Comprehensive Client Family Assessment - Essay Example

Assessing Client Families

To institute the best intervention, it is always important for healthcare professionals to always conduct a detailed assessment and, therefore, develop a conclusive point of view from which the intervention is derived. This essay describes an assessment of a patient and therefore formulate a case followed by appropriate intervention.

Part 1: Comprehensive Client Family Assessment

Demographic information

Patient KP, a male African American aged 40 years, with two children, one male, and another female. He is married to KI, an African American as well, aged 35 years.

Presenting problem

He came to the clinic and complained of challenges sleeping in the recent days, often having nightmares. Recently, he went into binge alcohol drinking, and his situation has since deteriorated, making him unable to take care of his family. He lives with his family, and the way he interacts with his children has also changed, as observed by his wife, who noted that he is bitter and seems to be in a lot of denials.

History of Present Illness

The current presentation had lasted for six months, and this follows his return from the service in the military. The wife thought this would improve, but things kept getting worse by the day, making them seek help. KP narrated that his problems began while he was in the field guarding the boarders when suddenly there was a blast. In the occurrence, there were many casualties, and some of those affected were his close friends. He kept insisting that it was his blame that he could not save his friends, especially his close friend MT who died in his own eyes. Further, he explains that his alcohol situation was to make him forget all his encounters at the warfront and find some peace of mind. Before presenting to the hospital, it had come to a point where he spent most of the time indoors for some unfounded fears.

Past Psychiatric History

KP did not have any history of psychiatric illness but noted that there were times during service that situations escalated, and he was down with a lot of stress, which lasted for a month.

Medical History

KP has had two histories of hospitalizations, and in the first, he was managing the stress disorder while the second one was due to an injury that he had sustained while on the battlefield. There was no history of chronic illnesses in the family, and neither had he suffered one before.

Substance use History

He casually took alcohol, a bottle of whisky every fortnight. He rarely smoked when outdoor. When he was on duty in another state, he occasionally took Marijuana for pleasure. When the symptoms became severe, he also took it as a way of numbing away his fears.

Developmental History

KP did not report any challenges growing up and grew up like any other normal child, achieving the required developmental milestones.

Family psychiatric history

KP's mother had suffered depression, although the case was well controlled using medications and psychosocial support. The father was a known alcoholic and often suffered anxiety attacks.

Psychosocial History

KP is social and quite sociable, interacts well with people, finding it easy to interact with people, but it was different after the current illness. He is a family man, and before the current ailment, he loved going out with his family and would bond well with his children and wife.

History of abuse and trauma

He did not acknowledge any history of trauma.

Review of Systems

GENERAL: the patient looked healthy and did not have any fever, fatigue, or malaise.

HEAD: the patient did not have any signs of trauma on the head.

ENT: there was no blurred vision, no challenges hearing, no abnormal presentations in the nose, no sinusitis, and no inflammation in the throat.

NECK: did not have any significant problems in the neck.

CARDIOPULMONARY: there was a regular heart rhythm.

GI: did not have any abdominal pain, no nausea, no vomiting.

GU: did not have any urinary challenges, no urinary urgency, no increase in urinary frequency, and abnormal genital presentation.

MS: had no muscular pain and did not report any fatigue.

HEME/SKIN: there was no presentation of injury on the skin and did not have any presentation of anemia.

PSYCH: did not seem anxious at the time of presentation.

Physical Assessment

KP had a reduction in weight, which was attributed to the recent findings that he had a reduced appetite.

Mental status exam

The patient was well oriented in terms of time, place, and space. His cognition was intact, and cognition was in place. His speech was slightly rushed and seemed to be in a hurry while talking at times became vulgar.

Differential diagnosis

Post-traumatic stress disorder: this is a disorder that presents in one who has an active encounter of trauma in their lives. An individual experiences the traumatic encounter's memories, and they affect their lives in a big way. Some of the symptoms include flashbacks, anxiety, and nightmares.

Acute Stress Disorder: this is an intense or unpleasant reaction that begins a short moment after encountering an overwhelming or traumatic encounter, which could have lasted for about a month. If the disorder progresses for a long period, it is bound to develop into post-traumatic stress disorder (“Acute Stress Disorder / Reaction, DSM 5 Code 308.3,” n.d.). Usually, the patient would present with arousal symptoms, negative mood, dissociative symptoms, and avoidance symptoms.

Generalized Anxiety Disorder: this is a condition with the persistence of panic disorder and excessive worry about several things. An individual may encounter or anticipate disaster, which would make them get concerned.

Case Formulation

Based on the presentation of the patient, he had post-traumatic stress disorder. According to DSM 5, the disorder's presentation manifests as a patient recalling traumatic events, having overly negative behaviors, and an exaggeration of one’s blame and others for the occurrence of the trauma. Some patients would become overly aggressive, reckless, and engage in self-destructive behaviors while having challenges sleeping. KP, according to the criteria outlined by the DSM 5, fits to be diagnosed with PTSD.

Treatment plan

Exposure therapy: this is a form of therapy where the therapist helps the patient to focus on a traumatic encounter and then tries to guide them to confront it realistically, although frightening continuously until the anxiety is under control (Foa et al., 2018). In this approach, the patient is encouraged to give details of the trauma, but within the therapy (Rothbaum & Schwartz, n.d.). The therapy is based on the principle that avoidance behavior is safety-seeking and seems protective and could worsen the symptoms, which would then reduce the quality of life.

Cognitive-behavioral therapy: this is a form of therapy that aims to help the patient manage their problems by changing the way they view life and think. The therapy would help change around the negative thoughts and therefore begin the positive thinking process. As the therapy progresses, the therapist would help the patient cope with distress and how they feel by identifying the thoughts that are not helpful or misrepresentations. At the end of therapy, the patient has enough control of their condition and can, therefore, think properly (Kanady et al., 2018). This therapy could, in the form of individual therapy sessions. However, it is also possible to plan and execute group sessions, especially family therapy, which would KP be able to live with his family in harmony.

Rehabilitation: KP had gravely started drinking, and this had greatly taken a toll on him. In this regard, therefore, it would be appropriate to rehabilitate and wean him off the alcohol and therefore enable him to resume his normal life activities (Pang, Hannan, & Lawrence, 2019). There would be a need to enroll him into the alcoholic anonymous, which would help instill in him the resilience that would enable him to quit the alcohol. The rehabilitation would also need to incorporate mechanisms that would help him quit the use of Marijuana and any other potential hard drugs.

Part 2: Family Genogram

Key

LT (Father): Mental Illness and alcoholism

OP: (Mother): Depression

KP: (Index person): PTSD, Alcoholism and drug abuse