Treatment Plan

PLEASE READ THE INSTRUCTIONS ATTACHED CAREFULLY!!

Please do not just go into symptom media and pick a video case. You must first log in to Symptom media then go to the link under the video assignment instructions each week and click on it and it will take you directly there.

Module Assignments:

For this assignment, you will watch an assigned video clip that depicts a patient needing psychiatric/mental health treatment. You then will complete a treatment plan for this patient, following the attached formatting. You are required to follow APA 7, which includes, a title page, your typed treatment plan, and a references page. Each video case that is assessed should result in a treatment plan that is a minimum of 3 pages in length, in addition to the title page and references page. This is a treatment plan, not a research paper.Follow the rubric guidelines for grading criteria.

Just like in practice, there are times when all the preferred information may not be available, yet you still will need to formulate a treatment plan for the patient. Your treatment plan must include in-text citations and proper APA 7 formatting. You are writing this as if you are the licensed PMHNP writing orders for this patient.

The following reference materials are required to be utilized and referenced:

  • DSM-5
  • Course Textbook
  • Drug guide of your choice (text or online) (that has a current DATE)
  • 1 scholarly peer reviewed journal article, dated within the last 5 years, that supports your treatment plan. UptoDate is a wonderful site, but it is not considered a scholarly peer reviewed journal article.

The APA 7 style of writing is required. This includes (but is not limited to):

  • Proper grammar and composition, capitalization and sentence structure
  • APA 7 approved font (such as 12-point Times New Roman)
  • Double spaced paper with 1” margins
  • Paragraphs are to be left margin justified only
  • Paragraph indentions
  • Heading Levels (see APA 7, p. 47-48)
  • References that are formatted as per APA 7. See chapter 9 of the APA 7.

How to properly cite and reference the DSM-5. Points WILL BE DEDUCTED for not referencing the DSM-5 correctly. Here, is the correct way to reference it on the references page and as an in-text citation.  For electronic versions:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th

ed.). https:doi.org/10.1176/appi.books.9780890425596

For printed version:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th

ed.). American Psychiatric Association.

Basic in-text citation for the DSM-5:   (American Psychiatric Association, 2013).

Treatment Plan: What to include and how to format the treatment plan

Your Treatment plan should include the following categories:

  1. Title page
  2. Content of treatment plan (The title of your treatment plan should be on line 1 of page 2).
    1. Brief description of the patient (do not repeat the entire video – BRIEF)
    2. Brief explanation of the presenting psychological symptoms (delusional, jealous, moody, talkative, appears depressed, etc)
    3. Any known medical history, allergies, etc. (If none, state No known allergies, No known medical history). 
    4. Your psychiatric diagnosis (supported by the DSM-5 criteria). You can state something like, This patient met criterion 1, 2, 4, 5,A, C, D and 7 from the diagnostic criteria on page 163-164 of the DSM-5 for the diagnosis of ……………
    5. List 2- 3 of the differential diagnosis from the DSM-5, and briefly state why that was chosen as a differential diagnosis, and not as the main diagnosis. (See course materials on Differential Diagnosis) (supported by the DSM-5).
    6. Suicide and/or homicidal risk assessment (Include the 5 components of a suicide risk assessment, do you want to kill yourself, what is your plan, do you have access to that plan, what is your intention, and what is keeping you here (the mitigating factors) See Nursing Suicide Risk Assessment PPT/Kaltura Module 1. Points are deducted if the 5 components of a suicide risk assessment are not written out. 
    7. What psychiatric tools or scales you used to help support your diagnosis (include citations).
    8. Medications being ordered (include a citation)
      1. Include name of medication(s) and what the med is used for 
      2. Include the route, dosage, frequency 
      3. Include black box warnings or what the pt needs to know/foods to avoid, etc. 
    9. Non-pharmacological treatments that are being ordered (include citation that supports these). Different diagnoses respond better to different forms of therapy. Some respond to CBT, others to Behavioral Therapy, others to Family Therapy, etc. 
    10. Any labs or medical tests that need to be completed to rule out organic causes, for medication monitoring, and so forth (include citation). (include a short line stating why each lab/test is being ordered)
    11. Questions that you would ask to help further solidify your diagnosis (brief list)
    12. Any further directives/resources for the patient (this would include, follow up with primary doctor to monitor HTN or diabetes; directives to follow-up with other members of the comprehensive treatment team; safety plan if you are sending the pt home and they have suicidal or homicidal thoughts; return for medication assessment in x number of weeks, etc. This also includes support group and hotline phone numbers for things like SI and SUD).
  3. References Page – include all citations used in the paper, formatted per APA 7, double spaced and in alphabetical order. References are to include the DSM-5, the course textbook, a drug book of your choice (text or online that has a date), and 1 scholarly journal article reference within the last 5 years, for each of the videos or discussion board prompts being assessed.

Note:

                Direct quotations should be kept to a minimum and properly cited as per the APA 7. It is imperative that you synthesize the course information into your own words, using minimal direct quotations from scholarly journal articles to support your treatment plan. Academic integrity is essential as proper citations give credence and reliability to your treatment plan. If your TII score is over 35%, see what areas of your paper you can re-word to avoid a grade of zero.

 

 

DSM-5 & Differential Diagnosis

 

To effectively treat patients, a reliable diagnosis and treatment recommendation is essential. The DSM-5 provides a definition for each mental health disorder along with diagnostic criteria that must be met for each diagnosis. These diagnoses are designed to “help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients” (American Psychiatric Association, 2013, p. 20). Diagnoses are then made after performing a clinical interview with the patient, using DSM-5 descriptions, criteria, and using clinician judgment (American Psychiatric Association, 2013).

 

  1. All psychiatric disorders have a categorical place in the DSM -5. It includes the symptoms that must be present with specifiers that allow for a more specific diagnosis that help with the development of a treatment plan. (Example: Major depressive disorder with psychotic features).

 

  1. Most psychiatric disorders (and psychiatric emergencies) require a thorough suicide risk assessment. Include all 5 components of the suicide risk assessment we learned in Module 1 Nursing Suicide Risk Assessment PPR/Kaltura. (Desire, plan, access, intent, mitigating factors). If you don’t ask them, your professor can not assess if you know how to do a suicide risk assessment.

 

  1. Differential diagnoses: A reliable diagnosis is required to effectively treat the patient and to have positive treatment outcomes. The differentials provide for clinicians and alternate diagnosis that could be considered if it is proven that the patient does meet the criteria for the primary diagnosis that was chosen.

 

A clinician does not randomly come up with a differential diagnosis on their own. The DSM-5 provides for clinicians, differential diagnosis for each primary diagnosis. They are listed in the DSM-5 at the end of each diagnosis chapter. The differentials are listed in order of prevalence. For example, of all the patients diagnosed with Bipolar 1, if that diagnosis was proven not to be correct, most often the correct diagnosis is found to be first, major depressive disorder, then second most frequent is the 2nd differential listed, then the 3rd most frequent is the 3rd differential that is listed. So the differentials should be alternate diagnosis that you considered or wrestled with as you were determining the primary diagnosis for the patient.

 

For example, if you have a patient who appears with a mood disorder, you may be considering depressive disorder or bipolar 1 disorder. Upon examining the diagnostic criteria in the DSM-5 for bipolar 1 (page 123-131) you determine that bipolar 1 is the diagnosis that the patient meets the criteria for. You must then look to the differential diagnosis that are listed in the DSM-5 (for bipolar 1 the differentials are on page 131-132) and you choose 2 or 3 of them that your patient closely matches the criteria for. You then briefly explain why you chose bipolar 1, as opposed to the differential diagnosis of major depressive disorder (for example).

               

If you have questions, please reach out to your professor for your section. It is better to ask early and then know how to do it correctly for the 7 weeks then to struggle without asking. We are here for you!

 

 Please watch and assess the following video case study: https://learn.symptommedia.com/

username: NKUNursing

password: NKUNursing0615

 

Rubric: CriteriaRatingsPts

This criterion is linked to a Learning OutcomeLearning outcome evaluation

Learning Outcome Evaluation (Include each element):Include initial diagnosis with differentials using only what the clip provides. Also include additional questions that may need to be asked to help clarify diagnosis. List differentials for this case. List any symptoms to support diagnosis.List treatment suggestions you have for this patient which may include psychosocial, cultural, and/or developmental considerations.List medication suggestions.Include any types of therapy, groups, or other forms of coping resources that may be available for support.Include an active current suicidal ideation assessment and an indication to refer to inpatient hospitalization if necessary. Include labs Include screening scales

 

This criterion is linked to a Learning OutcomeAnalysis of Elements

(Analysis of Elements)Evaluate each video clip stating your initial diagnosis with differentials using only what the clip provides. For each differential state why each one should be considered for this case. List any symptoms that influenced your decision to use your diagnosis and why. Discuss treatment suggestions you have for this patient which may include psychosocial, cultural, and/or developmental considerations. Support what you recommend.Discuss any pharmalogical suggestions to discuss side effects vs benefits vs risks for any medications along with the dosage you would start with in the case. For other nonpharmalogical recommendations include any types of therapy, groups, or other forms of coping resources that may be available for support.Include an active current suicidal ideation assessment and an indication to refer to inpatient hospitalization if necessary. Include labs and why each one would be ordered for this patient.Include some screening scales that could be used in a patient with this diagnosis.

 

Some items were explained and expounded upon and others needed more information stated.

 

This criterion is linked to a Learning OutcomeAPA 7th edition format and 

 

References

APA 7th editionSpacing and formatting correct with title page and references included.References within 5 yearsUse of evidence based peer reviewed journal articles in addition to text books in references

 

The assignment was submitted in accordance with APA 7th guidelines and on time by the deadline. References were current and within 5 years and evidence based peer reviewed journal articles were included in addition to text books.

 

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