Guidance to Student

Assignment 2: Practicum: Decision Tree

Childhood psychosis is extremely rare; however, children that present with psychosis must be carefully assessed and evaluated with appropriate interviewing of parent, child, and use of assessment tools.

For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with early onset schizophrenia.

Learning Objectives

Students will:

· Evaluate clients for treatment of mental health disorders

· Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders

The Assignment:

Examine Case 3: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

· Decision #1: Differential Diagnosis

· Which Decision did you select?

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?

· Decision #2: Treatment Plan for Psychotherapy

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?

· Decision #3: Treatment Plan for Psychopharmacology

· Why did you select this Decision? Support your response with evidence and references to the Learning Resources.

· What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.

· Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

· Also include how ethical considerations might impact your treatment plan and communication with clients and their families.

· Case #3 h strange behavior

BACKGROUND

Carrie is a 13-year-old Hispanic female who is brought to your office today by her mother and father. They report that they were referred to you by their primary care provider after seeking her advice because Carrie’s behavior has been difficult to manage and they don’t know what to do.

SUBJECTIVE

Carrie’s parents report that they have concerns about her behavior, which they describe as sometimes “not normal for a 13-year-old.” They notice that she talks to people who aren’t real. Her behavior is calm and “passive.” Her parents noted that when she was younger, she was irritable at times, but have noticed that this has given way to passivity. Her parents state that they understand that it’s normal for younger children to have “imaginary friends,” but they feel that at Carrie’s age, she should have grown out of these behaviors. Carrie’s parents report that she has friends that are half-cat and half-human, and “spirits” who speak with her “in her head.” She also reports that the people on television know when she is home and that they have certain shows “just for her.”

Carrie’s parents report that they have taken her to her pediatrician who has given her a “clean bill of health.” Carrie’s parents note that they had some early concerns as she was lagging in meeting developmental milestones. Initially, when she first started school, Carrie managed to keep up with her peers in terms of academic performance, but she was noticed by her teachers to be isolative. It was also noted by her teachers and guidance counselor that Carrie’s social skills do not seem to match what they see in other children her age. Initially the school counselor suspected that Carrie may have been suffering from attention deficit hyperactivity disorder (primarily inattentive type), but now is not certain and has recommended a psychiatric evaluation. Her grades were “ok” in school up until last year when she left junior high school, and entered high school, where the academic demands began to increase. Carrie’s teachers had wanted to hold her back a grade, but her parents acknowledge that they were “insistent” that this did not happen. Now they are describing some regrets over this as Carrie seems “more lost than ever” in her schoolwork. Carrie’s mother produced a copy of a paper that Carrie had to submit as a homework assignment. You attempt to read the assignment, but there does not appear to be any clarity to the work, and it can best be described as a hodge-podge of thoughts and ideas.

Carrie’s parents want you to know that although they are concerned about Carrie, they are opposed to giving her medications that would turn her “into a zombie.” Carrie’s mother also confides that her husband’s grandfather spent “a few years in the nut house.” When you probe further, she began crying and said, “He was schizophrenic … what if Carrie is schizophrenic?”

During your interview with Carrie, she seems pleasant, but somewhat distant. When you ask her about her friends at school, she shrugs her shoulders and says, “I don’t really have any. I don’t like those people.” You inquire if she is sad or upset that she doesn’t like them, to which she states “no, why should I be? I guess they would be friends with me if I asked, but I’m not interested. I could make them be my friends if I wanted, but I don’t … but if I wanted them to, all that I have to do is make up my mind that they will be my friend and they would have to.” When you ask Carrie if she believes that she can control the thoughts of others with her mind, she puts her index finger up to her mouth and looks toward the door. “My mom gets upset when I talk about these things. I try not to think about them either because if she is close enough, she could read my thoughts and they upset her. She may think that I am into witchcraft or something.”

When you ask Carrie about the homework assignment that you read, she explains that her teacher “is just miserable. She does not understand how I think—I think high, she just can’t get it.”

 

OBJECTIVE

The client is a 13-year-old Hispanic female client who appears appropriately developed for her age. She is dressed appropriately for the current weather, and ambulates with a steady upright gait. She does not appear to be demonstrating any noteworthy mannerisms, gestures, or tics. No psychomotor agitation/retardation apparent.

 

MENTAL STATUS EXAM

Carries is alert and oriented × 4 spheres. Her speech is clear, coherent, goal-directed, and spontaneous. Carrie self-reports her mood as “good.” However, her effect does appear somewhat constricted. Her eye contact is minimal throughout the clinical interview and at times, Carrie seems preoccupied. Carrie is oriented to person, place, and time. She endorses hearing and seeing strange “things that I talk to. They don’t scare me; they come to see me from another world.” No overt paranoia is appreciated. She does report delusions of reference (she believes that the people on TV play programs “just for her” and at times, television commercials were designed to tell her what to do), as well as other delusional thoughts (as described above). Carrie denies any suicidal or homicidal ideation.

At this point, please discuss any additional diagnostic tests you would perform on Carrie.

 

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO CARRIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis in decision one.

 

 

Case #3 o Decision Point One

Diagnosis; Early Onset Schizophrenia

Decision Point Two

 

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/09/mm/decision_tree/img/pill-blue.pngBegin Clozaril 100 mg orally daily

Begin Clozaril 100 mg orally daily

 

RESULTS OF DECISION POINT TWO

·  The client returns to the clinic in four weeks

·  Upon return to your office, Carrie’s parents report that they stopped giving Carrie the medication three days after it was begun. “We just couldn’t wake her up,” explains Carrie’s mother. Carrie continues to exhibit symptoms, and basically, nothing has changed from the initial presentation.

Decision Point Three

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6660/09/mm/decision_tree/img/pill-blue.pngBegin Risperdal 0.5 mg orally twice a day

 

 

Guidance to Student

Clozapine (Clozaril) is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). The 100-mg dose prescribed in this case has resulted in the significant sedation that Carrie experienced. As we saw, the parents became concerned about this and withdrew the medication, and several weeks may have lapsed between the cessation of medication and the presentation of Carrie in your office again (assuming the parents would bring her back to see you). Restarting the medication at 100 mg would result in the same sedation. While sedation is common with Clozapine, we attempt to minimize it by starting at a much lower dose and titrating upward. This type of dosing error (initiating treatment at 100 mg orally daily) would result in a delay in treatment, and possible injury to the client.

While Lamotrigine is sometimes used as adjunctive therapy in the treatment of schizophrenia, it is by no means an acceptable first-line treatment.

Risperdal 0.5 mg orally twice a day is the best choice in this scenario as the dose is the most appropriate. We can use a smaller dose and titrate upward as needed to achieve symptom control. At this starting dose, side effects would be minimized. It is also FDA-approved for the treatment of schizophrenia in those aged 13 years and older.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

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