NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

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NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD – Step-by-Step Guide

The first step before starting to write the NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD, it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment. 

It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.

How to Research and Prepare for NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list. 

You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.

How to Write the Introduction for NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.

How to Write the Body for NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.

How to Write the In-text Citations for NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:

The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.

How to Write the Conclusion for NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.

How to Format the Reference List for NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD

The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication. 

Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:

References

Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456

Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.

NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD Instructions

In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches. 

In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches. Have a look at NRNP 6675 Week 5 Assignment – Focused Soap Note for Schizophrenia Spectrum, other Psychotic and Medication-Induced Movement Disorders.

TO PREPARE

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
  • Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
  • Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.

THE ASSIGNMENT

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
  • Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
  • Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you could follow up with this patient. 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.).
  • 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).

BY DAY 7 OF WEEK 3

Submit your Focused SOAP Note.

NRNP 6675 Week 3 Assignment – Focused Soap Note for Anxiety, PTSD and OCD Example

Focused SOAP Note: PTSD, Anxiety, and OCD Disorders

Patient’s Initials D.C.

Age: 7 years

Subjective:

CC (chief complaint): “Well, he seems so anxious and worried all the time, silly

things like I’m going to die, or I won’t pick him up from school.”

HPI:

D.C., a 7-year-old male Caucasian patient, has been referred by his pediatrician to a psychiatrist for an evaluation. The patient’s mother indicated that although the doctor prescribed DDAVP to help the patient stop wetting the bed, it had no effect. However, she omitted including the frequency and dose of DDAVP treatment. The patient worries excessively and harbors terrible ideas about his mother and brother. He believes his classmates dislike him and call him “Mr smelly” and other derogatory names.

The patient claims that his teacher seems to be picking on him and that his classmates are oblivious to how he feels about his father not returning home. Although the mother mentions that he has trouble sleeping and worries about his mother’s death and abandonment, he has never tried to hurt himself. Due to his poor eating habits, he has lost three pounds in three weeks. D.C.’s mother decided not to inform her kid that his father had died in battle, and now she regrets it because she wonders what effect it would have had on her son.

Substance Current Use: The patient has no history of substance abuse. No one abuses drugs at home.

Medical History: No medical history has been provided.

Current Medications: The patient is prescribed DDVP for bedwetting.

Allergies: No allergies reported.

Reproductive Hx: No record

ROS

GENERAL: No fatigue, fever, or cold. The client has lost 3 pounds over three weeks.

HEENT: No diplopia, hearing loss, sore throat, runny nose, or sneezing reported.

SKIN: No bruising, rash, itching, or scars noted.

CARDIOVASCULAR: No palpitations, no chest pain, no edema, no chest discomfort.

RESPIRATORY: No shortness of breath, no cough, or sputum.

GASTROINTESTINAL: No reports of nausea, vomiting, abdominal pain, diarrhea, or blood in the stool.

GENITOURINARY: The client reports enuresis. No burning sensation on urination or odd odor of urine.

NEUROLOGICAL: No dizziness, headache, paralysis, ataxia, or tingling sensations on the extremities.

MUSCULOSKELETAL: No joint stiffness, no muscle pain, or back pains.

HEMATOLOGIC: No history of bleeding, bruising, or anemia.

LYMPHATICS: No lymph node enlargement and no history of splenectomy.

ENDOCRINOLOGIC: No reports of intolerance to heat or cold, no polydipsia or polyuria.

Objective:

Diagnostic results: No diagnostic tests are required or ordered at this stage.

Assessment

Mental Status Examination:

The patient looks appropriate for his age. D.C. appears tidy and well-groomed. He sits still, makes eye contact, and refrains from fidgeting. He is cooperative yet exudes excessive worry and melancholy. He walks steadily, but his voice is not very clear. The patient always worries that his mother will not pick him up from school, his brother and mother will not be found, and his mother might pass away.

He has lost his appetite, has trouble falling asleep, is agitated, has trouble concentrating, and claims to have bad dreams. His reasoning process is logical, and his communication is goal-oriented. In addition, he is unduly worried and in a euthymic state. D.C. does not intend to hurt anybody and does not have suicidal ideations. The client does not report any hallucinations. He is oriented X4 to time, place, person, and situation. His long-term and short-term memories are intact.

Diagnostic Impression

Primary diagnosis: Posttraumatic Stress Disorder (PTSD)

PTSD is a chronic condition resulting from exposure to a traumatic event, resulting in social, medical, and family functioning disturbances (Polimanti & Wendt, 2021). In addition to physical symptoms like headache and stomachache, children with PTSD may experience long-term symptoms like melancholy, anxiety, nervousness, violence, flashbacks, trouble in school, enuresis, difficulty concentrating, and physical symptoms like depression and anxiety (American Psychiatric Association, 2022).

According to the DSM-5 TR manual, a person must meet five or more significant signs. Direct or indirect exposure to a traumatic incident is the first sign. The other criteria include intrusive symptoms such as flashbacks, nightmares, emotional distress, and aversion to trauma-related stimuli (Williamson et al., 2021). Changes for victims include feeling alone, having a bad mood, and placing excessive blame on oneself and others.

Children may also exhibit changes in arousal, such as trouble falling asleep, aggressiveness, and attention issues. Most of the DSM-5 TR criteria for PTSD are met by D.C. The passing of his father was a challenging experience for him. Other significant symptoms he exhibits include nightmares, trouble falling asleep, lack of focus, and a sense of loneliness. PTSD could, therefore, be a definite diagnosis.

Differential Diagnosis

Generalized anxiety disorder (GAD)

Based on the information provided in the DSM-5 TR, the client in the case study meets the diagnostic criteria for Generalized Anxiety Disorder (GAD). The client has frequently exhibited excessive anxiety and worry over at least 6 months. His worries are not proportionate to the actual likelihood of events and are difficult to control. The client experiences restlessness, difficulty concentrating, irritability, and sleep disturbances. These symptoms significantly impact his social, occupational, and other vital areas of functioning.

The client’s presentation aligns with the diagnostic features of GAD, including pervasive and distressing worries that occur without specific triggers. Patients suffering from GAD are often at a very high risk of developing cardiovascular disorders, committing suicide, or at risk of death, and thus necessitates immediate interventions (DeMartini et al., 2019).

Acute Stress Disorder

This disorder develops as a result of a traumatic incident. The main symptoms are anxiety, fear, helplessness, and reliving a prior experience. According to the DSM-5 TR criteria for acute stress disorder, a person must have been exposed to, observed, or have knowledge of a close relative’s traumatic incident (American Psychiatric Association, 2022). At least nine key symptoms must be present, including recurring nightmares, flashbacks, persistent psychological distress, low mood, forgetfulness, avoidance of memories, disturbed sleep, and difficulties concentrating (American Psychiatric Association, 2022). D.C. displayed the majority of these signs. Acute stress disorder’s onset lasts between three days and one month, which eliminates the likelihood that it could be a differential diagnosis.

Obsessive-compulsive Disorder (OCD)

Children with OCD experience unwelcome and obsessive thoughts and ideas. The DSM-5 criteria state that victims must satisfy the requirements for obsessions and compulsions (Boland et al., 2022). Persistent thoughts and urges are the result of obsessions. Unwanted thoughts might lead to anxiety and suffering. In the case study, D.C. displayed obsessions such as recurrent thoughts about his mother, younger brother, and deceased father. Compulsions, on the other hand, are addictive acts that kids engage in repeatedly. The client did not, however, exhibit any compulsions. This suggests that he does not satisfy the OCD criteria in the DSM-5 TR.

Case Formulation and Treatment Plan:

The main treatment plan is to reduce his anxiety symptoms, promote his mental well-being, and help him develop more robust coping mechanisms to function better at home and school. The first goal is to lessen the client’s sensations of anxiety with relaxation techniques, including deep breathing exercises and cognitive-behavioral therapy (CBT) therapies that test and reframe anxious ideas and fears. Gradually exposure to fear-inspiring circumstances will also be used to lessen anxiety responses.

Improving the client’s coping mechanisms is another area of the therapeutic approach. Play therapy and expressive arts encourage emotional expression and create healthy coping mechanisms. He will also learn age-appropriate problem-solving techniques to handle life’s obstacles. Consistent routines and expectations will be set with his mother to encourage stability and predictability. Addressing his trauma and grief experiences is an essential therapeutic strategy. The healthcare workers will apply trauma-informed methodologies and give him and his mother psychoeducation on grieving and coping mechanisms. If extra support is required, a referral to a child and adolescent trauma expert or grief counseling will be considered.

Working together with his school is essential for his development. His emotional needs will be attended to, and an individualized education program (IEP) will be created to guarantee a positive learning environment. There will be an effort to promote anti-bullying policies, promote inclusivity, and give instructors tools to help students concentrate and focus. Regular family therapy sessions with his mother will be used as supportive services to enhance communication, build their connection, and give her assistance in managing his anxiety.

The plan will adhere rigorously to such ethical principles as confidentiality and informed consent. Cultural competence will be upheld throughout the treatment while honoring his cultural values and beliefs. Cooperation with local resources will be sought to address the socioeconomic and cultural aspects that can impact his mental health. The client and his mother will be taught about maintaining a healthy lifestyle, which includes regular exercise, enough sleep, and a balanced diet. This will focus on promoting health and preventing sickness.

Techniques for stress reduction and self-care will also be promoted. Community support programs will be considered to address the socioeconomic and cultural factors affecting his mental health. The client, his mother, and other pertinent parties will participate in frequent therapy sessions as part of this all-inclusive treatment plan. Progress will be continuously watched throughout his treatment, and modifications to the plan will be made in light of his unique needs and responses.

Reflection

I would approach the intervention with a few things in mind if I were working with D.C. and had the chance to lead the session again. My top priority would be creating a secure and reassuring therapeutic setting for him so he feels comfortable sharing his feelings and anxieties. I would use therapeutic strategies appropriate for each child’s age to encourage communication and emotional expressions, such as play therapy or expressive arts.

My intervention in the follow-up session would focus on psychoeducation for the client and his mother. I would explain to him that worrying is a typical human emotion, but I would assist him in distinguishing between everyday worries and excessive worries that interfere with daily living. I would teach him simple coping skills such as deep breathing or positive self-talk to treat his anxiety symptoms. I would also advise his mother to provide regular support and comfort and to set appropriate boundaries and expectations for his behavior.

I would follow all legal and ethical guidelines to safeguard his privacy and confidentiality while including his mother in the therapy process as his legal guardian. The client is a minor; therefore, his mother must give her informed consent before any treatment measures can be made. The client’s ethnic background and family dynamics must also be understood to ensure that therapies are respectful of and consistent with their cultural beliefs. This requires cultural competency and sensitivity.

Regarding illness prevention and health promotion, I would discuss how stress and anxiety affect everyone’s well-being. The client and his mother would learn the value of good lifestyle practices, such as regular exercise, enough sleep, and a balanced diet, to support her son’s emotional and physical health. While working with the school to create a welcoming and inclusive learning environment, I would look at ways to deal with bullying or other social issues that might factor into his concerns.

I would be cautious of any potential trauma-related symptoms and the need for a trauma-informed approach in therapy, given Dev’s history of loss and trauma connected to the passing of his father. Referrals to a child and adolescent trauma specialist or bereavement therapy will be considered to offer further assistance and treat any unresolved trauma.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Boland, R. J., Verduin, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49. https://doi.org/10.7326/aitc201904020

Polimanti, R., & Wendt, F. R. (2021). Posttraumatic stress disorder: from gene discovery to disease biology. Psychological Medicine, 1–11. https://doi.org/10.1017/s0033291721000210

Showraki, M., Showraki, T., & Brown, K. (2020). Generalized anxiety disorder: Revisited. The Psychiatric Quarterly, 91(3), 905–914. https://doi.org/10.1007/s11126-020-09747-0