PRAC 6665/6675 Clinical Skills Self-Assessment Form Tina Cherry College of Nursing-PMHNP, Walden University NRNP PRAC 6665C: Psychiatric Mental Health Nurse Practitioner Care Across the Lifespan I Jannia Mendez MSN APRN PMHNP BC September 4, 2022 PRAC 6665/6675 Clinical Skills Self-Assessment Form Desired Clinical Skills for Students to Achieve Confident (Can complete independently) Mostly confident (Can complete with supervision) Beginning (Have performed with supervision or needs supervision to feel confident) New (Have never performed or does not apply) Comprehensive psychiatric evaluation skills in: Recognizing clinical signs and symptoms of psychiatric illness across the lifespan X Differentiating between pathophysiological and psychopathological conditions X Performing and interpreting a comprehensive and/or interval history and physical examination (including laboratory and diagnostic studies) X Performing and interpreting a mental status examination X Performing and interpreting a psychosocial assessment and family psychiatric history X Performing and interpreting a functional assessment (activities of daily living, occupational, social, leisure, educational). X Diagnostic reasoning skill in: Developing and prioritizing a differential diagnoses list X Formulating diagnoses according to DSM 5-TR based on assessment data X Differentiating between normal/abnormal age- related physiological and psychological X symptoms/changes Pharmacotherapeutic skills in: Selecting appropriate evidence based clinical practice guidelines for medication plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management) X Evaluating patient response and modify plan as necessary X Documenting (e.g., adverse reaction, the patient response, changes to the plan of care) X Psychotherapeutic Treatment Planning: Recognizes concepts of therapeutic modalities across the lifespan X Selecting appropriate evidence based clinical practice guidelines for psychotherapeutic plan (e.g., risk/benefit, patient preference, developmental considerations, financial, the process of informed consent, symptom management, modality appropriate for situation) X Applies age appropriate psychotherapeutic counseling techniques with individuals and/or any caregivers X Develop an age appropriate individualized plan of care X Provide psychoeducation to individuals and/or any caregivers X Promote health and disease prevention techniques Self-assessment skill: Develop SMART goals for practicum experiences X Evaluating outcomes of practicum goals and modify plan as necessary X Documenting and reflecting on learning experiences X Professional skills: Maintains professional boundaries and therapeutic relationship with clients and staff X Collaborate with.

1. PRAC 6665/6675 Clinical Skills
Self-Assessment Form
Tina Cherry
College of Nursing-PMHNP, Walden University
NRNP PRAC 6665C: Psychiatric Mental Health Nurse
Practitioner Care Across the Lifespan I
Jannia Mendez MSN APRN PMHNP BC
September 4, 2022
PRAC 6665/6675 Clinical Skills
Self-Assessment Form
Desired Clinical Skills for
Students to Achieve
Confident (Can
complete
independently)
Mostly
confident (Can
complete with
supervision)

2. Beginning (Have
performed with
supervision or
needs
supervision to
feel confident)
New (Have
never performed
or does not
apply)
Comprehensive psychiatric evaluation skills in:
Recognizing clinical signs
and symptoms of
psychiatric illness across the
lifespan
X
Differentiating between
pathophysiological and
psychopathological
conditions
X
Performing and interpreting
a comprehensive and/or
interval history and physical
examination (including
laboratory and diagnostic
studies)

3. X
Performing and interpreting
a mental status
examination
X
Performing and interpreting
a psychosocial assessment
and family psychiatric
history
X
Performing and interpreting
a functional assessment
(activities of daily living,
occupational, social, leisure,
educational).
X
Diagnostic reasoning skill in:
Developing and prioritizing
a differential diagnoses list
X
Formulating diagnoses
according to DSM 5-TR
based on assessment data
X

4. Differentiating between
normal/abnormal age-
related physiological and
psychological
X
symptoms/changes
Pharmacotherapeutic skills in:
Selecting appropriate
evidence based clinical
practice guidelines for
medication plan (e.g.,
risk/benefit, patient
preference, developmental
considerations, financial,
the process of informed
consent, symptom
management)
X
Evaluating patient response
and modify plan as
necessary
X
Documenting (e.g., adverse
reaction, the patient
response, changes to the
plan of care)

5. X
Psychotherapeutic Treatment Planning:
Recognizes concepts of
therapeutic modalities
across the lifespan
X
Selecting appropriate
evidence based clinical
practice guidelines for
psychotherapeutic plan
(e.g., risk/benefit, patient
preference, developmental
considerations, financial,
the process of informed
consent, symptom
management, modality
appropriate for situation)
X
Applies age appropriate
psychotherapeutic
counseling techniques with
individuals and/or any
caregivers
X
Develop an age appropriate
individualized plan of care

6. X
Provide psychoeducation to
individuals and/or any
caregivers
X
Promote health and disease
prevention techniques
Self-assessment skill:
Develop SMART goals for
practicum experiences
X
Evaluating outcomes of
practicum goals and modify
plan as necessary
X
Documenting and reflecting
on learning experiences
X
Professional skills:
Maintains professional
boundaries and therapeutic
relationship with clients and

7. staff
X
Collaborate with multi-
disciplinary teams to
improve clinical practice in
mental health settings
X
Identifies ethical and legal
dilemmas with possible
resolutions
X
Demonstrates non-
judgmental practice
approach and empathy
X
Practices within scope of
practice
X
Selecting and implementing appropriate screening
instrument(s), interpreting results, and making
recommendations and referrals:
Demonstrates selecting the
correct screening
instrument appropriate for
the clinical situation

8. X
Implements the screening
instrument efficiently and
effectively with the clients
X
Interprets results for
screening instruments
accurately
X
Develops an appropriate
plan of care based upon
screening instruments
response
X
Identifies the need to refer
to another specialty
provider when applicable
X
Accurately documents
recommendations for
psychiatric consultations
when applicable
X

9. Summary of strengths:
I always maintain professional boundaries and a therapeutic
relationship with clients and staff.
My professionalism is my greatest strength. I understand my
responsibilities and know how to
set limits with clients and coworkers. I have a propensity of not
judging in my everyday life, and
thus it is not difficult to use this practice in my professional
activity. Identifying areas of
weakness is another strength. Especially when being entrusted
with health care decisions for
others, it is essential to know when to seek counsel and ask for
direction from those with more
proficiency. Communication is a key element to my
professionalism. Communicating with
multidisciplinary teams, patients, and families. Communication
involves using verbal, non-
verbal, and written forms. I strive to express empathy while
sharing information with patients
and family members. Sharing information with nurse
practitioners and physicians improves the
safety and welfare of patients (Durmaz et al., 2018).
Opportunities for growth:
This quarter I will have the opportunity to grow and improve
my skills in performing and
interpreting a psychosocial assessment and family psychiatric
history. Patient assessment is vital
in developing accurate diagnoses (Pelin & Ayise, 2019). During
this quarter I will focus on
assessing children and adolescents. I will broaden my
knowledge pertaining to ethical and legal
dilemmas concerning this patient population. This will facilitate

10. selecting the appropriate
evidence based clinical practice guidelines for
psychotherapeutic plan. Focusing on this patient
population this quarter will allow me to differentiating between
normal/abnormal age-related
physiological and psychological symptoms/changes in children
and adolescents.
Now, write three to four (3–4) possible goals and objectives for
this practicum experience. Ensure that
they follow the SMART Strategy, as described in the Learning
Resources.
1. Goal: This quarter I will independently select appropriate
evidence based clinical practice
guidelines for psychotherapeutic plan for modality appropriate
for situation. I will improve on
my skills by preforming psychiatric examinations for least 180.
At the end of independently
select an appropriate therapeutic plan for each client’s situation.
a. Objective: independently assess developmental
considerations,
b. Objective: independently assess symptom management
c. Objective: independently assess risk/benefit
2. Goal: This quarter I will Identify ethical and legal dilemmas
and develop possible resolutions by
the end of this quarter. I will develop my skills in this area by
collaborating with a
multidisciplinary team member e.g., social worker at least 20
times this quarter to discuss
legalities and financial considerations involving psychiatric
clients across the life span.

11. a. Objective: I will independently resolve ethical dilemmas
b. Objective: I will independently resolve legal dilemmas
c. Objective: I will independently identify the need for a
referral to social worker or legal
authority
3. Goal: This quarter I will independently differentiate between
normal/abnormal age-related
physiological and psychological symptoms/changes. I will
improve on my skills by assessing at
least 40 children and 40 older adults this quarter. By the end of
this quarter, I will be able to
independently differentiate between normal/abnormal age-
related physiological and
psychological symptoms/changes.
4.
a. Objective: To independently differentiate between
normal/abnormal physiological and
psychological symptoms/changes in children between five and
twelve
b. Objective: To independently differentiate between
normal/abnormal physiological and
psychological symptoms/changes in adolescents between
thirteen and seventeen
c. Objective: To independently differentiate between
normal/abnormal physiological and
psychological symptoms/changes in adults sixty-four and above
5. Goal:
a. Objective:
b. Objective:

12. c. Objective:
Signature: Tina Cherry
Date: September 4, 2022
Course/Section: PRAC 6665C-42
Reference
Durmaz, Y. C., Serin, E. K., & Polat, H. T. (2018).
Determination of Problem-Solving and
Communication Skills of Nursing/Midwifery Students.
International journal of caring
sciences, 11(3).
Pelin, K., & Ayise, K. (2019). Assessment of mentorship
applications in nursing clinical
education. International Journal of Caring Sciences, 12(2), 869-
876.
NRNP PRAC 6665C: Psychiatric Mental Health Nurse
Practitioner Care Across the Lifespan I
Comprehensive Focused SOAP Psychiatric Evaluation
Comprehensive Focused SOAP Psychiatric Evaluation
`
Focused SOAP Note and Client Case Presentation
Tina Cherry
College of Nursing-PMHNP, Walden University
NRNP PRAC 6665C: Psychiatric Mental Health Nurse
Practitioner Care Across the Lifespan I

13. Jannia Mendez MSN APRN PMHNP BC
October 11, 2022
Subjective:
CC (chief complaint): “I’m taking medication. I need an outlet
like work.”
HPI: K.G is a 25-year-old male accompanied by his mother. He
is alert and oriented to self, time, place and situation. He is also
calm and cooperative. The client reports his anxiety and
depression has improved. However, the client reports that since
his last visit, he has been smoking marijuana and drinking
alcohol everyday. His mother reports he drinks excessively to
the point of passing out. The client reports he has been taking
his medication but needs an outlet like work. The client says he
is sleeping well and rates his satisfaction with life as a five out
of ten, where ten represents total happiness.
Substance Current Use: The client is currently drinking alcohol
and smoking marijuana daily. He is also a daily tobacco smoker.
Medical History:
· HIV, dyslexia, ADHD
·
Current Medications: Paliperidone ER 6 mg tablet,
extended-release 24 hr, Take one tab nightly, BIKTARVY 50-
200-25 mg tablet
·
Allergies:
No allergies reported.
·
Reproductive Hx: The client is sexually active. No
children.

14. ROS: Psychiatric: The client reports changes in his moods,
depression, sadness, anxiety, hopelessness and worthlessness.
He denies suicidal ideations, homicidal ideations, visual or
auditory hallucinations at the time of interview.
GENERAL: The client is alert and oriented to place person,
time, and event. He looks well-nourished, and there are no
apparent signs of distress.
· HEENT: The skull of the client is normocephalic and
atraumatic. He does not report any significant vision changes or
pain in his eyes. He does not also report any difficulties in
swallowing or auditory challenges.
· SKIN: Appropriate for age, race and ethnicity. No
abnormalties noted.
· CARDIOVASCULAR: There is no report of orthopnea, edema,
or chest pain.
· RESPIRATORY: No wheezing or coughing. The client denies
experiencing any dyspnea.
· GASTROINTESTINAL: The client does not report any pain or
discomfort
· GENITOURINARY: The client does not report any hematuria
or dysuria.
· NEUROLOGICAL: The client does not report any focal
weaknesses, numbness, blackout, or seizures.
· MUSCULOSKELETAL: The client does not report any joint
pains or swellings.
· HEMATOLOGIC: The client does not report abnormal
bleeding or bruising.
· LYMPHATICS: No inflammations are reported.
· ENDOCRINOLOGIC: There are no reports of polydipsia or
polyuria.
Objective:
Diagnostic results: Vitals: Height 69 inches, weight: 179.5,

15. BMI: 26.51, BP: 112/66 mmHg, Temperature: 98.7 F, Pulse: 89
bpm, Respiratory Rate: 18 bpm
Assessment:
Mental Status Examination
The client is slightly dishevleled but appropriately dressed for
the occasion and season. During the mental status examination,
the client is calm and cooperative. He has a fair attitude and
pleasant demeanor. The client appears apprehensive when topics
such as adherence to medication are brought up. He has a full
affect, slightly restless and avoids eye contact. The client
expressed the desire to adhere to his medication regimine and
participate in therapy. He was also receptive to education on the
risks and dangers of using marijahana and drinking alcohol
while taking psychotropic medications. The client verbalized
understanding of provided education.
Diagnostic Impression:
Schizoaffective disorder, bipolar type (disorder) (F25.0/295.70)
Some prominent features of schizoaffective disorder bipolar
type are psychosis and mood symptoms (Schnitzer et al., 2020).
Its hallmarks include mood disorders and depression (Schnitzer
et al., 2020). The symptoms of schizoaffective disorder are
broad but include manic or depressive episodes and psychosis
(Schnitzer et al., 2020). Some other symptoms characteristic of
schizoaffective disorder bipolar type are an individual
neglecting their hygiene and appearance (Schnitzer et al., 2020).
Individuals suffering from the disorder are also likely to
experience mood swings which may see the individual
pendulum between exuberance and melancholy (Schnitzer et al.,
2020). Clients with schizoaffective disorder are also likely to
engage in risky sexual behavior, which may expose them to
sexually transmitted infections.
Substance abuse (disorder) (F19.10)
Substance abuse disorder is a mental health condition where the
affected individual has a persistent impulse to use a substance

16. and is unable to reduce, stop or control the use of the substance
(Finegan, 2021). Such individuals continue using a substance
even when they know its adverse effects on their health. The
individual also uses the substances in more significant amounts
than when they previously began using them (Finegan, 2021).
Eventually, an individual builds tolerance to the substance and
may need to use a more significant amount to achieve the same
effect a smaller amount previously did. Alcohol and marijuana
are two of the most commonly abused substances among
individuals suffering from substance abuse disorder (Finegan,
2021).
Difficulty sleeping (Z72.820/V69.4) Sleep deprivation
Sleep deprivation is a mental health condition where the
affected individual lacks a regular sleeping and waking cycle.
The individual can go on prolonged periods where they do not
sleep. It is a state where a person does not get enough sleep due
to a sleep disorder, psychiatric illness, chronic illness, effects
of a medication, or life events *. Without enough sleep, an
individual’s cognitive and mental functioning can be impaired
since they are not getting the rest they need.
Reflections:
One of the main learning points regarding this case was the
extent to which schizoaffective disorder can influence risky
sexual behavior in an individual. Impaired decision making
combined with risky sexual behavior leaves a high likelihood
for STI exposre. Individuals with schizoaffective disorder also
often struggle with substance abuse issues. This incividual has
competed an inpatient substance abuse program within the past
six months. However, he has relapsed several times and has yet
to accomplish any notable sobriety. One of the ethical
considerations that should be considered in this case is client
autonomy. Although his mother accompanies him, he is an adult
and, as such, can make autonomous decisions. Non-maleficence
should also be considered to ensure no harm comes to the client
while treating him and prescribing psychotropic medications.

17. Due to his history of substance abuse, stringent eduducation on
the risks and dangers of non-adherance to taking medications as
ordered must be reiterated during every encounter.
Case Formulation and Treatment Plan:
This individual has no recent reports of psychosis. Therefore,
this client should continue taking Paliperidone ER 6 mg tablet,
extended-release 24 hr, taking one tab nightly as ordered. This
medication seems to be stabalizing the client’s symptoms. The
client should also be subjected to cognitive behavioral therapy
to help address his abuse of marijuana and alcohol. Cognitive
behavioral therapy has been proven effective in managing
clients' substance abuse disorders (Magill et al., 2019). In
addition to cognitive behavioral therapy, the client can also be
subjected to motivational interviewing to encourage
ambivalence towards abusing alcohol and marijuana (Hawk &
D’Onofrio, 2018).The client should also be educated to ensure
they understand the severe health effects of continuing to abuse
alcohol and marijuana. This individual should be encouraged to
attend AA meetings and Focus on Recovery. Furthermore, a
follow-up appointment should be scheduled after four weeks to
evaluate his progress. The client and the mother should
verbalize the treatment plan to indicate they have a full
understanding of risks and benefits.
References
Finegan, B. A. (2021). Substance Abuse Disorder. In
Preoperative Assessment (pp.
301-304). Springer, Cham.
https://doi.org/10.1007/978-3-030-58842-7_48
Hawk, K., & D’Onofrio, G. (2018). Emergency department
screening and interventions
for substance use disorders.
Addiction science & clinical practice,
13(1), 1-6.

18. https://doi.org/10.1186/s13722-018-0117-1
Hudson, A. N., Van Dongen, H., & Honn, K. A. (2020). Sleep
deprivation, vigilant
attention, and brain function: a review.
Neuropsychopharmacology,
45(1), 21-30.
https://doi.org/10.1038/s41386-019-0432-6
Magill, M., Ray, L., Kiluk, B., Hoadley, A., Bernstein, M.,
Tonigan, J. S., & Carroll, K.
(2019). A meta-analysis of cognitive-behavioral therapy for
alcohol or other drug use disorders: Treatment efficacy by
contrast condition.
Journal of consulting and clinical psychology,
87(12), 1093.
https://doi.org/10.1037/ccp0000447
Schnitzer, K., Beckmann, D., & Freudenreich, O. (2020).
Schizoaffective disorder:
treatment considerations.
Psychiatric Annals,
50(5), 200-204.
https://doi.org/10.3928/00485713-20200409-01
© 2021 Walden University
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Rubric Detail
Select Grid View or List View to change the rubric's layout.
Name:

19. PRAC_6665_Week11_Assignment_Rubric
·
Grid View
·
List View
Excellent
Good
Fair
Poor
Assimilation and Synthesis: Content Reflection
45 (45%) - 50 (50%)
Reflection demonstrates a high level of critical thinking in
applying and integrating key course concepts and theories from
readings, lectures, and/or experiences. Insightful and relevant
connections are made through contextual explanations and
examples.
40 (40%) - 44 (44%)
Reflection demonstrates moderate level of critical thinking in
applying and integrating key course concepts and theories from
readings, lectures, and/or experiences. Connections are made
through explanations and/or examples.
35 (35%) - 39 (39%)
Reflection demonstrates minimal critical thinking in applying
and integrating key course concepts and theories from readings,
lectures, and/or experiences. Minimal connections made through
explanations and/or examples.
0 (0%) - 34 (34%)
Reflection lacks critical thinking. Superficial connections are
made with key course concepts and resources, and/or
assignments.
Assimilation and Synthesis: Personal Growth
27 (27%) - 30 (30%)
Expresses solid evidence of reflection on own work.
Demonstrates substantial personal growth and awareness of

20. deeper meaning through inferences, well developed insights,
and significant depth in awareness and challenges. Synthesizes
current experience into future implications.
24 (24%) - 26 (26%)
Expresses moderate evidence of reflection on own work.
Demonstrates satisfactory personal growth and awareness
through some inferences, insights, and challenges. There is
mention of the future implications of student’s current
experience.
21 (21%) - 23 (23%)
Expresses minimal evidence of reflection on own work.
Demonstrates less than adequate personal growth and awareness
through limited or simplistic inferences made, insights, and/or
challenges that are not well developed. Minimal thought of
future implications of student’s current experience.
0 (0%) - 20 (20%)
Expresses inadequate evidence of reflection on own work.
Personal growth and awareness are not evident and/or
demonstrate an impersonal experience. Lacks personal insights,
challenges, inferences, and/or future implications are
overlooked.
Written Expression and Formatting
14 (14%) - 15 (15%)
Well written and clearly organized using standard English,
characterized by elements of a strong writing style and basically
free from grammar, punctuation, usage, and spelling errors.
12 (12%) - 13 (13%)
Above average writing style and logically organized using
standard English with minor errors in grammar, punctuation,
usage, and spelling.
11 (11%) - 11 (11%)
Average writing style that is sometimes unclear and/or with
some errors in grammar, punctuation, usage, and spelling.
0 (0%) - 10 (10%)
Poor writing style lacking in standard English, clarity, language
used, and/or frequent errors in grammar, punctuation, usage,

21. and spelling. Needs work.
APA
5 (5%) - 5 (5%)
Contains no APA errors.
4 (4%) - 4 (4%)
Contains one to two (1–2) APA errors.
3.5 (3.5%) - 3.5 (3.5%)
Contains three to five (3–5) APA errors.
0 (0%) - 3 (3%)
Contains more than five (>5) APA errors.
Total Points: 100
Name:
PRAC_6665_Week11_Assignment_Rubric
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Journal
Welcome to the last week of your practicum! As you have
proceeded through the practicum experience, you have been
regularly challenged to reflect on your growth and development
as you made progress on your goals. Additionally, your
Preceptor has evaluated your skills and has provided feedback.
As you end this practicum, consider what you have gained from
the experiences in your practicum setting. Did you meet your
goals and objectives? What were the challenges and how did
you manage them? What were the successes and what lessons
can you take from those experiences and apply to future
experiences? Use your reflections to seek opportunities for
growth in the areas you found challenging, while
simultaneously celebrating your successes.
This week, your complete a reflective journal on your practicum
experience
Critical reflection of your growth and development during your

22. practicum experience in a clinical setting has the benefit of
helping you to identify opportunities for improvement in your
clinical skills, while also recognizing your strengths and
successes.
Use this Journal to reflect on your clinical strengths and
opportunities for improvement, the progress you made, and what
insights you will carry forward into your next practicum.
To Prepare
· Refer to the “Population-Focused Nurse Practitioner
Competencies” found in the Week 1 Learning Resources, and
consider the quality measures or indicators advanced nursing
practice nurses must possess in your specialty of interest.
· Refer to your Clinical Skills Self-Assessment Form you
submitted in Week 1, and consider your strengths and
opportunities for improvement.
· Refer to your Patient Log in Meditrek, and consider the
patient activities you have experienced in your practicum
experience and reflect on your observations and experiences.
Journal Entry (450–500 words)
Learning From Experiences
· Revisit the goals and objectives from your Practicum
Experience Plan. Explain the degree to which you achieved each
during the practicum experience.
· Reflect on the three (3) most challenging patients you
encountered during the practicum experience. What was most
challenging about each?
· What did you learn from this experience?
· What resources were available?
· What evidence-based practice did you use for the patients?
· What would you do differently?
· How are you managing patient flow and volume?
· How can you apply your growing skillset to be a social change
agent within your community?
Communicating and Feedback
· Reflect on how you might improve your skills and knowledge,
and communicate those efforts to your Preceptor.

23. · Answer the questions: How am I doing? What is missing?
· Reflect on the formal and informal feedback you received
from your Preceptor.