Assessing Clients

To prepare:

Select a client whom you have observed or counseled at your practicum site. ( EX 23 years old white male with depression and suicide ideations).

Review pages 137142 of the Wheeler text and the Hernandez Family Genogram video in this weeks Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.

The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):

Demographic information

Presenting problem

History or present illness

Past psychiatric history

Medical history

Substance use history

Developmental history

Family psychiatric history

Psychosocial history

History of abuse/trauma

Review of systems

Physical assessment

Mental status exam

Differential diagnosis

Case formulation

Treatment plan

Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Resources for reference:

Required Readings

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

• Standard 2 Diagnosis (pages 46-47)

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

• Chapter 5, Supportive and Psychodynamic      Psychotherapy (pp. 225238 and pp. 245258)