NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Sample Answer for NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders Included After Question

By Day 7 of Week 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? 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.).

A Sample Answer For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Title: NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

CC (chief complaint): ‘I am scared. I don’t want to be what people say I am because I ant going to change. I can’t.’

HPI: Lisa is a 29-year-old female that is in West Palm Beach, FL detox facility thinking about long-term rehab. Lisa has a history of smoking crack cocaine, cannabis, and taking alcohol. She reports smoking crack cocaine for approximately $100 daily, cannabis 1-2 times weekly, and alcohol 2-3 drinks weekly. Lisa reports that she fears being admitted to rehab due to fear of stigmatization and difficulties in being employed thereafter. Lisa has a history of theft convictions and drug possession. She is on 2-year probation with randomized drug screens. She has been trying to find a pattern for the calls for her not to test dirty urine. Lisa reports that the use of crack cocaine relieves her distressing experience due to cocaine addiction.

Past Psychiatric History:

  • General Statement: ‘I am scared. I don’t want to be what people say I am because I ain’t going to change. I can’t.’
  • Caregivers (if applicable): none
  • Hospitalizations: no history of hospitalizations provided.
  • Medication trials: no history of medication trials.
  • Psychotherapy or Previous Psychiatric Diagnosis: No history of previous psychotherapy. Lisa has a history of substance abuse disorder, as she has past drug possessions and theft convictions. She is also currently on 2-year probation with randomized drug screens.

Substance Current Use and History: Lisa has a history of smoking crack cocaine approximately $100 daily, cannabis 1-2 times weekly, and 2-3 alcohol drinks once weekly.

Family Psychiatric/Substance Use History: There is positive substance abuse and psychiatric conditions in the family. Lisa’s mother has a history of anxiety and the use of benzodiazepine. Lisa’s brother has a history of opioid use. Her father has a history of drug abuse and is currently in prison for sexually abusing her.

NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Psychosocial History: Lisa currently lives with her boyfriend, Jeremy. She has a daughter who lives with her friends. She is employed in a hospital where she has been using drugs to avoid being identified to be suffering from substance abuse disorder. She lives with her boyfriend in a rented house. Lisa fears the stigmatization that she would experience should she be admitted to the rehab.

Medical History:

  • Current Medications: Lisa is currently not on any medications
  • Allergies: Lisa is allergic to amoxicillin. She does not have any allergy to food or environmental agents such as pollen.
  • Reproductive Hx: Lisa has one daughter who currently lives with her friends. She is sexually active, as she lives with her boyfriend, Jeremy. Any other significant reproductive history is not given.

ROS:

  • GENERAL: The patient appears well-groomed for the occasion. She appears slightly underweight compared to individuals of her age. She demonstrates mild tremors of the upper extremities. She denies fever or child.
  • HEAD/NECK: The client denied lymphadenopathy, neck pain, rigidity, distended veins, and pain in swallowing. The head is normocephalic with no evidence of trauma or unequal hair distribution
  • EYES: The client denied vision changes, drainage, pain, or double vision. She does not use corrective lenses.
  • EARS/NOSE/MOUTH/THROAT: The patient denied changes in hearing, ear drainage, ear pain, and infections. She also denied nasal congestion, drainage, and nose bleeds. She denied halitosis, difficulties in swallowing, bleeding gums, sore throat, and sore tongue.
  • CARDIOVASCULAR: The client denied chest pain and palpitations.
  • PULMONARY:  The client denied shortness of breath, cough, dyspnea, wheezing, and chest pain.
  • GASTROINTESTINAL: The client denied abdominal tenderness, constipation, diarrhea, and bloating.
  • GENITOURINARY: The client denied urinary incontinence, painful urination, and increased frequency of urination.
  • MUSCULOSKELETAL:  The patient denied muscle pain, fractures, tenderness, and muscle weakness.
  • INTEGUMENTARY:  The client denied rashes, lumps, bruises, and lacerations.
  • NEUROLOGICAL:  The client reported the presence of upper arm tremors. She denied headache, dizziness, vomiting, and nausea.
  • PSYCHIATRIC: The client has a history of substance abuse disorder.
  • ENDOCRINE: The client denied cold or heat intolerance, polydipsia, and polyphagia.
  • HEMATOLOGIC/LYMPHATIC:  The patient denied lymphadenopathy.
  • ALLERGIC/IMMUNOLOGIC:  The client denied any history of food or environmental allergies. She is allergic to amoxicillin.

Objective: T-99.8, P-101, R-20, BP 178/94, Ht-5’6, Wt-140lbs

Physical exam: if applicable

Diagnostic results: Lisa’s admission lab works were done. The results were abnormal for ALT 168, AST 200, ALK 250, bilirubin 2.5, albumin 3.0, and GGT 59. UDS was positive for cocaine, and THC. It was negative for alcohol or other drugs. Other labs were within the normal range with BAL being 3.0.

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Assessment:

Mental Status Examination: Lisa is a 29-year old female who appears dressed for the occasion. She oriented to self, time, space, and events. She demonstrates mild tremors of the upper limbs. She appears anxious and fearful about being in rehab. Lisa denies illusions, delusions, and hallucinations. Her thought process is intact. She demonstrates the repetition of words during the assessment. She does not have suicidal thoughts, plans, or attempts.

Differential Diagnoses:

  1. Substance use disorder: Lisa’s primary diagnosis is substance use disorder. According to DSMV, substance use disorders arise from the use of drugs that include cannabis, caffeine, hallucinogens, inhalants, sedatives, opioids, anxiolytics, stimulants, and tobacco among others. A patient is diagnosed with the disorder if he presents with specific complaints. They include taking the drug in larger quantities or for a prolonged duration, wanting to stop or cut down the drug or substance but unsuccessful, and spending too much time in getting, using, or recovering from the substance (Proctor et al., 2019). It also includes suffering from urges or cravings for the drug, failing to perform in social and occupational roles due to substance use, and continuing substance use despite affecting relationships and performance. Patients must also give up their social and occupational activities for the substance, using the substance despite putting them in danger, and needing more of the drug to achieve the desired effect. Patients also develop withdrawal symptoms if they stop taking the drug, which can be relieved by taking the drug (John et al., 2018). Lisa meets most of the above criteria for being diagnosed with substance use disorder. She uses caffeine, cannabis, and alcohol. She also depends on caffeine to function optimally. Lisa is aware of the negative effects of substance abuse and has not its use despite being informed about its effects. Substance abuse has also affected her occupational functioning, roles, and success of their business and relationships. Therefore, substance use disorder is Lisa’s primary diagnosis.
  2. Generalized anxiety disorder: Generalized anxiety disorder is the secondary diagnosis that should be considered for Lisa. According to DSMV, patients are diagnosed with an anxiety disorder if they experience excessive anxiety and worry that cause behavioral disturbances. The excessive fear and worry should occur for at least six months with patients finding it hard to control their emotions. The accompanying symptoms include being restless, easily fatigued, irritable, and experiencing sleep disturbances and muscle tension (Munir et al., 2022). Lisa reports fear of rehab and the stigma associated with rehabilitation. As a result, the fear that she experiences does not qualify her to be diagnosed with a generalized anxiety disorder since it has not occurred for a long period and is not associated with any of the above accompanying symptoms.
  3. Post-traumatic stress disorder: The other secondary differential that should be considered for Lisa is post-traumatic stress disorder. Post-traumatic stress disorder is mainly diagnosed in individuals with traumatic experiences (Price et al., 2019). The DSMV sets criteria that should be met for a patient to be diagnosed with post-traumatic stress disorder. They include direct or indirect exposure to traumatic events and symptoms that include intrusion, negative changes in mood and thoughts, avoidance, and changes in reactivity and arousal. The symptoms should persist for at least one month and cause significant interference with life or distress. The symptoms should not be attributable to other causes such as medical conditions, medication use, and substance abuse (Carmassi et al., 2020). Lisa has a traumatic experience of being sexually abused by her father. However, the traumatic experience does not cause symptoms that include avoidance, intrusion, changes in mood and thought processes, reactivity, and arousal, hence, it is the least likely diagnosis for her.

Reflections: Lisa’s case study has increased my understanding of substance abuse disorders. It expanded my understanding of the different symptoms and criteria that should be considered in diagnosing patients with the disorder. I believe that I developed an accurate diagnosis for the patient. One of the things that I would do differently should I encounter a similar patient is to explore the social factors that influence substance abuse. Social factors such as unstable families and peer pressure may affect clients’ efforts to abstain from substances (Sliedrecht et al., 2019).

As a result, exploring them would inform the adoption of effective treatment interventions. Ethical considerations that include the promotion of safety in the adopted treatments guide the management of substance use disorders. Providers should also incorporate patients’ views into the treatment plans as a way of ensuring autonomy in the treatment process. Lisa should be educated about lifestyle and behavioral interventions that she needs to adopt to facilitate weight and blood pressure control.

References

Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders, 276, 205–211. https://doi.org/10.1016/j.jad.2020.06.056

John, W. S., Zhu, H., Mannelli, P., Schwartz, R. P., Subramaniam, G. A., & Wu, L.-T. (2018). Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients. Drug and Alcohol Dependence, 187, 79–87. https://doi.org/10.1016/j.drugalcdep.2018.01.035

Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized Anxiety Disorder (Nursing). In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK568696/

Price, M., Legrand, A. C., Brier, Z. M. F., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52–58. https://doi.org/10.1016/j.jpsychires.2018.11.016

Proctor, S. L., Hoffmann, N. G., & Raggio, A. (2019). Prevalence of Substance Use Disorders and Psychiatric Conditions Among County Jail Inmates: Changes and Stability Over Time. Criminal Justice and Behavior, 46(1), 24–41. https://doi.org/10.1177/0093854818796062

Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97–115. https://doi.org/10.1016/j.psychres.2019.05.038

A Sample Answer 2 For the Assignment: NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Title: NRNP 6635 Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders

Subjective:

CC (chief complaint): “I am scared.”

HPI: Lisa Tremblay is a 33-year-old female in a detox facility. She states that she fears getting into rehab because of what other people will think about her. She fears that people will think of her as a person with an addiction. She also worries about her business, which she says is over after operating for nine months. According to Lisa, the business collapsed because of her boyfriend, Jeremy, who took money from the account. The boyfriend spent the money to pay cocaine debts, and this caused the business to lose $ 80,000. Lisa was introduced to cocaine by her boyfriend, who made her believe it was non-addictive. However, she developed a cocaine addiction. Lisa reports that she feels uneasy if she does not smoke cocaine. Smoking cocaine makes her feel good, and she usually wants to smoke more when the feeling of highness reduces. According to Lisa, she does not need help because Jeremy promised her that she would be okay, and she believes him because she loves him.

Past Psychiatric History:

  • General Statement: No psychiatric history.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History:

Take opiates worth about $100daily.

Uses cannabis 1–2 times weekly.

Drinks 1/2 gallon of vodka daily. She reports drinking with her friends but states that she is in control of her alcohol consumption.

Family Psychiatric/Substance Use History:  The patient’s mother has a history of agoraphobia and benzodiazepine abuse.

The father was imprisoned due to drug abuse.

The patient’s older brother has a history of opioid use.

Psychosocial History: The patient lives with her boyfriend, Jeremy, whom she reports having a strained relationship with after he cheated on her. She has a daughter with an ex-boyfriend, and the girl lives with her friends. Lisa and her boyfriend had started a web design business, which collapsed after he withdrew money to pay cocaine debts. The patient has a legal history of arrest after being found in possession of drugs. She was sexually abused by her estranged father when she was 6-9 years old. The father was incarcerated for sexual abuse and drug charges. Lisa’s mother lives in Maine. She has not heard from her older brother for ten years. She reports sleeping 5-6 hours/day, and her appetite increases when high.

Medical History: The patient has Hepatitis C. She is considering treatment for Hep C+ but needs detox first.

  • Current Medications:  None
  • Allergies: Allergic to Azithromycin.
  • Reproductive Hx: None

ROS:

  • GENERAL: Denies fever, chills, weight changes, or malaise.
  • HEENT: Denies eye pain, ear pain, discharge, rhinorrhea, or sore throat.
  • SKIN: Denies rashes, lesions, or discoloration.
  • CARDIOVASCULAR: Denies dyspnea, edema, chest pain, or palpitations.
  • RESPIRATORY: Denies wheezing, cough, SOB, or sputum.
  • GASTROINTESTINAL:  Positive for reduced appetite. Denies abdominal pain or bowel changes.
  • GENITOURINARY: Denies dysuria or abnormal PV discharge.
  • NEUROLOGICAL: Denies dizziness, paralysis, or tingling sensations.
  • MUSCULOSKELETAL: Denies muscle/joint pain or limitations in movement.
  • HEMATOLOGIC: Denies bruising or bleeding.
  • LYMPHATICS: Denies lymph node swelling. 
  • ENDOCRINOLOGIC: Denies excessive sweating, increased hunger, acute thirst, or polyuria.

Objective:

Physical exam: if applicable

Vital signs: BP-180/110; T- 100.0; P- 108; R-20; Ht- 5’6; Wt-146lbs

Diagnostic results:

ALT-168

AST-200

ALK-250

Bilirubin-2.5

Albumin-3.0;

GGT-59

Urine drug test positive for opiates, THC, and alcohol

BAL-308

Assessment:

Mental Status Examination:

The patient appears nervous and constantly fidgets and looks out through the window. She is alert and oriented to person, place, and time. Her self-reported mood is ‘worried,’ and her affect is broad. She has clear and coherent speech. Her thought process is coherent and goal-oriented. She exhibits no hallucinations, delusions, or suicidal/homicidal ideations. Memory, abstract thought, and judgment are intact. Insight is present.

Differential Diagnoses:

Substance Use Disorder (SUD): The DSAM-V criteria for diagnosing SUD include four basic categories: Physical dependence, Impaired control, Social problems, and risky use (American Psychiatric Association, 2022; Livne et al., 2021). The patient is physically dependent on cocaine and usually feels terrible when she has not smoked it. She gets high to trigger her appetite and has developed a cocaine addiction. She also has impaired control and cannot stop using cocaine. She continues to use cocaine despite causing social problems like problems with her boyfriend and her business collapsing. Lisa spends lots of money on opiates, about $100daily. Furthermore, she uses opiates in risky settings and has been arrested for possessing drugs.

Alcohol Use Disorder (AUD): AUD is characterized by a problematic pattern of alcohol use that results in clinically significant impairment or distress (American Psychiatric Association, 2022; Palmer et al., 2019). The patient presents with clinical features of AUD, like taking large amounts of alcohol. She reports taking 1/2 gallon of vodka daily. Besides, her urine drug test is positive for alcohol, making AUD a differential diagnosis.

Generalized Anxiety Disorder (GAD): GAD is diagnosed based on excessive, unjustified anxiety or worry, which interferes with essential activities of daily living (Boland et al., 2022; Szuhany & Simon, 2022). Lisa reports being worried about going to rehab because people will think she has an addiction. This may interfere with her treatment and recovery of opiate addiction and abuse.

Reflections: SUD is the appropriate diagnosis for this patient since she presented with a pattern of symptoms associated with using cocaine. In a different situation, I would inquire if the patient has a history of domestic violence since women who abuse substances face violence in their relationships. Legal considerations related to this patient include privacy and confidentiality. The clinician should assure the patient of confidentiality of what she says and what is recorded. Health promotion should aim to educate the patient on the effects of alcohol, cannabis, and cocaine use on her overall health.

References

American Psychiatric Association. (2022). Substance-related and addictive disorders. In Diagnostic and statistical manual of mental disorders

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

Livne, O., Shmulewitz, D., Stohl, M., Mannes, Z., Aharonovich, E., & Hasin, D. (2021). Agreement between DSM-5 and DSM-IV measures of substance use disorders in a sample of adult substance users. Drug and alcohol dependence227, 108958. https://doi.org/10.1016/j.drugalcdep.2021.108958

Palmer, R. H. C., Brick, L. A., Chou, Y. L., Agrawal, A., McGeary, J. E., Heath, A. C., Bierut, L., Keller, M. C., Johnson, E., Hartz, S. M., Schuckit, M. A., & Knopik, V. S. (2019). The etiology of DSM-5 alcohol use disorder: Evidence of shared and non-shared additive genetic effects. Drug and alcohol dependence, pp. 201, 147–154. https://doi.org/10.1016/j.drugalcdep.2018.12.034

Szuhany, K. L., & Simon, N. M. (2022). Anxiety Disorders: A Review. JAMA328(24), 2431–2445. https://doi.org/10.1001/jama.2022.22744