SOAP Response student 3
Respond at least 2 times each, 1.5 pages to each response to all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in SOAP. Also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient. Responses exhibit synthesis, critical thinking, and application to practice settings…. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources…. Responses demonstrate synthesis and understanding of Learning Objectives…. Communication is professional and respectful to colleagues…. Presenters’ prompts/questions posed in the case presentations are thoroughly addressed…. Responses are effectively written in standard, edited English. Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7. Student 3 SOAP Week 9: SOAP NOTES Kirsten Steen College of Nursing-PMHNP, Walden University PRAC 6675: PMHNP Care Across the Lifespan I Dr. Demisia Brown January 24, 2024 Three objectives: 1.) You will gain better knowledge of how to medically and therapeutically treat a person with an eating disorder, specifically anorexia nervosa. 2.) You will gain knowledge of how mental illness can play a role in eating disorders. 3.) You will better understand what coping skills people with eating disorders need to help keep them from relapsing. Subjective: CC: “My eating disorder went down hill really fast” HPI: A 47-year-old Caucasian female (identified as MW) presents to the hospital for eating disorder (ED) treatment. Her ED began at around age 18 when she started restricting food and overexercising. She reported receiving treatment from other inpatient facilities and outpatient clinics for her disorder since that time. MW has participated in a partial hospitalization program (PHP) and has been in residential and inpatient treatment several times over the last ten years for her eating disorder. The patient was still working on weight restoration while in PHP. Unfortunately, MW reported that after discharging from the PHP program, her ED “went downhill,” and she decreased her caloric intake to 300-500 calories per day. In the last two weeks, there have been 2 to 3 days with no caloric intake. Since July 2023, she has lost 30 lbs. MW denies water restriction or water loading. She does not feel she drinks enough water and only has “a couple cups” daily. She said she enjoys drinking coffee and Diet Coke in place of water. MW reported that her obsession with exercise got “really, really bad,” but then “I got so weak that I have not exercised in the last few weeks.” Initially, her exercise regime mainly consisted of kick-boxing for 90 minutes a day, but then dropped it to 30 minutes a day and then stopped entirely due to intense weakness and dizziness. She reported that she is “dizzy all of the time” and has problems feeling sensations in her toes and fingers, which are always cold, she said. She mentioned that her bones ache, as well. She reported heart palpitations. Denies laxative or diuretic use. Denies using diet pills. Denies bingeing or purging. Upon admission to the hospital, her BMI was 18.2. The patient refused to eat meals or snacks after being admitted. She was put on fall precautions and placed in a wheelchair and uses a shower chair for safety. She has struggled dramatically with increased anxiety and depression over the past month, with anxiety being more prominent as reported. She was diagnosed in 1996 with Bipolar 1 disorder but has not had a manic episode since 2022. MW reported three previous suicide attempts in her early twenties by overdose. No medical interventions were needed at those times, she said. She currently reports passive suicidal ideation and says that sometimes she uses her ED as a way of self-harm and that she does not care if it kills her. She hopelessly reported, “I am never going to get better; literally, I might as well just kill myself with my eating disorder .”MW reports feeling irritable, anxious, low energy, apathetic, and hopeless. She said she always feels something will go wrong, but when she feels “great,” she “can get so much done,” especially after exercising. She said that she cannot function well without exercise, and she has an intense desire to do anything it takes to exercise, even if it interferes with her family obligations. She states that she thinks about her body image and ED 98% of the day that she is awake. The thought of eating food creates an immense amount of anxiety. MW consistently sees herself as “the largest person in the world” when she looks in the mirror. She rates anxiety as 10/10 and rates depression as 8/10. Denies panic attacks. She reports problems with insomnia, nightmares, flashbacks from previous trauma, and obsessions and compulsions with food and exercise. Denies any previous falls, concussions, or head injuries and reports meeting all developmental milestones as a child. Social History: MW is an author, wife, and mother of six children. She lives at home with her husband and children and reports having a relationship with them. She had been married once before, but her previous husband passed away ten years ago from a cardiac arrest. MW has a supportive network from her family, sister, and mother. She enjoys reading, writing, and exercise. She identifies as LDS but does not attend church regularly. Substance Use History/Current Use • • • 3-4 cans diet coke and 2 cups of coffee a day. Denies use of nicotine Denies use of marijuana, illicit substances Denies using/abusing alcohol. Medical History: • No significant medical or surgical history other than giving birth to six babies Reproductive History: • GRAVADA-6 • PARA-6 • LMP: 1/5/24—Regular periods without excessive cramping or bleeding • Birth Control Method: condom Psych History: Behavioral Health Hospitalizations • CFC April 2023 – Sept 2023 – 24 hour care and PHP • CFC in May 2022- August 2022 • CFC in Nov 2021 – March 2022 • Behavioral Health Hospitalization in 2014 for mania and SI Family History: • Maternal Uncle has bipolar disorder • Brother likely has bipolar, substance abuse • Son has bipolar disorder • Daughter may have bipolar disorder Medication Trials: • Naltrexone for obsessions/compulsions-not effective • Vraylar for depression, but wasn’t taking in enough calories-not beneficial • Abilify for depression/mood-not effective Current Medications: • clonazepam 0.25 mg PO BID for anxiety • lamotrigine 400 mg PO Q AM for mood stabilization • trazodone 300 mg PO Q HS for insomnia • vilazodone 40 mg PO Q AM for depression/anxiety Pt verbalized understanding of what medications she is taking Allergies: • NKDA • No food allergy • No seasonal allergy ROS: • • • • • • • • • GENERAL: MW reports increased weakness, dizziness, fatigue, loss of appetite, and feeling cold. HEENT: No hearing loss, sneezing, congestion, runny nose, or sore throat. Wears glasses and contacts, has noticed blurred vision recently. INTEGUMENTARY: Denies rash or itching, dry skin or bruising. No pruritus, lesions, open skin, wounds/self harm, or scars. No tattoos. CARDIOVASCULAR: poor circulation with restriction. Bilateral edema in lower extremeties +2, non-pitting. Reports frequent postural dizziness, lightheadedness, palpitations, SOB and chest pain on exertion occur intermittently. Reports syncopal episode a few weeks ago. HR 58, QT 412 QTc 414. Cappilary refill >10. No chest pain, chest pressure, or chest discomfort. RESPIRATORY: SOB with exertion. Denies dyspnea or chest pain. No cough. No S/SX of COVID reported. GASTROINTESTINAL: intermittent diarrhea and abdominal pain, denies laxative abuse. BMs Q day. LBM 11/7, loose. Reports intermittent nausea with eating. Denies heartburn, vomiting, black/tarry stools, rectal bleeding, and hematemesis. MW reports symptoms of hypoglycemia. GENITOURINARY: LMP: 1/5/2024. No pain, pressure, urgency, or frequency with urination. NEUROLOGICAL: numbness bilateral hands and feet with poor circulation, Denies any hx of seizures, concussion, or neuralgia. Reports headaches with dehydration. Difficulty staying asleep-wakes up at 3 a.m. MUSCULOSKELETAL back and neck pain Denies any joint pain. Most recent DEXA scan 2 years ago. • • • • GENITOURINARY: Menarche began at age 14, has a regular period. Denies any hx of endometriosis, ovarian cysts, or PCOS. URINARY–Denies frequency, urgency, dysuria, or history of incontinence or kidney stones. HEMATOLOGIC: No report of anemia or abnormal bruising or other disorders associated with blood cells. LYMPHATICS: No enlarged nodes. No history of splenectomy. ENDOCRIOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. No report of thyroid problems or diabetes. Reports symptoms of hypoglycemia. Objective Diagnostic Results Vitals: • B/P: 118/64 • R: 18 • P: 86 • Wt: 125.4 • BMI: 18.2 • EKG: HR:58, QT/QTC: 416/412 (wnl) Abnormal Labs: BUN: 5 (low) Sodium 132 (low) Alkaline Phosphatase 41 (Low) CL: 95 Anorexia nervosa can lead to severe malnutrition, electrolyte imbalances, and nutritional deficiencies that can affect the heart’s function and may result in cardiac complications such as arrhythmias or abnormal heart rhythms. The disorder can lead to electrolyte imbalances such as potassium, which is crucial for normal heart function. An EKG can also provide information about the heart’s structure and identify any signs of cardiac enlargement or other structural abnormalities that can manifest in EDs (Electrocardiogram – statpearls – NCBI bookshelf, n.d.). A prolonged QT/QTC interval is how long it takes for the heart to recharge between beats, and when it is prolonged for too long, the patient runs the risk of developing a fatal heart condition known as Torsades de Pointes (Long QT syndrome (LQTS). Johns Hopkins Medicine, n.d.). Fortunately, MW’s EKG is wnl. A BMI of less than 18.5 is considered underweight. MW’s BMI is 18.2. An individual with a BMI of 18 is considered underweight, which may have health implications. Being underweight can be associated with various health risks, including nutritional deficiencies, a weakened immune system, and potential impacts on reproductive health (Body Mass Index in adults, 2024). A low BUN level in anorexia indicates malnutrition, low protein intake, and muscle wasting. Part of the body’s metabolism includes the breakdown of protein, but when a person does not ingest enough protein through foods, there is not enough to break down, thus creating lower BUN levels. Additionally, the muscles are a significant source of protein, so a decrease in muscle mass can contribute to lower BUN levels. MW’s BUN is a 5 (low) since levels between 6-20 mg/DL are normal (Keller, 2019). MW’s sodium is 132 (low) since normal is 135-145 MeQ/L. When restricting food, they can lack sodium and other electrolytes, which keep the heart and body/brain functioning optimally (MediLexicon International, n.d.). A low alkaline phosphatase level occurs with malnutrition and can cause problems with bone health and sometimes liver dysfunction. MW’s level is 41. Normal is considered 44-147 IU/L (MediLexicon International, n.d.). When a chloride level is low, like MW’s, it could be related to dehydration, which can affect the electrolytes in the body that help the heart function correctly. MW’s level is 95 (low). 99-106 MeQ/L is normal. So, with the current lab values, it reveals malnutrition for MW. Mental Status Exam: MW is alert and oriented X 4, is casually dressed, and is in no apparent distress. Her attitude is calm and cooperative, with good eye contact. There is no psychomotor agitation or retardation, and no tics/tremors. Her speech has an average volume, rate, rhythm, and productivity. There are no repetitive phrases, and she can accurately name objects, feelings, and emotions. Her mood is reported to be depressed, and her affect is congruent with the emotion. Her thought process is organized and linear, with no loose associations. No psychosis. No visual or auditory hallucinations. Her recent and remote memories are intact. She has an adequate attention span and focus. Her fund of knowledge is average, and her judgment and insight are fair. Diagnostic Impression Anorexia Nervosa, restricting type F50.02 According to the Diagnostic and Statistical Manual of mental disorders: DSM-5 (2017), anorexia nervosa (AN) is a specific ED characterized by certain criteria and is diagnosed based on a combination of behavioral, psychological, and physical features. The DSM-5 outlines the following criteria for the diagnosis of anorexia nervosa: the individual consistently restricts food intake, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. MW limited her calorie intake to 300-500 calories daily and did not eat anything for two consecutive days. The individual must have a distorted body image and an intense fear of gaining weight or becoming fat, even though they are considered underweight. MW consistently sees herself as “the largest person in the world” when she looks in the mirror. The DSM-5 further classifies anorexia nervosa into two subtypes: Restricting Type and Binge-Eating/Purging Type. The restricting type is characterized by severe food restriction without regular binge eating or purging episodes. The Binge/Purge Type involves recurrent episodes of binge eating or purging behaviors such as self-induced vomiting or the misuse of laxatives (Diagnostic and statistical manual of mental disorders: DSM-5, 2017) . Individuals with the Restricting Type of AN engage in severe food restriction, leading to significantly low-calorie intake, resulting in weight loss. Unlike the Binge-Eating/Purging Type, individuals with the Restricting Type do not regularly engage in binge-eating episodes or inappropriate compensatory behaviors such as vomiting. The individual may also participate in over-exercising to burn off any additional calories (Harrington, 2015). MW used exercise as a way to reduce her body weight Obsessive Compulsive Disorder F42 The DSM-5 describes Obsessive-Compulsive Disorder (OCD) as an anxiety disorder characterized by the presence of obsessions and compulsions. Some key features and criteria for diagnosing OCD according to the DSM-5 include Obsessions, which are defined as intrusive and unwanted thoughts, images, or urges that cause significant anxiety or distress. People with OCD attempt to ignore or suppress the thoughts but find they are often difficult to control (Sussex Publishers, n.d.). MW stated that she thinks about her ED 98% of the day, which causes her a significant amount of anxiety and stress. Compulsions are repetitive behaviors or mental acts that an individual feels compelled to perform in response to an obsession or according to rigid rules. MW stated that she feels compelled to exercise 90 minutes daily to feel better about herself. The compulsions are aimed at preventing or reducing anxiety or preventing a dreaded event or situation. The obsessions and compulsions are time-consuming and take up more than one hour a day or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Diagnostic and statistical manual of mental disorders: DSM-5, 2017). MW’s 90-minute daily exercise habits have interfered with her family obligations. Finally, the symptoms are not due to the direct psychological effects of a substance or general medical condition. They are not better explained by the symptoms of another mental disorder (Diagnostic and statistical manual of mental disorders: DSM-5, 2017). Bipolar 1 Disorder F31 Bipolar 1 Disorder is a mood disorder characterized by the occurrence of at least one manic episode, and the essential feature is a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week or any duration if hospitalization is necessary. Additionally, during the mania, three or more of the following symptoms must be present (four if the mood is only irritable). 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep. 3. Increased talkativeness or pressure to keep talking. 4. Flight of ideas or racing thoughts. 5. Distractability. 6. Increased goal-directed activity or psychomotor agitation. 7. Excessive involvement in pleasurable activities with a high potential for painful consequences like reckless behavior, excessive spending, or sexual indescretions (Diagnostic and statistical manual of mental disorders: DSM-5, 2017). The mania must be severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalization to prevent harm to self or others, or there are psychotic features. Furthermore, the disturbance must not be due to the direct psychiological effects of a substance or general medical condition (Diagnostic and statistical manual of mental disorders: DSM-5, 2017). It is essential to note that Bipolar 1 Disorder requires the presence of at least one manic episode. Individuals with this disorder may also experience depressive episodes, but a major depressive episode is not required for the diagnosis of Bipolar 1. Additionally, the course of Bipolar 1 Disorder can involve alternating episodes of mania and depression, and treatment typically includes mood stabilizers, psychotherapy, and other interventions to manage symptoms and improve functioning (Lee & Swartz, n.d.). I have chosen to add Bipolar 1 Disorder as a diagnosis for MW since she was previously diagnosed with the disorder and reports that within the last two years, she has had a manic episode. She also stated that she sometimes feels energized and can “get so much done.” Reflection As a PMHNP student working with MW daily, I am starting to understand her thoughts, perspectives, and feelings about her body, weight, and fear of food. Her underlying negative core beliefs can continue to exacerbate her ED if she is not taught how to cope with triggers and stressors. She will be exposed to mirrors, scales, and food in the real world. People will talk about beauty and the perfect image, which can trigger her if she is not primed with coping skills and a better view of herself and her body. She may have to examine her relationships and other aspects that impact her mental health and prioritize the positive factors that will encourage and contribute to a better self-image and acceptance. I must reflect on the presence of co-occurring mental health conditions such as her anxiety, depression, and obsessive-compulsive features and how they interact with and influence her ED. Individual and group therapy may help MW get to the root of why her obsession with food restriction and negative body image started. Medication and re-feeding can help, but not fix, the foundational component of her mental problems. A third reflection factor is understanding MW’s motivation for seeking treatment and making changes. Does she want to get well, or has her ED become part of her identity that she is afraid to let go? I must explore factors that may enhance or hinder her commitment to recovery. Reflecting on these aspects allows me to gain deeper insights into MW’s unique experience and tailor her treatment approach accordingly. I could start by building a therapeutic alliance and fostering open communication. Case Formulation and Treatment Plan The plan for MW is to prioritize medical stabilization and nutritional rehabilitation and address any acute health risks, then establish a multidisciplinary treatment team including a PMHNP, therapist, dietician, and any other medical or mental professionals to help provide comprehensive care. • Continue inpatient level of care treatment with four psychiatric follow-ups per week. Admit MW to the inpatient unit for nutritional rehabilitation, intensive treatment, therapy, support, medical, dietary, and therapeutic interventions aimed at stabilizing her condition and general eating patterns. • Continue with wheelchair and elevator safety precautions and utilize the shower chair until orthostatic blood pressures are better and dizziness has significantly subsided. MW may have to use a walker with a seat attached to ambulate. • Continue to take her medications as prescribed, provide patient education with every assessment, and increase or decrease dosages or change to a different medication if her current regimen is not as effective as hoped. • Encourage MW to participate in all aspects of individual therapy, group therapy, family therapy, body image groups, dietary therapy, and other specialized programming or activities. Provide psychoeducation about ED and address any misconceptions or myths. • • • Check MW’s vital signs TID and prn for symptoms of low blood pressure, and continue with monthly EKGs if wnl or weekly if QT/QTC is prolonged. Draw CMP, CBC, Mg, Phos, and Alt levels weekly. Work with the dietician to create an individualized meal plan, gradually reintroducing and normalizing food intake while addressing nutritional deficiencies. Provide Boost supplement for food refusals. Start Melatonin 5 mg QHS and 5 mg PRN if she continues to wake up before 3 a.m. Health Promotion Health promotion for individuals with EDs involves a comprehensive approach addressing physical and mental well-being. Treatment for EDs must be tailored to each patient individually as their nutritional needs require. • Provide regular medical check-ups to monitor physical health and nutritional status and address any complications associated with the ED. • Work with the dietician to establish a balanced meal plan. • Use CBT and DBT or other evidence-based psychotherapies to address underlying psychological factors contributing to the ED. • Incorporate interventions and teach MW better-coping methods to help improve her body image and self-esteem, including mindfulness-based practices and acceptance and commitment therapy. • Re-introduce a more balanced exercise plan for MW since exercise helps her relieve anxiety and feel better. Patient Education Patient education for people with eating disorders is a crucial component of treatment to help them understand their condition, promote recovery, and develop a healthy relationship with food. Some considerations for patient education include: • Explain the physical consequences of the ED that impact bone health, nutritional deficiencies, and electrolyte imbalances, and explain the long-term adverse effects that continued malnutrition can cause. • Educate the patient about the psychological aspects of ED, including distorted body image, perfectionism, and the role of control, and help them understand the link between thoughts, feelings, and behaviors. • Discuss the common co-occurring mental health conditions, such as anxiety and depression, and explain how addressing both the ED and these conditions is essential for comprehensive treatment. • Promote body positivity and self-esteem by challenging unrealistic beauty standards to help them foster a healthy relationship with their bodies. Social Determinate of Health For individuals with EDs, several social determinants of health may play a role in the development, progression, and recovery from these conditions. Some vital social determinants include: • • • How cultural and societal expectations and social media regarding body image and beauty standards can contribute to the development of EDs. Economic factors such as financial stress and limited access to nutritious food can impact nutritional habits and contribute to EDs. Societal expectations and norms related to gender and sexual identity may influence body image concerns and the prevalence of EDs, particularly in the LGBTQ population. Three Questions for my audience: 1.) What would you address first: the physical or mental aspect of MW’s illness? 2.) What coping skills would you teach to help prevent relapse with MW’s ED? 3.) What other ideas do you have for patient education before discharge. PRECEPTOR VERFICIATION: I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning. Preceptor signature: ________________________________________________________ Date: ________________________ References Body mass index in adults. www.heart.org. (2024). https://www.heart.org/en/healthyliving/healthy-eating/losing-weight/bmi-in-adults Diagnostic and statistical manual of mental disorders: DSM-5. (2017). American Psychiatric Association. Electrocardiogram – statpearls – NCBI bookshelf. (n.d.-b). https://www.ncbi.nlm.nih.gov/books/NBK549803/ Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. C. (2015). Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American Family Physician. https://www.aafp.org/pubs/afp/issues/2015/0101/p46.html Keller, U. (2019). Nutritional Laboratory markers in malnutrition. Journal of clinical medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6616535/ Lee, J., & Swartz, K. L. (n.d.). Bipolar I disorder: Johns Hopkins Psychiatry Guide. Bipolar I Disorder | Johns Hopkins Psychiatry Guide. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787045/ all/Bipolar_I_Disorder Long QT syndrome (LQTS). Johns Hopkins Medicine. (2021). https://www.hopkinsmedicine.org/health/conditions-and-diseases/long-qt-syndrome-lqts MediLexicon International. (n.d.-a). Alkaline phosphatase (ALP) level test: High and Low Levels. Medical News Today. https://www.medicalnewstoday.com/articles/321984 MediLexicon International. (n.d.). Low sodium levels (hyponatremia): Symptoms and causes. Medical News Today. https://www.medicalnewstoday.com/articles/323831 Sussex Publishers. (n.d.). 3 kinds of OCD thoughts and how to deal with them. Psychology Today. https://www.psychologytoday.com/intl/blog/demystifying-ocd/202202/3-kindsocd-thoughts-and-how-deal-them
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