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NRNP 6675 Week 5 Focused SOAP Note and Patient Case Presentation

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  • April 26, 2022
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Week 5: Focused SOAP Note and Patient Case Presentation

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum




Introduction

Psychosis is a mental condition in which a person's ideas and perceptions are disrupted,

and the individual may have difficulty distinguishing between what is real and what is not.

, A health condition, medications, or drug usage can all contribute to psychosis. Delusions,

hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has

incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from

the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support,

family support and education, and talk therapy are all options for treatment. More or less every

mental intervention is backed by evidence accumulated during the patient's initial interview; each

patient's therapy begins with a thorough medical and mental health evaluation, the incorporation

of trust, and a discussion of past mental health history, substance misuse history, family mental

health history, and so on. In this example, the patient's evaluation was documented, and a

diagnosis was made based on the information collected from the patient during the evaluation.

When the case was being developed, a therapeutic approach was designed. The patient is a 53-

year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after

his sister recommended a visit to the psychiatrist because patient's behavior changed since the

mother passed away.

Patient Initial: S.T Age: 53 Gender: Male

Subjective Data:

CC: "I was brought here by my sister because since my mother passed away, I was living on my

own and not bothering anyone. Those people outside my window they are after me. They just

want me dead".

HPI: When patient was asked " what people?". Patient said " the government sent them to get

me because my taxes are high". Suddenly patient asked the provider if she can see the birds or

hear any loud noise. The provider responded by redirecting the patient that she does not hear any

voice or see anything. When the provider how long he is been hearing the voices or seeing

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