Walden NURS6550 Week 2 Hernandez Family Assessment

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues. As you examine the Hernandez Family: Sessions 1-6 videos in this week’s Learning Resources, consider how you might assess and treat the client family.

Learning Objectives

Students will:

Assess client families presenting for psychotherapy

To prepare:

Review this week’s Learning Resources and reflect on the insights they provide on family assessment.
View the Hernandez Family: Sessions 1-6 videos, and consider how you might assess the family in the case study.

Note: For guidance on writing a comprehensive client assessment, refer to pages 137–142 of Wheeler (2014) in this week’s Learning Resources.

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The Assignment

Address in a comprehensive client assessment of the Hernandez family the following:

Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse and/or trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan

Note: Any item you are unable to address from the video should be marked “needs to be added to” as you would in an actual comprehensive client assessment

By Day 7

Submit your Assignment.

Submission and Grading Information

Sample Assessment

Hernandez Family Assessment

Hernandez Family: Sessions 1-6

videos in this week’s Learning Resources, consider how you might assess and treat the client family.

Learning Objectives

Students will:

· Assess client families presenting for psychotherapy

To prepare:

· Review this week’s Learning Resources and reflect on the insights they provide on family assessment.

· View the Hernandez Family: Sessions 1-6 videos, and consider how you might assess the family in the case study.

Note:

For guidance on writing a comprehensive client assessment, refer to pages 137–142 of Wheeler (2014) in this week’s Learning Resources.

The Assignment

Address in a comprehensive client assessment of the Hernandez family the following:

· Demographic information

· Presenting problem

· History or present illness

· Past psychiatric history

· Medical history

· Substance use history

· Developmental history

· Family psychiatric history

· Psychosocial history

· History of abuse and/or trauma

· Review of systems

· Physical assessment

· Mental status exam

· Differential diagnosis

· Case formulation

· Treatment plan

Note:

Any item you are unable to address from the video should be marked “needs to be added to” as you would in an actual comprehensive client assessment

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014).

Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice.

New York, NY: Springer.

Chapter 12, “Family Therapy” (pp. 429–468)

Nichols, M. (2014).

The essentials of family therapy

(6th ed.). Boston, MA: Pearson.

Chapter 3, “Basic Techniques of Family Therapy” (pp. 29–48)

Chapter 4, “The Fundamental Concepts of Family Therapy” (pp. 49–68)

American Psychiatric Association. (2013).

Diagnostic and statistical manual of mental disorders

(5th ed.). Washington, DC: Author.

Note:

It is highly recommended that you use this resource as a reference guide throughout the course.

L’Abate, L. (2015). Highlights from 60 years of practice, research, and teaching in family therapy.

American Journal of Family Therapy, 43

(2), 180–196. doi:10.1080/01926187.2014.1002367

Mojta, C., Falconier, M. K., & Huebner, A. J. (2014). Fostering self-awareness in novice therapists using internal family systems therapy.

American Journal of Family Therapy, 42

(1), 67–78. doi:10.1080/01926187.2013.772870

Nichols, M., & Tafuri, S. (2013). Techniques of structural family assessment: A qualitative analysis of how experts promote a systemic perspective.

Family Process, 52

(2), 207–215. doi:10.1111/famp.12025

Papero, D. V. (2014). Assisting the two-person system: An approach based on the Bowen theory. Australian & New Zealand Journal of Family Therapy, 35(4), 386–397. doi:10.1002/anzf.1079.

Required Media

Laureate Education (Producer). (2013a).

Hernandez family> Sessions 1—6

[Video file]. Author: Baltimore, MD.

N.B: PLEASE ATTACH WITH THIS ASSIGNMENT IS THE 6 VIDEO TRANSCRIPT DOWNLOADED IN PDF FORMAT FOR THIS ASSIGNMENT SINCE THE VIDEO AND THE AUDIO IS NOT AVAILABLE AT THIS TIME, AND A SAMPLE FORMAT FOR THE ASSIGNMENT.

Accessible player –Downloads– Download Video w/CC Download Audio Download Transcript

Psychotherapy.net (Producer). (2006).

Tools and techniques for family therapy.

[Video file]. Mill Valley, CA: Author.

N.B: PLEASE THIS SAMPLE IS JUST A FORMAT FOR ONLY HERNANDEZ CASE STUDY, BUT ASSIGNMENT IS TO WRITE ON HERNANDEZ FAMILY ASSESSMENT

sampleforhernandezfamilyassessment.docx

Running head: THE HERNANDEZ CASE STUDY 1

THE HERNANDEZ CASE STUDY 2

Running head: HERNANDEZ CASE STUDY 1

N.B. THIS SAMPLE IS JUST A FORMAT FOR ONLY HERNANDEZ, BUT YOU NEED TO WRITE FOR HERNANDEZ FAMILY ASSESSMENT. Walden NURS6550 Week 2 Hernandez Family Assessment

The Hernandez Case Study

[email protected]

December 9, 2017

HERNANDEZ CASE STUDY 2

The Hernandez Case Study

Part 1: Comprehensive Client Family Assessment

Demographic information

Juan Hernandez Junior is an 8-year-old, Latino, male.

Presenting problem

Juan Hernandez Junior described a punishment at school that led to them calling the ACS. The school social worker was told of how the Hernandez parents made him kneel on his knees for hours while holding two heavy encyclopedias in each hand as a form of punishment. He reiterated that this punishment had been used on them on several occasions and this led to the ACS sending a worker to their home. The ACS worker thought that the concern was credible since this form of punishment was abusive and suggested that they start attending family sessions and visit the local community mental agency to complete a parenting group.

History or present illness

Parent’s reports Hernandez has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged in 2010.

Past psychiatric history

Parents report that Juan Jr. has been of sound psychiatric health.

HERNANDEZ CASE STUDY 3

Medical history

Parents report that Juan Jr has been healthy. However, his mother has been diagnosed with diabetes recently.

Substance use history

Both parents have no history of substance abuse nor does Juan Jr.

Developmental history

Parents reports no delays

Family psychiatric history

Parents report no psychiatric problems in their family history.

Psychosocial history

Juan Jr is quite sociable. He and his parents go to the beach and the park near their home on weekends to socialize and play.

History of abuse/trauma

Prior to the current problem that involves the form of punishment that the Hernandez are using on their children, there are no other abuse incidents that Juan Jr. has experienced.

Review of systems

Gen

: Has no fever, night sweats, heat intolerance, weakness or fatigue.

HERNANDEZ CASE STUDY 4

Head

: No migraine headaches reported.

ENT

: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck

: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.

Cardiopulmonary:

Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, and hypertension.

: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, and change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin

: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro

: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych

: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

Physical assessment

Vital Signs:

HERNANDEZ CASE STUDY 5

47 Height: inches

Weight: 129lbs

Temp: 37 0C.

RR: 16

BP: 120/59

Pulse: 79 BPM

Appearance: Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.

Mental status exam

The whole family comes to the appointment since they should do both family sessions and a positive parenting program for the parents. Juan Senior comes on with a lot of anger and resentment towards the counselor a she sees no point in attending the classes.

Differential diagnosis

The parents grew up too fast and are projecting their feelings on their children.

Diagnosis

Anger Management issues

Case formulation

The Hernandez parents, Juan Senior and Elena are brought for sessions by the ACS as a result of their son’s abuse allegations. Juan Hernandez is a 27-year-old Latino man who works as a casual worker at the airport with back problems due to the amount of heavy lifting he should do

daily. He has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged. Additionally, he takes approximately six to eight beers every weekend.

HERNANDEZ CASE STUDY 6

On the other hand, Elena is a 25-year-old Latino woman born in Puerto Rico but raised in New York who was recently diagnosed with diabetes. She has no drug abuse problem nor a criminal history. She drinks 1 or 2 drinks a month.

Treatment plan

Treatment Goals

The weekly parenting classes and family sessions will teach the parents effective and safe discipline skills, the importance of recognizing age-appropriate behavior, managing one’s frustrations, and the child development techniques that boosts child’s self-esteem and their sense of confidence. It will also help the family come to terms with the situation at hand.

Estimated Completion:

3 Months

Objective #1

The parents will be able to discipline their children effectively and using safe options.

Treatment Strategy / Interventions:

This will be done through teaching the parents the most effective and safe discipline skills they can use. These may include techniques such as setting

limits like taking away their privileges and using time-out. This can only be successful if the parents fully understand the age appropriate behavior of each stage s they do not cross boundaries and punish them unnecessarily.

Estimated Completion: 3 Months

Objective #2

In the end, the parents should be able to find child development techniques that will boost their children’s self-esteem and ensure they have a strong sense of confidence. They should also be able to manage their frustrations as a family.

HERNANDEZ CASE STUDY 7

Treatment Strategy / Interventions

: Through role playing, both the parents and the children are able to find a way to understand the feelings of the other so they can rectify any issues they might have had. This will help ensure order at home is maintained without the need for discipline and that the parents do not put unrealistic expectations on their children.

Estimated Completion: 3 Months

Social Support system:

Friends and family

HERNANDEZ CASE STUDY 8

Reference

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.