Walden University - NURS 6640WK3ASSGN2. Comprehensive Client Family Assessment: NURS 6640 Week 3 Assignment. 100%.

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Comprehensive Client Family Assessment Walden University NURS 6640 Psychotherapy with Individuals Practicum Experience Time log and Journal Demographics Information: The client is an 18-year-old... African-American male who lives with both of his parents in a suburb of Atlanta Georgia. The client has two siblings, a brother who is 11 and a sister who is 15-years-old. He attends Brookwood high school and is in a class with other children with special needs. Presenting Problem: The client’s parents state that he has been having trouble going to bed. He has trouble staying asleep and often makes loud noises that keep the rest of the family awake at night. The client is nonverbal and only makes sounds. The family is seeking a resolution for the client’s insomnia. The client’s current medication regimen is not effective. History of Present Illness: The client has a history of insomnia for the past several years. The client has been prescribed Benadryl, Xanax, Clonidine, and Trazadone for sleep with some effects but none long lasting. The family has prevented the client from taking naps after school in efforts to help with night sleep. Those efforts did provide some results however, they were short lasting. Past Psychiatric History: The client has a history of insomnia for the past 10 years or so. He has a history of severe mental retardation, developmental delays, microcephaly, Cerebral Palsy, and spastic quadriplegia. The client has self-injurious behaviors as evident from a long-standing retinal detachment from hitting self and head banging. He sees his psychiatrist monthly for follow-ups and medication adjustments. Medical History: The client has a past medical history of microcephaly, retinal detachment with blindness in right eye. The client had limited vision in his left eye and is considered legally blind. The client is affected by multiple sinus and ear infections. The client is 5’ 3” and 105 lbs with a BMI of 18.6, which is within normal limits for his height and weight. The client has no known drug allergies. The client’s immunizations are all up to date. Developmental History: The client was born a month from his due date. He was diagnosed with microcephaly in utero. His mother stated that her family has a history of having children that are microcephalic, however this history was unknown to her until after the client’s birth. The client has not achieved any of his milestones and remains totally dependent. He requires assistance with all aspects of daily living. The client’s parents stated that he has the mind of a three-year-old. Psychosocial History: The client lives with his mother, father, and two siblings. He attends Brookwood high school and rides the bus to and from school. He often goes out on community field trips with his school. Going to the mall is one of his favorite activities. The client is active in his community, often attending school basketball games and other school functions. He often attends his brother’s and sister’s sports activities also. The client is well known in his community often being noticed by others at the grocery stores or shopping centers where the family frequents. The client likes to eat, drink, and listen to music. He often dances while the music is playing. He makes loud noises to express his feeling. [Show More]

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