NURS 6640 WK4 Assignment.docx - CLIENT ASSESSMENT 1 Client...

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CLIENT ASSESSMENT Client Assessment NURS 6640Walden University 1
CLIENT ASSESSMENT My journal’s purpose is to assess a patient and create an individualized restorative plan of care. In able to obtain a standardized plan of treatment, an evidenced-based practice of care DSM-5 criteria will be used after exploring the patient’s disease process and creating an individualized treatment plan suitable to aid in managing his diagnosis.DemographicsJS is a 40-year old African American man, unmarried and unemployed. He was living with his single aged mother before adult group home and day counseling. He reported of attended a military school. He was an avid user of drugs. He was displaced during Hurricane Harvey and verbalizes inability to copy with loss.Presenting problemsThe patient feels highly depressed due to his loss and displacement during the hurricane Harvey, “I have lost control of my external locus and I feel helpless.”History of present illnessPatient is very depressed with schizophrenic behavior. His onset was last year during Hurricane Harvey and symptoms are apparent and unchanging. His depressive mood was exacerbated with clarity of him not being a member of CIA or SSI and not being able to reconnect with his mother due to their displacement. He acknowledges depressive symptoms such as decrease in appetite, anhedonia and feeling weak. He is well groomed and did not endorse any suicidal and homicidal ideations. He enjoys riding bicycle but doesn’t desire in such recreational activity any longer. He sleeps 6-8 hours at night with 1-2 hours naps in the afternoon when not at the day center. He is always at the day center for counseling 3-4 days a week, “but some days, it feels like a tug of war to come in”. For his anxiety, he is taking Xanax 2mg every 6 hours as needed. He acknowledges that the only over the counter medication he takes is for a cold when he gets one.2
CLIENT ASSESSMENT Past Psychiatric HistoryHe stated that his initial encounter with a psychiatrist was when he was 25 years of age,when he lost his best friend whom he lost to gang activity. He is currently diagnosed with depression with schizophrenic and bipolar characteristics. He was on Paxil 20mg by mouth daily. He had been seen by a psychiatrist until age 29, when he stopped. He denies any psychiatric hospitalization in the past. His need for mental health started after the Hurricane Harvey, which made his depression with schizophrenic behavior worse.Medical HistoryThe patient has no medical history, but a surgical history due to an ankle fracture he obtained during the Hurricane Harvey trying to help others. He said his immunization chart isup-to-date and doesn’t think he will be getting a flu shot this year, because he believes it doesn’t work.

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