Nursing Diagnosis Treatment Plan

will schedule an appointment to discuss and create a budget plan. Patient is currently free from all illicit drugs, which has helped her Adderall medication to be more beneficial. Primary Counselor will encourage Pt. to follow through with all mental health appointments. Counselor will prompt Pt. to develop a positive self-image. Pt. has denied having any auditory or visual hallucinations during the last quarter as evidenced by group and individual session notes. Pt. has had some setback in achieving her goals of decreasing her family conflicts and resolving intimate relationship issues. Counselor will encourage Pt. to attend the AMS parenting group and share her expectations regarding having a more functional family unit. During the next quarter therapy sessions, Counselor will utilize role-playing, role reversal, modeling, and behavioral rehearsal to assist Pt. in order to develop positive ways to resolve conflict with ex-husband. Pt.’s current treatment plan goals focus on opiate use disorder, financial, mental health services and parent-child relational problems. During the upcoming quarter, current goals will continue to be

Objectives/Progress: As the Pt. has participated in the AMS program since 8/24/16 and he has been able to maintain abstinence from all illicit drugs for 6 months straight t. Pt.'s UDS has shown no evidence of drug use or lapse/relapse. Pt. is currently in the action stage of change as indicated by reminding himself of how much progress he has made and ability to change his behavior and achieve goals during the past quarter. He has currently obtained a full-time job as a shelving installer. Patient reports as scheduled to receive maintenance medication services as instructed by AMS Doctor and attends all mandatory one therapy session once a month. He continues to share his understanding of being powerless and unmanageable over his addiction. During the next quarter sessions, Counselor will support a realistic view of change through small steps.

Substance abuse: The client reported abstaining from using illicit substances at this time. The client reported feeling motivated and his plan to remain sober while in the program. Client confirmed that he continues with his methadone maintenance program.

Pt. has been in the AMS program for 2 years. Pt. has had no positive UDS results for two years. Pt. is on a dose of 150 of methadone and he is responding as expected to his prescribed medication. Pt. demonstrated responsible attitude by attending monthly AMS groups faithfully. Pt. has discontinued all illicit drugs use and now he has used financial income in a more self-sustaining manner. Pt is effectively addressing this area by making regular payments as scheduled. Demonstrates treatment maturity and appropriately participating in medical treatment services. Pt. was taught calming strategies, such as relaxation and breathing techniques as indicated by previous counselor documentation. Pt. was assigned to this writer caseload and counselor

Met with client for ISP review and to discuss treatment progress. Client appeared to be stable and engaged in the conversation. Client reported that she completed the FAFSA and is planning to go to Everette Community College in the summer. Client reported no use of substances. Client reported coping with temptation by walking away from the situations. Client was reminded that her relapse potential was moderate to high at this time and that she thus would be cautioned to avoid any unintended consequences; with help and support from treatment and her family, client would make his treatment a success. Reviewed ISP in Dim.5 dated 11/29/17, reported completion on approach C, but was unable to identify which peer pressure could be positive (approach

The patient appears to be happy and focused on her recovery process. This writer discussed with the patient briefly about her treatment plan goals and also, briefly discussed tapering off methadone, at which the patient is willing to pursue but at a seldom pace. There was no evidence of

D-The patient reports nothing has changed since his last encounter with this writer. The patient reports he is stable on his current dose, completed his Methadone Stabilization today, and looking forward to his take home bottle, at which is pending for determination by the clinic's TEAM. During the course of the session, this writer discussed topics that was addressed in group and what he have learned.

Patient didn't call or show up for his scheduled individual counseling session today at 7 am; however, he received his dose of methadone at the Clinic around 9 :30 am. This writer called pt.’s phone number on file to reschedule a mandatory individual session. Counselor will be flag pt. in the system to see counselor before dosing tomorrow, 12/15/16 to discuss his recovery progress, what the program expects of him at this stage and how to get the most of out

Our client, Ertha Williams is a 99 year old female who lives alone in a low-income apartment complex on the second floor in Monroe, Michigan. Ertha suffers from chronic kidney disease and has a history of hypertension and type one diabetes. Due to her chronic kidney disease Ertha has regular scheduled dialysis appointments three times a week, but since the death of her son and husband and her inability to drive it is difficult for Ertha to get to her dialysis appointments. She also has difficulties preparing the multiple medication she is required to take to manage her hypertension and diabetes. After her last dialysis appointment the nurse reported that Ertha appeared frail and emaciated. Ertha herself also stated that she worries about financial issues frequently and has good and bad days occasionally. Based on these findings Ertha is in need of some assistance to help alleviate some of the problems and stresses she is undergoing. Several nursing diagnoses can be established based on Ertha’s current situation and through these diagnoses it will be easier to establish what kind of services Ertha will need from the surrounding community of Monroe and what types of barriers she might encounter in attempting to access these services.

Patient states that he was on unit in April of this year. Patient states that after discharge he tried to get into a program (Salvation Army in Manhatten), but there were no beds available. Patient reports that he went back to his same enviromemtn, Jersey City and started drinking and using heroin. Patient said that he had no health insurance so he was unable to fill his prescription. Patient reports that he applied for Medicaid and is currently waiting to see if he is going to be approved. Patient stated that he would like to go to Meadowview in Seacucus. Patient states that he reason why he uses is to self-medicate because he has no insurance. Patient stated that he would like to get into long-term rehab that does not require him

Counselor met with Pt. for an individual session. Counselor and Pt. discussed her progress in treatment and description of her medication compliance. Pt. reported wanting a higher dosage of methadone to side effects (cold). Pt. mentioned that she would like to switch to Vivitrol medication because she is going to move with her mother house in Lewes, DE and she cant come to the clinic everyday. Pt. requested, discussed and completed an AMS Modality Switch form. Counselor encouraged Pt. to talk about her current triggers and possible solutions she can plan ahead of time. Pt. stated, "I have no triggers." Counselor elicited the client’s perceptions on her several positive urine analysis. Pt. indicated that she use crack cocaine when she is depressed.

A-Based on the writer’s assessment, the client is motivated to change for the better. He test negative for one UA on 11/17/2015 and positive during his enrollment at the clinic for opioids. He continues to say throughout the session about wanting to his reduce his use of methadone. It appears that the client is in a maintenance stage. There was no evidence of SI/HI. All components of MSE were WNL functioning.

Objectives/Progress: Pt. continues to maintain total abstinence and Phase 7 status of the tx program. During the last quarter, Pt. denied any recovery issues or concerns and he is maintaining compliance with all tx criteria and obligations. Pt. has become more open during groups by acknowledging and accepting his chemical dependence; this openness was noted and reinforced. During the last quarter, Pt. provided input of ongoing activities that he is working on at this

D- The patient arrived on time for her counseling session. Reported unstable on her dose and accepted a dose increase of 5mgs as she is still experiencing withdrawals and cravings. The patient admits to using illicit drugs recently- heroin-5 bags by inhalation, cocaine-a couple of lines by inhalation, and smoke a couple of days of THC. Alternatives were discussed, which led to a discussion about the patient's treatment plan goals. The patient reported that she has a hearing with SSA, referring to her Disability hearing on September 7, 2016.

Ineffective breathing pattern related to decreased oxygen saturation, poor tissue perfusion, obesity, decreased air entry to bases of both lungs, gout and arthritic pain, decreased cardiac output, disease process of COPD, and stress as evidenced by shortness of breath, BMI > 30 abnormal breathing patterns (rapid, shallow breathing), abnormal skin colour (slightly purplish), excessive diaphoresis, nasal flaring and use of accessory muscles, statement of joint pain, oxygen saturations of 85-95% 2L NP, immobility 95% of the day, and adventitious sounds throughout lungs (crackles) secondary to CHF, hypertension, pain caused by gout and arthritis, and obesity