Clinical Pathway Map with Synopsis – nursingtermpaper

Clinical Pathway Map with Synopsis – nursingtermpaper

Clinical Pathway Map with Synopsis

Clinical Pathway Map Assignment and Synopsis (2-part assignment)
Clinical pathways (CPWs) are tools used to guide evidence-based practice.  The purpose of CPWs is to implement the use of evidence-based guideline recommendations into the clinical process of care.  The CPWs are actual steps taken in a course of treatment or the actual plan of care.  It aims to develop standardized care of a specific problem, diagnosis, or procedure in a specific population. 
Part 1:
For this assignment, you will review the case study below and develop a comprehensive clinical pathway for a suicidal patient.  YOU ARE THE PROVIDER and the case study is your psychiatric evaluation.  The pathway should be specific and based on this specific patient. A sample CPW is shown below. Your CPW must be solely based on your plan of care. BE SPECIFIC. You will be required to have at least 1 evidence-based peer reviewed article that is no more than 5 years old for CPW immediate course of action (no book references allowed for this assignment).  Make sure to give your diagnosis and list all provisional diagnosis in the CPW for this patient.  You must address each component in the sample CPW below and the use of a concept map of your preference is required. (Microsoft Word and other resources- such as Google/YouTube- can assist you with this).
Part 2:
Additionally, you will write a synopsis related to the case study provided. Write the synopsis utilizing the prompts below. 1 sentence per prompt- except #1 and #5 should have at least 2 sentences. No more or less than 7 sentences for this assignment. Your CPW and Synopsis should be cohesive. You will need 2 evidence-based peer reviewed articles that are no more than 5 years old for the synopsis, no book references for this assignment allowed.  Here is a link that has several psychotherapist and their theories that you may utilize as a guide.   https://drive.google.com/file/d/1o1v54sXLcvp8rnuNYjCen-Lw4En0yyYW/viewLinks to an external site.
(Please note that each of the 3 references at the end of this assignment should be referenced in 7th edition APA format.)

State the Background significance of the situation related to the case study
Provide a problem statement for this patient case study (what is the issue or challenge here you that you want to want to address and change regarding the patient?).
Give 3 measurable goals for this patient.
Identify 1 relevant Psychotherapy Theory for this patient.
Describe why you chose this psychotherapeutic pathway for this patient.

 
Case Presentation
Client is a 75-year-old Caucasian male. He is a retired veteran widowed and lives alone. Arrived at the hospital via ambulance. He is lethargic with speech unintelligible. He was administered supportive care by medical staff with a psychiatric consultation. 
 
History of Present Illness
Patient endorses that he drinks a 12 pack of alcohol (beer) daily. He also takes hydrocodone 7.5mg/325mg three times per day. Patient acknowledges that he was not specifically trying to kill himself but understood the potential risk of taking pain medications and drinking alcohol. He also verbalized, “Dying may not be so bad, I sometimes wish that I would not wake up. I am tired of living like this, nobody cares about me. Death might be a relief.” Patient denies having any close relationships and denies any hobbies or activities outside of drinking alcohol.
 
Past Psychiatric History
Inpatient treatment at Clams Mental Health Center in Tampa Florida in 2018. He was prescribed Wellbutrin- which he was noncompliant with. He stayed 10 days in the facility and reports that he had good results with Wellbutrin but stopped taking it because he “just didnâ€t go get it refilled”. 
Patient reports that he is up most of the night and only sleeps a few hours during the day. Energy level is “not good”. Denies any problems with his appetite. Denies any history of hallucinations, paranoia, or suicide attempts. Depression started years ago after his wifeâ€s death in 2017. Positive for social withdrawal. Reported “no hobbies, friends, family that I see or speak to.” Regarding symptomatology, patient reported, “I feel irritable and sad most of the day. Essentially, I feel like Iâ€ve been taken over by sadness, my wife died, my life is over, so I drink to help numb the pain.”
 
Substance History
Patient reports the following:
Started drinking alcohol excessively after wife died in 2017. Drinks a 12 pack of beer per day. Last drink was prior to hospitalization- which was yesterday. Endorses longest period of sobriety has been 1 week. No AA/NA affiliation, sponsorship, or A&D treatment in the past. Denies any history of blackouts. CAGE (positive +4). Smokes half pack of cigarettes per day  and has been smoking for about 20 years. Denies any illicit drug use. Reports that he takes the Hydrocodone as prescribed.
 
Medical History
No Known Drug Allergies. Denies any known physical ailments/impairments. Wears corrective lenses, no difficulty with hearing. Patient denies any history of seizures, TBI, thyroid, heart, gastric, kidney, or lung disease/dysfunction. Last bowel movement was 2 days ago (describes as normal for him). Denies any past surgeries. Reports he does not take any medications except for hydrocodone and a stool softener daily. 
 
Trauma
Denies any trauma history with exception of wife dying of a heart attack while at work.
 
Family History
Reports that his mother had a history of depression and HTN and is now deceased-“she died of old age 12 years ago”. Father died in a tractor accident about 17 years ago. Father did not have any known mental or medical issues. Parents were married. Maternal uncle killed himself when patient was 12. No known family history of drugs/alcohol. He has one younger brother that he has not spoken with in about 5 years- “we have never been close.”
 
Developmental History
Patient reports that he was reared by both parents. Reports that he met all his developmental milestones as a child. Had a “good childhood. I was happy.” Reports that he was active in high school. Made As and Bs in school, played football, and married his high school sweetheart. Productive citizen and was in the military for 25 years- E7, honorable discharge. Has some VA benefits- “I am 40% service connected.”
 
Social History
Retired from military. Married x1-wife died in 2017. Does not have any children. No legal issues past or present. Religion is Baptist. Lives in the home that he owns. Has a car for transport. Hobbies “none”.  Support person- “myself.”
 
Mental Status Exam
This is a 75-year-old Caucasian male.  He appears his stated age.  Grooming and hygiene appeared fair.  Appropriate eye contact during conversation.  No abnormal motor movements noted on admission.  Regarding his speech, his speech was regular rate, tone, and volume.  Thought processes were goal directed. Regarding thought content, he currently denies suicidal or homicidal ideations, but verbalized passive suicidal ideations to undersigned during interview. He denied thoughts of paranoia/others wanting to harm him. He denied auditory/visual hallucinations, there was no internal responsiveness noted.  He is alert, and x4 to all spheres.  His intellectual functioning was estimated to be average, and this is based on conversation, communication skills, and use of vocabulary.  He expressed his mood as “feeling sad.”  His affect was labile.  His attention and concentration were adequate during conversation.  He was able to spell the word world forward and backwards.  He was able to complete the Serial 3â€s without difficulty.  His recent and remote memory were noted to be intact.  His immediate recall was 3 out of 3, short term recall 2 out of 3.  He was able to discuss personal recent and remote events with timeline ostensibly intact.  His general fund of knowledge was noted to be intact AEB   able to recall the current President and four of his predecessors.  He was also able to briefly discuss world news.  His abstracts were noted to be intact regarding proverb interpretation and similarities.  He was observed to be cooperative, but dysphoric.  His insight and judgment impaired regarding his current situation, ability to care for self, and make appropriate decisions.  This assumption was based upon the patientâ€s history and viewing and assessing of his current presentation.

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