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.

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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.

GI: 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.

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

MS: 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:

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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.

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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

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Part 2: Family Genogram includes Juan Hernandez Junior’s family.

Paternal grandparents’ maternal grandparents

Hernandez’s uncles Hernandez’s father Hernandez’s mother Aunt

His brother Hernandez Hernandez’s sister

Sister in-law

His nephew

HERNANDEZ CASE STUDY 9

Week 7 Assignment 1 Captain of the Ship

Obsessive Compulsive

Kamp University

Nurs 4582: PMHNP Role II

Dr. Hohn Doe

March 18, 2016

Obsessive Compulsive Disorder (OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions (Sadock, Sadock, & Ruiz, 2014). These recurring obsessions or compulsions cause severe distress to the person. An obsession is a recurrent and intrusive thought while a compulsion is a conscious, standardized, recurrent behavior. The purpose of this paper is to explore management strategies of OCD in adult clients. As the PMHNP, I will discuss a case and recommend treatment modalities, medical management, follow-up plan and collaboration in the care of a client with OCD.

History of present illness (HPI) and Clinical Impression

HPI: K. K. a 22 yo CF referred for a psychiatric evaluation by her PCP. Karen reports a complaint of “I need help, I can’t keep a job because of these rituals I have.” She reports that she cannot maintain a job because of her rituals of checking locks. Karen has recurrent thoughts that she had left the door of her apartment and car unlocked. She reports leaving work several times daily to check the locks on both her car and apartment. Additionally, because she often had the thought that she had not locked the door to the car, it was difficult for her to leave the car or apartment until she had repeatedly checked that it was secured causing her to be late for work. She has been fired several times for tardiness and poor attendance however checking the locks decreases her anxiety about security. Karen denies any medical issues and is not currently taking any medications. She also denies the use of any alcohol, tobacco or illicit drugs. Reports a family history of depression in both maternal and paternal grandmothers. Karen recognizes that she is needs help and is eager to begin treatment.

Assessment: A healthy, well-groomed 22yo CF in no acute distress. A, A&Ox4, pleasant and appropriately dressed. Makes good eye contact however mood is depressed with a flat affect; recent and remoter memory are intact. Karen’s thoughts are circumstantial and preoccupied with obsessions and compulsions. Her insight and judgment are fair. Denies SI/HI/AVH.

Clinical Impression: Based on the diagnostic criteria in APA (2013), a diagnosis of OCD is made.

Psychopharmacology

If the patient’s symptoms cause a significant impairment in function or distress, treatment is recommended (Fenske and Petersen, 2015). Based on Karen’s report of losing several jobs because of tardiness and attendance, there is a significant impairment in social and home functionality. Karen also reports that her rituals cause her significant distress. The standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if the SSRI is not effective (Sadock, Sadock, & Ruiz, 2014). I will initiate Prozac 40mg oral daily as it is Food and Drug Administration (FDA) approved for treatment of OCD (Stahl, 2014). I will have the patient return to clinic in week to assess for tolerability and increase to the suggested 80mg oral daily. Higher dosages have often been necessary for a beneficial effect (Stahl, 2014). I prefer to initiate with an SSRI (Prozac) as opposed to tricyclic (Clomipramine) for the less troubling adverse effects associated with Clomipramine. Karen will be informed that she might experience sleep disturbances, nausea, diarrhea, headache and anxiety which are all adverse effects of SSRIs. The desired outcome of pharmacotherapy is to reduce the patient’s intrusive thoughts that cause the compulsions that interfere with her home and work life. Well controlled studies have found that pharmacotherapy, behavior therapy, or combination of both is effective in significantly reducing the symptoms of patients with OCD (Fenske and Petersen, 2015).

Psychotherapy

Some studies indicate that behavior therapy is as effective as pharmacotherapies in OCD and some indicate that the beneficial effects are longer lasting with behavior therapy (Sadock, Sadock, & Ruiz, 2014). Many clinicians consider behavior therapy the treatment of choice for OCD and also because it can be conducted in both outpatient and inpatient settings. With the prinicpal behavioral approaches being exposure and response prevention, patients must be committed to improvement as Karen is. Behavior therapy will be initiated the same week as pharmacotherapy. The goal of therapy is to change the client’s behavior to reduce dysfunction and to improve her quality of life. A psychotherapist will be consulted to intiate and manage therapy sessions.

Medical Management

I will consult with Karen’s PCP for updates and additional concerns. Since she has been with her PCP for more than 5 years, he has good insight into her life. We will discuss baseline labs such as CBC, CMP, TSH, hepatic panel. Since with SSRIs, nausea, headache dry mouth and diarrhea are common side effects, monitoring the patient’s electrolytes is important. I would also recommend an EKG for baseline and follow up after medication initiation as SSRIs can lengthen the OT interval in otherwise health people (Sadock, Sadock, & Ruiz, 2014). Community resources such as the local chapter of the OCD Foundation will be provided to Karen for support services.

Follow -up Plan and Collaboration

Karen was instructed to follow up in 1 week to monitor tolerability and compliance of medicaiton and dose adjustment. Subsequently, she will return every 4 weeks for medication management. She is also instructed to begin behavior therapy the same week as medication are initiated and to follow up weekly for therapy sessions. I will consult with the therapist weekly for updates and any concerns or questions. I will reiterate and reinforce to both the PCP and therapist the importance of monitoring for suicidal ideations as the patient is taking an antidepressant and abuptly stopping will increase risk of suicide. About one-third of patients with OCD have major depressive disorder, and suicide is a risk for all patients with OCD (Sadock, Sadock, & Ruiz, 2014).

Conclusion

A poor prognosis is indicated by Karen yielding to rather than resisting compulsion or the need for hospitalization. A good prognosis for Karen is indicated by good home, social and occupational adjustment. The importance of an interdisciplinary team including PCP, therapist and other ancillaries will benefit the client for a better quality of life.

 

Literature Evaluation Table

Student Name:

Change Topic: Obese children under the age of 12 can be described as those children with a BMI index of 30 or more. My capstone project proposes an intervention that involves increasing knowledge on nutrition education involving proper diet and engaging in physical activities.

Criteria	Article 1	Article 2	Article 3	Article 4
Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article	Bleich, S. N., Segal, J., Wu, Y., Wilson, R., & Wang, Y. doi: 10.1542/peds.2013-0886. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691541/	Tester, J. M., Phan, T. T., Jared M. Tucker, J. M., Leung, C.W., Gillette, M. L., Sweeney, B. R., Kirk, S., Tindall, A., Olivo-Marston, S. E., & Eneli, I. U. DOI: 10.1542/peds.2017-3228 http://pediatrics.aappublications.org/content/141/3/e20173228	Cunningham, S. A., Kramer, M. R., & Narayan, K. V. DOI: 10.1056/NEJMoa1309753 http://www.nejm.org/doi/10.1056/NEJMoa1309753	Arthur M. L., Scharf, J. R., DeBoer, M. D. DOI: 10.1016/j.nut.2017.12.008 http://www.nutritionjrnl.com/article/S0899-9007(18)30025-X/fulltext
Article Title and Year Published	Title: Systematic review of community-based childhood obesity prevention studies. Year: 2013	Characteristics of Children 2 to 5 Years of Age with Severe Obesity. Year: 2018	Incidence of Childhood Obesity in the United States Year: 2014	Association between kindergarten and first-grade food insecurity and weight status in U.S. children. Year: 2018
Research Questions (Qualitative)/Hypothesis (Quantitative), and Purposes/Aim of Study	The purpose of the study was to conduct a systematic review of community based childhood obesity prevention.	The purpose of the study was to investigate the characteristics of obese children between the age of 2 and 5 years.	The paper aimed at identifying the prevalence of obesity in the United States at the national level.	The aim of the paper was to determine if food insecurity is an independent risk factor for obesity in U.S. children
Design (Type of Quantitative, or Type of Qualitative)	Systematic Review	Qualitative	Qualitative	Qualitative
Setting/Sample	Intervention was exclusively in a community setting eg, home, school, primary care, child care	Sample included children between 2 and 5 years. N=7028, from NHANES (1999–2014) Classification: normal weight, overweight, obesity	7738 participants who were in kindergarten in 1998 in the United States.	Early Childhood Longitudinal Study—Kindergarten Cohort 2011
Methods: Intervention/Instruments	Comparative Review as recommended by the Agency for Healthcare Research and Quality Methods Guide	Survey weights were used to account for probability sampling design. This analysis was done in accordance with recommendations from the National Center for Health Statistics.	Height and weight were measured seven times between 1998 and 2007. An obese baseline was set and the population analyzed	Statistical analyses were performed to evaluate longitudinal associations between food security and body mass index (BMI) z-score.
Analysis	Relevant articles were searched from Medline, Embase, Psych-Info, CINAHL, and the Cochrane Library. It was also based on medical subject headings terms and text words of key articles that we identified a priori.	Multinomial logistic and linear regressions were conducted, with normal weight as the referent.	The study used Growth Charts to calculate each child’s BMI CDC’s standard thresholds of the 85th percentile for overweight and 95th percentile for obesity. estimates of prevalence and incidence were stratified according to sex and quantile	Regression models were formulated on race/ethnicity, household income, and parental education.
Key Findings	The study’s search revealed 9 relevant articles, four of which use combined diet and physical activity approaches to childhood obesity. It is also important to note that at least one of the articles revealed significant improvements in intermediate weight-related outcome, which can be related to the physical activity that results from the intervention.	Findings from the results revealed that factors such as race, ethnicity, household income and level of education of parents as well as other factors such as breastfeeding will affect the weight of a child. The study also revealed that energy intake and Healthy Eating Index 2010 scores were not significantly different in children with Severe Obesity.	Significant statistics obtained from the study revealed that there were no significant increases in prevalence between the ages of 11 and 14 years. It was also revealed that prevalence of obesity was higher among Hispanic children than among non-Hispanic white children of all ages while those from the wealthiest families had a lower prevalence of obesity. The incidence of obesity between the ages of 5 and 14 years was 4 times as high among children who had been overweight at the age of 5 years as among children who had a normal weight at that age.	Findings of the study indicated that children with household food insecurity had increased obesity prevalence from kindergarten through grade 3.
Recommendations	Based on the review conducted, the study identifies a research gap, noting that not much has been done to determine the impact of community-based childhood obesity prevention programs on primary or secondary weight outcomes. From the literature available, however, the article recommends the use of this intervention as a combination of events would lead to more effective ways to prevent weight gain.	The study recommends a better understanding of behavioral and physiologic mechanisms and relationships behind the risk factors behind weight problems among children	Based on the findings, the study recommends a better understanding of the ding risk over a lifetime and identifying potential ages for intervention.	The study identified food-insecure children as most prone to obesity calling for interventions to focus on this area.
Explanation of How the Article Supports EBP/Capstone Project	This article provides the research gap that would be exploited by working on the capstone. It asserts that more needs to be done to provide better interventions on weight management. It also pointed out that multiple settings may be more effective at preventing weight gain in children than single-component interventions located in the community only. This information is critical for purposes of coming up with better EPB through the capstone.	This article provides a better understanding of the characteristics of obese children and classifies them into different categories. It also provides an overview of other characteristics based on social and economic aspects.	The study has provided the much needed information on the prevalence of obesity in the country. This provides a rationale for the importance of having the necessary EBP that can be used as interventions to the problem, one of which will be provided by the capstone.	This article also emphasized on some of the most prone characteristics of childhood obesity. It identified food-prone children as having the highest chances. The capstone project will therefore consider this when coming up with an intervention

Criteria	Article 5	Article 6	Article 7	Article 8
Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article	Fetter, S. D., Scherr, R. E., Linless, D. J., Dharmar, M., Sara, E. Schaefer, E. S., & Zidenberg-Cherr, S. DOI: 10.1080/07315724.2018.1436477 https://www.tandfonline.com/doi/full/10.1080/07315724.2018.1436477	Lydecke, J. A., Riley, K. E., & Grilo, C. M. DOI: 10.1002/eat.22858 https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22858	Marcum, C. S., Goldring M. R., McBride, C. M., & Persky, S. DOI: 10.1093/abm/kax041 https://academic.oup.com/abm/article-abstract/52/3/252/4822907?redirectedFrom=fulltext	Vollmer, R. L. DOI: https://doi.org/10.1016/j.jneb.2017.12.009
Article Title and Year Published	Effect of the Shaping Healthy Choices Program, a Multicomponent, School-Based Nutrition Intervention, on Physical Activity Intensity. Year published: 2018	Associations of parents’ self, child, and other “fat talk” with child eating behaviors and weight. Year published: 2018	Modeling Dynamic Food Choice Processes to Understand Dietary Intervention Effects. Year published: 2018	An Exploration of How Fathers Attempt to Prevent Childhood Obesity in Their Families. Year published: 2018
Research Questions (Qualitative)/Hypothesis (Quantitative), and Purposes/Aim of Study	The main aim of the study was to determine whether physical activity patterns improved School-Based Nutrition intervention.	The study aimed at identifying the relationship between parenting and eating behaviour and how they all relate wo weight gain.	The article aimed at identifying limitations in dietary behaviour and how micro-level choices undertaken by people on a daily basis affect it as an intervention to obesity.	The objective of the article was to understand how fathers, a parent, understand overweight preschoolers
Design (Type of Quantitative, or Type of Qualitative)	Qualitative	Qualitative	Qualitative	Qualitative
Setting/Sample	Youth enrolled in a Shaping Healthy Choices Program	581 Parents of preadolescents or adolescents	221 mothers	117 US fathers with an average of 35 years, 85% white
Methods: Intervention/Instruments	Pre and post-intervention assessments were conducted alongside a control experiment Youth at the control and intervention schools wore a Polar Active monitor on their non-dominant wrist 24 h/d for at least 2 consecutive days.	Parents were interviewed and asked if they talk about weight gain (fat talk) with their children (pre-adolescents and adolescents.	The study modelled the choices of the 221 mothers who had adopted an information-based intervention for their children.	Online survey with nine questions.
Analysis	Multiple linear regression was used to evaluate change in physical activity Statistical significance was set at p < 0.05.	Fat-Talk was categorized into self‐fat talk, obesity‐fat talk and child-fat-talk. All these were analyzed based on the responses given by each parent	Relational event modeling, where participants were grouped into control information, childhood obesity risk information and childhood obesity risk information plus a personalized family history	Content analysis was used to analyze their responses using constant comparative method
Key Findings	There were no significant differences in the change in MVPA between the schools.	A bigger percentage of parents admit to talking to their children about obesity i.e. child-fat talk. Generally, sons are easier to talk to than daughters	The results indicated that choice inertia decreased and the overall rate of food selection increased among participants receiving the strongest intervention condition	From the results of the survey, it was revealed that there are distinct causes of childhood obesity that can be prevented or treated using parents, specifically, fathers. They can be used to identify child excess weight at an early stage and work towards correcting the situation. This also includes identifying barriers to changing behaviour and overcoming them.
Recommendations	According to the authors, the overall small physical activity intensity pattern shift supports that physical activity is an important area to target within a multicomponent nutrition intervention aimed at preventing childhood obesity.	The study recommended the use of different types of talks about obesity.	The study therefore recommended that better food choices can help make any dietary behaviour intervention better	The article therefore recommends fathers as the best parents to base the intervention on. It also recommends engaging mothers as well.
Explanation of How the Article Supports EBP/Capstone	The study provides an in-depth analysis into how physical activity can be used as an intervention to prevent childhood obesity. The results will be used to compare with those found after the capstone project is complete.