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 Child and adolescents with different psychiatric conditions). 8 different notes with different patients scenarios.
PROGRESS NOTES
SOAP FORMAT
Psychiatric Mental Health Nurse Practitioner with Child and Adolescent Patients
Note 1:
Subjective: The patient, a 14-year-old adolescent diagnosed with bipolar disorder, reports feeling increasingly irritable and agitated over the past week. He describes difficulty concentrating and sleeping, and expresses frustration about frequent arguments with his parents and peers.
Objective: The patient presents with psychomotor agitation, pressured speech, and flight of ideas. He appears fatigued and reports poor appetite, resulting in weight loss of 5 pounds in the past month.
Assessment: The patient demonstrates symptoms consistent with a hypomanic episode. The decrease in appetite and weight loss suggest the presence of an atypical presentation of bipolar disorder.
Plan: Initiated treatment plan including psychoeducation on stress management techniques and exploration of triggers for mood episodes. Prescribed low-dose anti-anxiety medication to alleviate symptoms of agitation. Scheduled follow-up appointment in one week to monitor progress.
Note 2:
Subjective: The patient, an 8-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD), exhibits a decreased attention span and difficulty completing school assignments. The parents express concerns about his impulsivity and disruptive behaviors both at home and school.
Objective: During the session, the patient struggles to maintain attention and frequently interrupts, often blurting out answers before a question is completed. He demonstrates hyperactivity by frequently squirming in his seat and appearing restless.
Assessment: The patient presents with symptoms consistent with ADHD, predominantly hyperactive-impulsive type. The symptoms are negatively impacting both academic performance and peer relationships.
Plan: Collaborated with parents and school to develop an individualized education plan (IEP), which includes modifications and accommodations to support the patient’s learning needs. Initiated stimulant medication trial to address symptoms of ADHD. Scheduled follow-up appointment in four weeks to re-evaluate treatment effectiveness.
Note 3:
Subjective: The patient, a 16-year-old adolescent diagnosed with major depressive disorder, describes feeling persistently sad, hopeless, and fatigued for the past three months. She reports difficulty falling asleep and waking up early in the morning. She states that she has lost interest in activities she used to enjoy and often isolates herself from friends and family.
Objective: The patient exhibits a flattened affect, psychomotor retardation, and poor concentration. She reports weight loss of 10 pounds in the past month without intentional dieting or exercise.
Assessment: The patient demonstrates symptoms consistent with a major depressive episode. The weight loss suggests a potential comorbid eating disorder.
Plan: Initiated treatment plan including antidepressant medication and referral to a therapist experienced in treating eating disorders. Conducted a suicide risk assessment and developed a safety plan with the patient and her parents. Scheduled weekly therapy sessions for further assessment and treatment.
Note 4:
Subjective: The patient, a 10-year-old child diagnosed with autism spectrum disorder (ASD), presents with increased aggressive and self-injurious behaviors at home and school. The parents report difficulty managing his challenging behaviors and express concerns about the impact on his social and academic functioning.
Objective: During the session, the patient displays repetitive and stereotypical behaviors, such as hand flapping and rocking back and forth. He exhibits difficulty with transitions and engaging in reciprocal social interactions with both peers and adults.
Assessment: The patient demonstrates symptoms consistent with ASD, with additional challenges related to aggressive and self-injurious behaviors.
Plan: Collaborated with parents and school to develop a behavior intervention plan (BIP) to address the patient’s challenging behaviors. Recommended additional support services, such as occupational therapy, to assist with sensory integration and emotional regulation. Scheduled follow-up appointment in six weeks to evaluate the effectiveness of the BIP.
Note 5:
Subjective: The patient, a 12-year-old child diagnosed with oppositional defiant disorder (ODD), presents with persistent anger and defiance towards authority figures, including parents and teachers. The parents report difficulty setting limits and managing his explosive outbursts.
Objective: During the session, the patient exhibits argumentative and defiant behavior. He demonstrates a lack of remorse for his actions and frequently engages in power struggles with adults.
Assessment: The patient presents with symptoms consistent with ODD, characterized by a pattern of angry and irritable mood, argumentative and defiant behavior, and vindictiveness.
Plan: Collaborated with parents and provided them with strategies for setting limits and implementing consistent consequences. Introduced cognitive-behavioral therapy techniques to help the patient develop coping skills and improve impulse control. Scheduled family therapy sessions to address underlying family dynamics contributing to the maintenance of ODD behaviors.
Note 6:
Subjective: The patient, a 15-year-old adolescent diagnosed with post-traumatic stress disorder (PTSD), reports experiencing intrusive memories, nightmares, and flashbacks related to a traumatic event that occurred six months ago. She expresses a fear of leaving her house and avoids situations that remind her of the trauma.
Objective: The patient displays symptoms of hyperarousal, including hypervigilance and exaggerated startle response. She demonstrates emotional numbing and avoids discussing the traumatic event.
Assessment: The patient presents with symptoms consistent with PTSD, including avoidance, intrusive thoughts, and hyperarousal.
Plan: Initiated trauma-focused cognitive behavioral therapy to address the patient’s PTSD symptoms and to help her process the traumatic event. Provided psychoeducation on grounding techniques and stress management strategies to manage hyperarousal symptoms. Scheduled weekly therapy sessions for ongoing support.
Note 7:
Subjective: The patient, a 9-year-old child diagnosed with obsessive-compulsive disorder (OCD), describes experiencing intrusive thoughts and engaging in compulsive behaviors that consume a significant amount of his time. He reports distress and anxiety when unable to perform these rituals.
Objective: During the session, the patient demonstrates obsessive thoughts related to contamination and engages in repetitive handwashing rituals. He expresses distress with his inability to control these thoughts and urges.
Assessment: The patient presents with symptoms consistent with OCD, characterized by recurrent and intrusive thoughts, as well as compulsive behaviors aimed at reducing anxiety.
Plan: Initiated exposure and response prevention therapy to target the patient’s OCD symptoms. Developed a hierarchy of feared situations to gradually expose the patient to his feared stimuli. Scheduled weekly therapy sessions to monitor progress and adjust treatment interventions as needed.
Note 8:
Subjective: The patient, an 11-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD), reports ongoing difficulties with impulsivity and disorganization, which negatively impact his academic performance. He expresses frustration about forgetting assignments and losing focus during classroom activities.
Objective: During the session, the patient exhibits difficulty sustaining attention. He frequently interrupts and struggles with planning and organizing tasks.
Assessment: The patient presents with symptoms consistent with ADHD, predominantly inattentive type. These symptoms significantly impair his learning and functional abilities.
Plan: Collaborated with parents and teacher to implement strategies for improving organizational skills and time management. Recommended the use of assistive technology, such as a digital calendar or reminders, to aid with task completion. Scheduled monthly check-in sessions to assess progress and modify interventions accordingly.
Overall, these progress notes provide examples of the activities completed by a Psychiatric Mental Health Nurse Practitioner working with child and adolescent patients presenting with various psychiatric conditions. The practitioner engages in comprehensive assessments, collaborates with parents and schools, develops treatment plans, and implements evidence-based interventions tailored to individual needs. These notes highlight the importance of a holistic approach to address the biopsychosocial aspects of mental health in children and adolescents.