Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.

For this Assignment, you will practice assessing and diagnosing a patient in a case study who is experiencing a substance-related or addictive disorder. With this and all cases, remember to consider the patient’s cultural background.

To Prepare:
Review this week’s Learning Resources and consider the insights they provide.
Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
By Day 7 of Week 8
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:
Subjective: What details did the patient provide regarding their chief complaint and symptomology 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 priority to lowest 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.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Learning Resources
Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm16

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Chapter 20, Substance Use and Addictive Disorders
Chapter 31.16, Adolescent Substance Abuse
Document: Comprehensive Psychiatric Evaluation Template

Document: Comprehensive Psychiatric Evaluation Exemplar

Required Media (click to expand/reduce)

Classroom Productions. (Producer). (2016). Addictive disorders [Video]. Walden University.

Complex Care Consulting. (2018, April 4). Addiction neuroscience 101 [Video]. YouTube. https://www.youtube.com/watch?v=bwZcPwlRRcc

Video Case Selections for Assignment (click to expand/reduce)

Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected.

Symptom Media. (Producer). (2017). Training title 82 [Video]. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-82

Symptom Media. (Producer). (2018). Training title 114-2 [Video]. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-114-2

Symptom Media. (Producer). (2018). Training title 151 [Video]. https://video-alexanderstreet-com.ezp.waldenulibrary.org/watch/training-title-151

Document: Case History Reports

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6635_Week8_Assignment_Rubric
Grid View
List View
Excellent Good Fair Poor
Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected.

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
18 (18%) – 20 (20%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
16 (16%) – 17 (17%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
14 (14%) – 15 (15%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies.
0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.
In the Objective section, provide:
• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
18 (18%) – 20 (20%)
The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
16 (16%) – 17 (17%)
The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.
14 (14%) – 15 (15%)
Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.
0 (0%) – 13 (13%)
The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.
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.
23 (23%) – 25 (25%)
The response thoroughly and accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
20 (20%) – 22 (22%)
The response accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.
18 (18%) – 19 (19%)
The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.
0 (0%) – 17 (17%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or, assessment documentation is missing.
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!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
9 (9%) – 10 (10%)
Reflections are thorough, thoughtful, and demonstrate critical thinking.
8 (8%) – 8 (8%)
Reflections demonstrate critical thinking.
7 (7%) – 7 (7%)
Reflections are somewhat general or do not demonstrate critical thinking.
0 (0%) – 6 (6%)
Reflections are incomplete, inaccurate, or missing.
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).
14 (14%) – 15 (15%)
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
12 (12%) – 13 (13%)
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.
11 (11%) – 11 (11%)
Three evidence-based resources are provided to support assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.
0 (0%) – 10 (10%)
Two or fewer resources are provided to support assessment and diagnosis decisions. The resources may not be current or evidence based.
Written Expression and Formatting—Paragraph development and organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.

Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.
3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment is vague or off topic.
0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.

No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting—English writing standards:
Correct grammar, mechanics, and punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors
3 (3%) – 3 (3%)
Contains several (three or four) grammar, spelling, and punctuation errors
0 (0%) – 2 (2%)
Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Total Points: 100
Name: NRNP_6635_Week8_Assignment_Rubric

Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

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