List 8 PROGRESS NOTES in SOAP format of the . Describe the activities you completed during this time period with patients. NOTE: ( The progress notes has to be related with what the Psychiatric Mental Health Nurse Practitioner do with Adult and Older adult with different psychiatric conditions). 8 different notes with different patients scenarios.
SOAP format (Subjective, Objective, Assessment, Plan) progress notes are commonly used in the medical field, including psychiatric mental health practice. These notes allow healthcare professionals, such as psychiatric mental health nurse practitioners (PMHNPs), to document their interactions with patients, track patient progress, and develop effective treatment plans. In this assignment, we will provide eight progress notes in SOAP format, highlighting activities completed by a PMHNP with adult and older adult patients presenting with different psychiatric conditions.
Note 1:
Subjective: The patient, a 35-year-old female, reports feeling extremely sad, experiencing pervasive feelings of worthlessness, and difficulty sleeping. She also mentions a loss of interest in activities she used to enjoy.
Objective: The patient appears visibly disheveled, with decreased eye contact and slumped posture. She exhibits psychomotor retardation. Her affect is consistently sad throughout the session. The patient’s sleep patterns have been disrupted with difficulty falling and staying asleep, resulting in fatigue.
Assessment: Based on the patient’s self-report and observed symptoms, she meets the diagnostic criteria for major depressive disorder. Risk of suicide should be assessed.
Plan: The PMHNP will conduct a comprehensive assessment, including a suicide risk assessment, and establish a therapeutic relationship with the patient. Pharmacological treatment with an antidepressant and referral for psychotherapy will be considered.
Note 2:
Subjective: The patient, a 65-year-old male, reports agitation, irritability, and difficulty concentrating. He mentions racing thoughts and a decreased need for sleep. The patient states he feels invincible and that his business ventures will make him incredibly wealthy.
Objective: The patient presents with psychomotor agitation. He talks rapidly, exhibits pressured speech, and displays inflated self-esteem. He does not display any evidence of hallucinations or delusions.
Assessment: Based on the patient’s self-report and observed symptoms, he meets the diagnostic criteria for bipolar I disorder, currently in a manic episode. Risk of harm to self or others should be evaluated.
Plan: The PMHNP will assess the patient’s risk of harm to self or others and monitor his mental status closely. Pharmacological treatment with mood stabilizers, such as lithium, and psychoeducation will be initiated. Family involvement is recommended for support.
Note 3:
Subjective: The patient, a 40-year-old female, reports experiencing persistent anxiety, including excessive worry, restlessness, and physical symptoms such as muscle tension and fatigue. She mentions feeling on edge and having difficulty controlling her worries.
Objective: The patient appears tense, with increased muscle tension and fidgeting. She exhibits rapid speech and reports difficulty concentrating. The patient’s vital signs are within normal limits.
Assessment: Based on the patient’s self-report and observed symptoms, she meets the diagnostic criteria for generalized anxiety disorder. The PMHNP will assess any comorbid conditions, such as depression.
Plan: The PMHNP will conduct a comprehensive assessment, including ruling out comorbid conditions, and establish psychoeducation on anxiety management techniques. Cognitive-behavioral therapy (CBT) and pharmacotherapy with anxiolytic medications like selective serotonin reuptake inhibitors (SSRIs) may be considered.
Note 4:
Subjective: The patient, an 80-year-old male, reports experiencing confusion, disorientation, and memory problems. His family members express concerns about his safety, as he often wanders outside and gets lost.
Objective: The patient displays evidence of cognitive impairment, with deficits in attention, memory, and orientation. He exhibits executive dysfunction, as evidenced by difficulty completing simple tasks and making decisions.
Assessment: Based on the patient’s self-report and observed symptoms, he shows signs of cognitive impairment consistent with probable Alzheimer’s disease. The PMHNP will assess the patient’s cognitive and functional abilities.
Plan: The PMHNP will conduct a comprehensive assessment, including medical and cognitive evaluations, and involve the patient’s family in the care. Pharmacotherapy options, such as cholinesterase inhibitors or memantine, may be considered for symptom management.
Note 5:
Subjective: The patient, a 45-year-old female, reports intrusive thoughts, nightmares, and hypervigilance following a traumatic event. She states feeling on edge and avoiding reminders of the trauma.
Objective: The patient displays symptoms of hyperarousal, such as jumpiness, sleep disturbances, and exaggerated startle response. She exhibits avoidance behaviors and shows signs of emotional distress when discussing the traumatic event.
Assessment: Based on the patient’s self-report and observed symptoms, she meets the diagnostic criteria for post-traumatic stress disorder (PTSD). Risk assessment for self-harm should be conducted.
Plan: The PMHNP will assess the patient’s risk of self-harm and establish a therapeutic relationship. Evidence-based treatment options, such as trauma-focused cognitive-behavioral therapy (TF-CBT) or eye movement desensitization and reprocessing (EMDR), will be considered.
Note 6:
Subjective: The patient, a 70-year-old male, reports experiencing auditory hallucinations, predominantly hearing critical voices berating him. He also mentions feeling suspicious of others and believes that he is being followed.
Objective: The patient appears preoccupied and occasionally talks to himself. He exhibits paranoid ideation and has impaired reality testing. There is no evidence of delusions of grandeur or self-harm intent.
Assessment: Based on the patient’s self-report and observed symptoms, he meets the diagnostic criteria for paranoid schizophrenia. The PMHNP will assess the patient’s level of functioning and risk to others.
Plan: The PMHNP will conduct a comprehensive assessment and initiate pharmacotherapy with antipsychotic medications. Psychoeducation regarding the nature of the illness and the importance of adherence to treatment will be provided.
Note 7:
Subjective: The patient, a 60-year-old female, reports feeling hopeless, lacking energy, and having difficulty initiating and completing tasks. She mentions decreased appetite and unintentional weight loss.
Objective: The patient appears sad and fatigued, with psychomotor retardation. She displays reduced facial expressions and diminished speech output. The patient’s symptoms are consistent with major depressive disorder.
Assessment: Based on the patient’s self-report and observed symptoms, she meets the diagnostic criteria for major depressive disorder. Risk assessment for suicidal ideation should be conducted.
Plan: The PMHNP will assess the patient’s risk of suicide and develop a therapeutic relationship. Pharmacotherapy with an appropriate antidepressant and referral for psychotherapy will be considered.
Note 8:
Subjective: The patient, a 50-year-old male, reports difficulty falling and staying asleep, resulting in daytime fatigue and impaired concentration. He states feeling irritable and restless, with a decreased interest in activities he used to enjoy.
Objective: The patient appears tired, with dark circles under his eyes. He exhibits psychomotor restlessness and displays decreased attention span. The patient’s symptoms are consistent with insomnia disorder.
Assessment: Based on the patient’s self-report and observed symptoms, he meets the diagnostic criteria for insomnia disorder. The PMHNP will assess any underlying medical or psychiatric conditions contributing to sleep disturbance.
Plan: The PMHNP will conduct a comprehensive assessment, including evaluating for comorbid conditions, and establish sleep hygiene techniques. Non-pharmacological interventions, such as cognitive-behavioral therapy for insomnia (CBT-I), will be considered. Medication options for short-term symptom relief may also be discussed.
These progress notes illustrate the activities completed by a PMHNP with adult and older adult patients presenting with various psychiatric conditions. They show the importance of comprehensive assessments, evidence-based treatment modalities, and potential pharmacotherapy in the management of psychiatric disorders.