Psychiatric Case Study Examples for NRNP-6635 Assignments: SOAP Notes, Treatment Plans, and Rationales

In psychiatric nursing, documenting and analyzing patient cases through frameworks like SOAP notes (Subjective, Objective, Assessment, Plan) is a common practice. These frameworks help to systematically assess a patient’s condition and guide clinical decision-making. Additionally, treatment plans and rationales are created to ensure evidence-based, individualized care.

Below is an example of a psychiatric case study for NRNP-6635 assignments, including SOAP notes, treatment plans, and rationales.

Case Study 1: Generalized Anxiety Disorder (GAD)

Patient Information:

Age: 32
Gender: Female
Presenting Concern: Excessive worry and tension for the past six months
Diagnosis: Generalized Anxiety Disorder (GAD)

SOAP Note for Case 1

S (Subjective):
The patient reports feeling anxious most days of the week for the past six months. She worries excessively about her work performance, health, and family issues. The patient states, “I can’t stop worrying, even when things are going well.” She also reports trouble sleeping, irritability, and muscle tension. She has difficulty concentrating at work and feels fatigued. The anxiety has been interfering with her ability to engage in social activities.

O (Objective):

Appearance: Well-groomed, alert, and oriented to time, place, and person.
Affect: Anxious, tense.
Speech: Normal rate and volume, though occasionally strained.
Behavior: Restless, fidgeting with hands during interview.
Mental status: No psychosis observed. Patient’s thought process is logical but focused on worries. No suicidal ideation noted.
Vital signs: BP 130/80 mmHg, HR 90 bpm.
Cognitive functioning: Intact, but difficulty focusing on tasks.

A (Assessment):
The patient’s presentation is consistent with Generalized Anxiety Disorder (GAD). Symptoms of excessive worry, physical tension, difficulty concentrating, and sleep disturbances align with DSM-5 criteria for GAD. The patient reports significant distress in her daily functioning, especially at work and in social situations. The severity of her anxiety suggests a moderate level of impairment, but there is no evidence of psychosis or severe mood disturbance.

P (Plan):

Psychotherapy: Initiate Cognitive Behavioral Therapy (CBT) to address maladaptive thought patterns and teach relaxation techniques.
Medications: Consider starting a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline (Zoloft) for anxiety management. Monitor for side effects.
Sleep hygiene: Educate the patient on improving sleep hygiene practices.
Follow-up: Schedule a follow-up appointment in 2 weeks to assess response to treatment and adjust the plan if necessary.
Referral: If needed, refer to a psychiatrist for further medication management.

Case Study 2: Major Depressive Disorder (MDD)

Patient Information:

Age: 45
Gender: Male
Presenting Concern: Persistent low mood, lack of interest in daily activities
Diagnosis: Major Depressive Disorder (MDD)

SOAP Note for Case 2

S (Subjective):
The patient reports feeling “empty” and “hopeless” for the past two months. He has lost interest in activities he once enjoyed, including spending time with family and hobbies. He states, “I don’t care about anything anymore; everything feels like a chore.” The patient is having trouble sleeping, reporting that he wakes up multiple times during the night. Appetite is decreased, and he has lost 8 pounds in the last month. He denies suicidal ideation but feels “stuck” and “overwhelmed.” The patient also reports fatigue and low energy levels, with little motivation to complete tasks.

O (Objective):

Appearance: Slumped posture, poor eye contact, unkempt appearance.
Affect: Depressed, tearful at times.
Speech: Soft, slow speech with little variation in tone.
Behavior: Limited engagement during the interview, minimal physical movement.
Mental status: No hallucinations or delusions. Thought process is slow, but coherent.
Vital signs: BP 120/76 mmHg, HR 72 bpm.
Cognitive functioning: Mild difficulty with concentration.

A (Assessment):
This patient meets the criteria for Major Depressive Disorder (MDD) based on the duration of symptoms (lasting for over two months) and the presence of key depressive features: anhedonia, low mood, fatigue, and changes in appetite and sleep patterns. There is a moderate level of impairment, particularly in social and occupational functioning, but no immediate risk for self-harm or suicide.

P (Plan):

Psychotherapy: Initiate Cognitive Behavioral Therapy (CBT) to help address negative thought patterns and develop coping skills for managing stress and mood.
Medications: Start Sertraline (Zoloft) 50 mg daily. Gradually titrate up to the effective dose based on response and tolerability.
Support: Encourage the patient to engage in social support systems, such as family or support groups.
Monitoring: Monitor for side effects of SSRIs, particularly early signs of agitation or suicidal thoughts.
Follow-up: Schedule a follow-up in 1-2 weeks to assess the patient’s response to medications and therapy.

Case Study 3: Schizophrenia

Patient Information:

Age: 28
Gender: Male
Presenting Concern: Auditory hallucinations, paranoid delusions
Diagnosis: Schizophrenia

SOAP Note for Case 3

S (Subjective):
The patient reports hearing voices that “tell me to do things” and feeling as if “people are watching me all the time.” He states, “I know they are after me, trying to harm me.” These symptoms have been present for about six months and are worsening. The patient reports social withdrawal and difficulty engaging with others at work. He denies any current substance use but admits to discontinuing his antipsychotic medication a few months ago because “it didn’t help.” He is fearful of being hospitalized again.

O (Objective):

Appearance: Disheveled, poor hygiene.
Affect: Flat, with minimal facial expression.
Speech: Slow, with occasional disorganized speech.
Behavior: Fidgety, avoiding eye contact.
Mental status: The patient is oriented to time, place, and person but has a disorganized thought process. Delusions of persecution are evident, and auditory hallucinations are reported. No suicidal ideation, but the patient is at risk for harm due to paranoia.
Vital signs: BP 130/85 mmHg, HR 80 bpm.
Cognitive functioning: Mild memory difficulties, difficulty staying on topic during conversation.

A (Assessment):
The patient presents with schizophrenia, evidenced by auditory hallucinations, persecutory delusions, and social withdrawal. His lack of medication adherence may be contributing to the exacerbation of his symptoms. The patient is at moderate risk for harm due to his paranoia, though no immediate danger to self or others is identified.

P (Plan):

Psychotherapy: Initiate supportive psychotherapy to help the patient build coping strategies for managing psychotic symptoms.
Medications: Reinstate Olanzapine (Zyprexa) 10 mg daily, with gradual titration based on response and side effects. Monitor for common side effects such as sedation or weight gain.
Education: Educate the patient and family on the importance of medication adherence and the chronic nature of schizophrenia.
Referral: Refer to a psychiatrist for medication management and further assessment.
Follow-up: Schedule follow-up appointments weekly for the first month to monitor symptoms and ensure medication compliance.