practicum: Decision Tree

Assignment 1: Practicum: Decision Tree

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting symptoms of a mental health disorder.

Learning Objectives

Students will:

• · Evaluate clients for treatment of mental health disorders
• · Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

The Assignment:

Examine Case 2: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

· Decision #1: Differential Diagnosis

· Which Decision did you select?

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?

· Decision #2: Treatment Plan for Psychotherapy

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?

· Decision #3: Treatment Plan for Psychopharmacology

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

· Also include how ethical considerations might impact your treatment plan and communication with clients and their families.

BACKGROUND

Tyrel is an 8-year-old black male who is brought in by his mother for a variety of psychiatric complaints. Shaquana, Tyrel’s mother, reports that Tyrel has been exhibiting a lot of worry and “nervousness” over the past 2 months. She states that she notices that he has been quite “keyed up” and spends a great deal of time worrying about “germs.” She states that he is constantly washing his hands because he feels as though he is going to get sick like he did a few weeks ago, which kept him both out of school and off the playground. He was also not able to see his father for two weekends because of being sick. Shaquana explains that although she and her ex-husband Desmond divorced about 2 years ago, their divorce was amicable and they both endeavor to see that Tyrel is well cared for.

Shaquana reports that Tyrel is irritable at times and has also had some sleep disturbances (which she reports as “trouble staying asleep”). She reports that he has been more and more difficult to get to school as he has become nervous around his classmates. He has missed about 8 days over the course of the last 3 weeks. He has also stopped playing with his best friend from across the street.

His mother reports that she feels “responsible” for his current symptoms. She explains that after he was sick with strep throat a few weeks ago, she encouraged him to be more careful about washing his hands after playing with other children, handling things that did not belong to him, and especially before eating. She continues by saying “maybe if I didn’t make such a big deal about it, he would not be obsessed with germs.”

Per Shaquana, her pregnancy with Tyrel was uncomplicated, and Tyrel has met all developmental milestones on time. He has had an uneventful medical history and is current on all immunizations.

OBJECTIVE

During your assessment of Tyrel, he seems cautious being around you. He warms a bit as you discuss school, his friends at school, and what he likes to do. He admits that he has been feeling “nervous” lately, but when you question him as to why, he simply shrugs his shoulders.

When you discuss his handwashing with him, he tells you that “handwashing is the best way to keep from getting sick.” When you question him how many times a day he washes his hands, he again shrugs his shoulders. You can see that his bilateral hands are dry. Throughout your assessment, Tyrel reveals that he has been thinking of how dirty his hands are; and no matter how hard he tries to stop thinking about his “dirty” hands, he is unable to do so. He reports that he gets “really nervous” and “scared” that he will get sick, and that the only way to make himself feel better is to wash his hands. He reports that it does work for a while and that he feels “better” after he washes his hands, but then a little while later, he will begin thinking “did I wash my hands well enough? What if I missed an area?” He reports that he can feel himself getting more and more “scared” until he washes his hands again.

MENTAL STATUS EXAM

Tyrel is alert and oriented to all spheres. Eye contact varies throughout the clinical interview. He reports his mood as “good,” admits to anxiety. Affect consistent to self-reported mood. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes were apparent. He denies suicidal ideation.

Lab studies obtained from Tyrel’s pediatric nurse practitioner were all within normal parameters. An antistreptolysin O antibody titer was obtained for reasons you are unclear of, and this titer was shown to be above normal parameters.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PMHNP GIVE TO TYREL?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Decision Point One

Obsessive Compulsive Disorder

Decision Point Two

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/05/mm/decision_tree/img/pill-blue.pngBegin Fluvoxamine immediate release 25 mg orally at bedtime

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Upon return to the clinic, Tyrel’s mother reported that he has had some decrease in his symptoms. She states that the frequency of the handwashing has decreased, and Tyrel seems a bit more “relaxed” overall.

· She also reports that Tyrel has not fully embraced returning to school, but that his attendance has improved. She reported that over this past weekend, Tyrel went outside to play with his friend from across the street, which he has not done in a while.

Decision Point Three

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/05/mm/decision_tree/img/pill-red.pngIncrease Fluvoxamine to 50 mg orally at bedtime Practicum: Decision Tree.

Guidance to Student

In terms of an actual diagnosis, the child’s main symptoms are most consistent with obsessive-compulsive disorder. There may also be an element of social phobia developing, but at this point, the PMHNP has not assessed the nature of the school avoidance—that is, why is the child avoiding school. Notice that nothing in the scenario tells us that the PMHNP has assessed this. Practicum: Decision Tree.

Fluvoxamine immediate release is FDA-approved for the treatment of OCD in children aged 8 years and older. Fluvoxamine’s sigma-1 antagonist properties may cause sedation and as such, it should be dosed in the evening/bedtime.

At this point, it would be appropriate to consider increasing the bedtime dose, especially since the child is responding to the medication and there are no negative side effects. Practicum: Decision Tree.

Atypical antipsychotics are typically not used in the treatment of OCD. There is also nothing to tell us that an atypical antipsychotic would be necessary (e.g., no psychotic symptoms). Additionally, the child seems to be responding to the medication, so there is no rationale as to why an atypical antipsychotic would be added to the current regimen.

Cognitive behavioral therapy is the psychotherapy of choice for treating OCD. The PMHNP should augment medication therapy with CBT. If further assessment determines that Tyrel has social anxiety disorder, CBT is effective in treating this condition as well. Practicum: Decision Tree.

NURS 660 Week 4: Trauma and Stressor-Related Disorders in Childhood

“He was drunk again, so I should have known better. I should have stayed away from the house, but that would have made him madder. He has done this before, but not nearly this bad. He broke my wrist as I was protecting my mom. The neighbor heard the screaming and called the cops. They hauled him away, but I know he will be back. She always lets him come back.”

Avery, age 14

In August of 2005, thousands of children lost their homes in Hurricane Katrina. On December 14, 2012, the students at Sandy Hook Elementary School experienced the death of 20 of their classmates and six of their teachers. Every day, children experience physical and sexual abuse and neglect by their parents or caregivers. These types of trauma have a lifelong impact on the children involved and those witnessing the events. As much as we try to prevent unwanted childhood trauma and stressors, the phenomena are present in our culture. Practicum: Decision Tree. Childhood trauma is a significant contributor to both physical and mental health problems in children and adults.

This week, you examine several cases of child abuse and neglect, and you recommend strategies for assessing for abuse. You analyze influences of media and social media on mental health and evaluate the need for mandatory reporting of abuse. You also submit your Practicum Journal and Assignments. Practicum: Decision Tree.

Photo Credit: StaffordStudios / Getty Images

Learning Resources

Required Readings

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

· Chapter 31, “Child Psychiatry” (pp. 1216–1226)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

· “Trauma- and Stressor-related Disorders”

Note: You will access this book from the Walden Library databases.

Pfefferbaum, B., & Shaw, J. A. (2013). Practice parameter on disaster preparedness. Journal of the American Academy of Child & Adolescent Psychiatry, 52(11), 1224–1238. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00550-9/pdf Practicum: Decision Tree

American Psychiatric Nurses Association. (2017). Childhood and adolescent trauma. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageID=4545

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

Optional Resources

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.

· Chapter 50, “Provision of Intensive Treatment: Intensive Outreach, Day Units, and In-Patient Units” (pp. 648–664)

· Chapter 58, “Disorders of Attachment and Social Engagement Related to Deprivation” (pp. 795–805)

· Chapter 59, “Post Traumatic Stress Disorder” (pp. 806–821)

· Chapter 64, “Suicidal Behavior and Self-Harm” (pp. 893–912)

Discussion: Treating Childhood Abuse

In 2012, statistics in the United States indicated that state CPS agencies received 3.4 million referrals for child abuse and neglect. Of these, nearly 700,000 children were found to be victims of maltreatment: 18% were victims of physical abuse and 78% were victims of neglect (CDC, 2014). Child sexual abuse makes up roughly 10% of child maltreatment cases in the United States (CDC, 2014). The CDC considers sexual abuse at any age a form of violence. Child abuse of any kind can lead to an increased state of inflammatory markers in adulthood, as well as multiple physical illnesses and high-risk behavior such as alcoholism and drug abuse. If a PMHNP identifies child abuse, there may be a need to report the abuse to authorities. Practicum: Decision Tree. Once able to provide treatment, the PMHNP can be instrumental in reducing the long-term effects of child abuse.

In this Discussion, you recommend strategies for assessing for abuse and analyze influences of media and social media on mental health. You also evaluate the need for mandatory reporting of abuse.

Learning Objectives

Students will:

· Recommend strategies for assessing for abuse

· Analyze influences of media and social media on mental health

· Evaluate the need for mandatory reporting of abuse

To Prepare for this Discussion:

· Read the Learning Resources concerning treating childhood abuse.

· Read the Child Abuse Case Study in the Learning Resources. See Child Abuse Case Study

Assignment Question to be addressed Practicum: Decision Tree

· What strategies would you employ to assess the patient for abuse? Explain why you selected these strategies.

· How might exposure to the media and/or social media affect the patient?

· What type of mandatory reporting (if any) is required in this case? Why?

Child Abuse Case Study

NURS 6660: Psychiatric Mental Health Nurse Practitioner Role I: Child

and Adolescent

Child Abuse Case Study
NURS 6660: Psychiatric Mental Health Nurse Practitioner Role I: Child and Adolescent
Morgan, a 19-year-old male comes to your office to discuss his current mood and symptoms. This is his first visit to a mental health clinic. “I’ve had 26 jobs in the last 2years; I finally have a job that I like and I want to make it work.” As you begin to get to know him, he tells you that his mood is down and that he also has times where he has “more energy and motivation”: “That’s when I am able to get a new job.” Practicum: Decision Tree. He says that he has difficulty interacting with coworkers. “I feel like I can’t talk to them.” If it wasn’t for his supportive girlfriend, he wouldn’t be able to function. “She understands me and accepts me; she knows what I have been through.”
As the PMHNP listens to the client and explores what he means by some of his statements, you try to put together his story. He mentions that he has been having nightmares and is not sleeping well. He says he startles easily. He becomes withdrawn when he begins to talk about the reason for the nightmares.“This all started a few weeks ago when a cousin of mine got out of jail.” He haltingly tells the story of his parents’ mental illness and how he had to live with various relatives. “One cousin who I stayed with a lot took advantage of me. He molested me.” They found out he also molested other children and he went to jail. “It gives me the creeps that he is out of jail. I have to face what he did to me.” Morgan asks about his diagnosis. The PMHNP tells him that he has some symptoms that sound like depression and anxiety, and that when a child has a traumatic experience, it can reoccur and stay with a person for many years. He acknowledges that he thought about PTSD but wasn’t sure what the symptoms look like.
As you think about Morgan’s story, consider the following questions: Where did he fall between the cracks? Are there agencies who advocate for children like him? There are thousands of children like Morgan. They were in a vulnerable family situation and the “responsible” adult was not able to care for the child. Sometimes it takes yearsfor clients to remember and disclose the abuse. Practicum: Decision Tree

Week 4: Trauma and Stressor-Related Disorders in Childhood

“He was drunk again, so I should have known better. I should have stayed away from the house, but that would have made him madder. He has done this before, but not nearly this bad. He broke my wrist as I was protecting my mom. The neighbor heard the screaming and called the cops. Practicum: Decision Tree. They hauled him away, but I know he will be back. She always lets him come back.”

Avery, age 14

In August of 2005, thousands of children lost their homes in Hurricane Katrina. On December 14, 2012, the students at Sandy Hook Elementary School experienced the death of 20 of their classmates and six of their teachers. Every day, children experience physical and sexual abuse and neglect by their parents or caregivers. These types of trauma have a lifelong impact on the children involved and those witnessing the events. Practicum: Decision Tree. As much as we try to prevent unwanted childhood trauma and stressors, the phenomena are present in our culture. Childhood trauma is a significant contributor to both physical and mental health problems in children and adults.

This week, you examine several cases of child abuse and neglect, and you recommend strategies for assessing for abuse. You analyze influences of media and social media on mental health and evaluate the need for mandatory reporting of abuse. You also submit your Practicum Journal and Assignments.

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Practicum: Decision Tree.

Required Readings

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

• Chapter 31, “Child Psychiatry” (pp. 1216–1226)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

• “Trauma- and Stressor-related Disorders”

Note: You will access this book from the Walden Library databases.

Pfefferbaum, B., & Shaw, J. A. (2013). Practice parameter on disaster preparedness. Journal of the American Academy of Child & Adolescent Psychiatry, 52(11), 1224–1238. Retrieved from http://www.jaacap.com/article/S0890-8567(13)00550-9/pdf Practicum: Decision Tree.

American Psychiatric Nurses Association. (2017). Childhood and adolescent trauma. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageID=4545

Document: Childhood Abuse Case Study (PDF)

 

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

Note: All Stahl resources can be accessed through the Walden Library using the link. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear. Practicum: Decision Tree.

To access information on the following medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

Posttraumatic stress disorder
citalopram clonidine desvenlafaxine escitalopram fluoxetine fluvoxamine mirtazapine nefazodone paroxetine prazosin (nightmares) propranolol (prophylactic) sertraline venlafaxine

Note: Many of these medications are FDA approved for adults only. Some are FDA approved for disorders in children and adolescents. Many are used “off label” for the disorders examined in this week. As you read the Stahl drug monographs, focus your attention on FDA approvals for children/adolescents (including “ages” for which the medication is approved, if applicable) and further note which drugs are “off label.” Practicum: Decision Tree.

Optional Resources

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.

• Chapter 50, “Provision of Intensive Treatment: Intensive Outreach, Day Units, and In-Patient Units” (pp. 648–664)
• Chapter 58, “Disorders of Attachment and Social Engagement Related to Deprivation” (pp. 795–805)
• Chapter 59, “Post Traumatic Stress Disorder” (pp. 806–821)
• Chapter 64, “Suicidal Behavior and Self-Harm” (pp. 893–912)

Discussion: Treating Childhood Abuse

In 2012, statistics in the United States indicated that state CPS agencies received 3.4 million referrals for child abuse and neglect. Of these, nearly 700,000 children were found to be victims of maltreatment: 18% were victims of physical abuse and 78% were victims of neglect (CDC, 2014). Child sexual abuse makes up roughly 10% of child maltreatment cases in the United States (CDC, 2014). Practicum: Decision Tree. The CDC considers sexual abuse at any age a form of violence. Child abuse of any kind can lead to an increased state of inflammatory markers in adulthood, as well as multiple physical illnesses and high-risk behavior such as alcoholism and drug abuse. If a PMHNP identifies child abuse, there may be a need to report the abuse to authorities. Once able to provide treatment, the PMHNP can be instrumental in reducing the long-term effects of child abuse.

In this Discussion, you recommend strategies for assessing for abuse and analyze influences of media and social media on mental health. You also evaluate the need for mandatory reporting of abuse. Practicum: Decision Tree.

Learning Objectives

Students will:

• Recommend strategies for assessing for abuse
• Analyze influences of media and social media on mental health
• Evaluate the need for mandatory reporting of abuse

To Prepare for this Discussion:

• Read the Learning Resources concerning treating childhood abuse.
• Read the Child Abuse Case Study in the Learning Resources.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts and cannot post anonymously Practicum: Decision Tree. Please check your post carefully before clicking Submit!

By Day 3

Post:

• What strategies would you employ to assess the patient for abuse? Explain why you selected these strategies.
• How might exposure to the media and/or social media affect the patient?
• What type of mandatory reporting (if any) is required in this case? Why?

By Day 6

Respond to at least two of your colleagues by providing at least two ways that their strategies may be expanded or improved.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 4 Discussion Rubric

Post by Day 3 and Respond by Day 6

To participate in this Discussion:

Week 4 Discussion

Assignment 1: Practicum: Week 1 Practicum Journal

By Day 7

Submit your Assignment. Refer to Week 1 for additional guidance.

Submission and Grading Information NURS 6660 Trauma and Stressor-Related Disorders

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK4Assgn1+last name+first initial.(extension)” as the name. NURS 6660 Trauma and Stressor-Related Disorders
• Click the Week 4 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 4 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK4Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database. Practicum: Decision Tree.
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 4 Assignment 1 Rubric NURS 6660 Trauma and Stressor-Related Disorders

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 4 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 7

To submit your Assignment:

Week 4 Assignment 1

Assignment 2: Practicum: Week 3 Decision Tree

By Day 7 NURS 6660 Trauma and Stressor-Related Disorders

Submit your Assignment. Refer to Week 3 for additional guidance.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK4Assgn2+last name+first initial.(extension)” as the name.
• Click the Week 4 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 4 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area. Practicum: Decision Tree.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK4Assgn2+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric: NURS 6660 Trauma and Stressor-Related Disorders

Week 4 Assignment 2 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 4 Assignment 2 draft and review the originality report.

Submit Your Assignment by Day 7

To submit your Assignment:

Week 4 Assignment 2 NURS 6660 Trauma and Stressor-Related Disorders

Assignment 3: Board Vitals

This week you will be responding to twenty Board Vitals questions that cover a broad review of your Nurse Practitioner program courses up to this point.

These review questions will provide practice that is critical in your preparation for the national certification exam that’s required to certify you to practice as a nurse practitioner. These customized test questions are designed to help you prepare for your Nurse Practitioner certification exam. It is in your best interest to take your time, do your best, and answer each question to the best of your ability. NURS 6660 Trauma and Stressor-Related Disorders

You can access Board Vitals through the link sent to you in email or by following the link below:

By Day 7 NURS 6660 Trauma and Stressor-Related Disorders

Complete the Board Vitals questions.

Practicum Reminder

Time Logs

You are required to keep a log of the time you spend related to your practicum experience and enter every patient you see each day. You can access your time log from the Welcome Page in your Meditrek account. You track time individually for each patient you work with. Please make sure to continuously input your hours throughout the term.

Making Connections

This week, you examined several cases of child abuse and neglect and recommended strategies for assessing for abuse. You analyzed influences of media and social media on mental health and evaluated the need for mandatory reporting of abuse. You also submitted your Practicum Journal and Assignments. Practicum: Decision Tree.

Next week, you analyze case studies to determine the diagnosis and treatment of anxiety disorders.