Mental Health Evaluation of An Adolescent Client Case Study

  1. Select a pediatric/adolescent client or case that you have worked within either in your current nursing practice or your PMHNP student clinical setting. Ensure that you correctly remove the appropriate information (name, etc.) to remain HIPAA compliant.
  2. Prepare a full mental health evaluation on your pediatric/adolescent client. Use the resources presented in the course to help guide your evaluation. Kaplan & Saddock’s Synopsis of Psychiatry has a robust list of the categories of information you should collect and present in your evaluation report (5.1. Parts of the Initial Psychiatric Interview). This should include the following:
    1. A full psychiatric, physical, social, family, and birth and developmental history including verbal reports of the client, your observations of the client, and a summary of any diagnostic aids that you have used.
    2. The use of at least one psychiatric screening or assessment tool from the literature to assist in your assessment of the client
    3. A full physical assessment in addition to the mental status exam and psychiatric history
  3. Develop a DSM-5 diagnostic assessment:
    1. Support your diagnosis through a thoughtful, evidence-based rationale of the data collected in your evaluation.
  4. Propose a practical, evidence-based plan of care:
    1. Keep in mind the role of the psychiatric-mental health nurse practitioner is to assess all aspects of the patient’s health status, including health promotion, and disease prevention. Psychiatric care is interdisciplinary. Your plan of care may include the use of other mental health professionals for the delivery of appropriate care. For example, someone who has been chronically back pain, and has been out of work may have these factors contributing to his or her depression and may require a pain specialist and social services to address those aspects of the client’s poor psychological functioning.

Expert Solution Preview

Introduction: In this assignment, we will be evaluating a pediatric/adolescent client’s mental health condition and creating a practical, evidence-based plan of care. We will be using resources such as Kaplan & Saddock’s Synopsis of Psychiatry to collect and present information and develop a DSM-5 diagnostic assessment. As psychiatric-mental health nurse practitioners, our role is to assess all aspects of the patient’s health status and provide interdisciplinary care for optimal patient outcomes.

1. Pediatric/adolescent client case:
A 14-year-old male, referred by his school counselor for frequent absences and social isolation. He reports feeling “empty” and “numb” most of the time, has difficulty sleeping, and has lost interest in activities he previously enjoyed. He reports no medical history and no family history of mental illness.

2. Full mental health evaluation:

Psychiatric History: The client currently reports feeling hopeless, numb, and disinterested in daily activities. He has been experiencing difficulty falling asleep and staying asleep for several weeks. He denies any suicidal ideation or intent.

Physical History: Client denies any physical health issues

Social History: The client lives with his parents and a younger sibling. The client’s parents are supportive but work long hours. The client denies the use of drugs or alcohol.

Family History: No family history of mental illness reported.

Birth and developmental history: No significant history reported.

Diagnostic Aids: Patient Health Questionnaire-9 (PHQ-9) was used to assess the client’s symptoms of depression. The client scored a 16 on the PHQ-9, indicating severe depressive symptoms.

3. DSM-5 diagnostic assessment:
Diagnosis: Major Depressive Disorder, single episode, severe

Rationale: The client reports symptoms consistent with the diagnosis of Major Depressive Disorder, including feelings of hopelessness, disinterest in daily activities, and difficulty sleeping. The PHQ-9 score of 16 also supports this diagnosis.

4. Plan of care:
The plan of care for this client includes a combination of pharmacological and non-pharmacological interventions. The client will be prescribed an initial dose of an SSRI medication, and the dosage will be increased based on the client’s response. The client will also be referred to a cognitive-behavioral therapist to address the underlying psychological factors contributing to his depression. The therapist will provide the client with coping skills and tools to manage his depression. The therapist will work with the client’s family and school to help create an improved support system at home and school. Follow-up visits will be scheduled with the client to monitor his progress. Finally, the client will be provided with resources and information on community support groups and hotline numbers for crisis situations.

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