Nursing Treatment Pl A Case Study

The aim of this study is to provide a detailed account of the nursing care for a patient who is experiencing a breakdown in health. One aspect of their care will be discussed in relation to the nursing process. The model used to provide an individualised programme of care will be discussed and critically analysed.

1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.

A: Client showed progress in treatment and appears to be in the action stage of change at this time.

D- The patient arrived on time for her session and reports being stable on dose and haven't used any illicit drugs. This writer advised the patient that this writer was in fact in receipt of missed phone call about coming to the session at 10:30 am rather than 10 am due to her mother in the process of selling the house. This writer addressed with the patient about letter from CHR from her counselor, Jade Bray stating about the patient non-compliance with her appointment due transportation barrier. According to the patient, she is going through hardship as her mother is no longer taking her to her appointment as the patient says, " She's tired of bringing me everyone, Charlene. She complains about bringing me here and does not understand why I can't even get a bottle...:Like c'mon. What do I have to do?" This writer explained to the patient about TEAM decision, at which the patient disagree with the decision. This writer asked the patient about her "judgement." According to the patient, she feels she is making judgement by not engaging any further altercation with patient at the clinic, dosing daily, coming to her counseling session, and trying to get help from Chrysalis for

Supervisor Comments: This writer met with Cherron to address services due by counselor and reminded the Cherron about submitting his services by staff by day every week on Friday, of which Cherron have been doing. Cherron is still behind on his treatment; however, he was able to update this writer about the status of where he is with getting current with his work. Based on the services due provided from Cherron, Cherron is in need of 5 patient signatures and few was already submitted to the Clinical Director, but pending. This writer offered to help Cherron if he is in need to obtained the patient signature.

3. The patient had informed this writer initially of his goals of wanting to return back to the Hartford Dispensary due to the length of time he has been with the clinic and his positive rapport with his prior counselor at the other facility. The patient was compliant with his individual sessions with this writer and provided cancellation if unable to attend the session in the meantime while he awaits on the process of completion with his intake at Hartford Dispensary.

D-The patient arrived on time for her session. Reports stable on her dose. This writer discussed about tapering off on her methadone, at which the patient is willing to consider doing, but needs more time. She then says, " I might consider doing it next month, but not right now......I was doing it before, but it stopped....just want to take my time." The patient then discussed about having to go to SSA to obtain the payment for the funeral cost. The patient is upset about the small amount she is about to receive. This writer discussed the grieving process of her loss of her husband and also, her mother in law. The patient appeared to be annoyed with her son for not participating in his grandmother funeral arrangement and also, not showing

D-Spoke with the patient as she was being curbside dose. This writer reiterate about TEAM recommendation, at which the patient declines the notion of being placed in a skilled nursing facility due to her medical issues.This writer informed the patient that her level of care is inappropriate for this treatment and a high level of care would be more efficient. According to the patient, she's working with Chrysalis and is willing to sign an ROI for this writer to communicate with her case worker Anthony, aka Tony. Reported stable on her dose.

D-The patient arrived on time for her appointment. Reports stable on her dose and denies the need for a dose increase when offered by this writer. This writer commends the patient complying with daily dosing; however, this writer addressed the patient UDS result patterns of positive and negative. The patient last two urines were positive for cocaine. According to the patient, a lot has been going on in her life. The patient's father has had a heart attack this past month. Also, the patient has an estranged relationship with her mother and her 17 year old daughter. During the course of the session, the patient discussed her drug history and her dysfunctional family. Alternatives and suggestions were discussed as well.

D-The patient reports she is stable on her current dose and haven't experienced any withdrawals and/or cravings. The patient further mentioned that work is going okay, but still exploring other job opportunities. This writer provided positive feedback towards the patient's recovery process. In addition, the patient reports she has to do a pneumonia test as it was suggested by her PCP today. This writer requested for the patient to detailed if she's experiencing any symptoms and would like to consult with the clinic medical doctor. Based on the patient, she reports she was experiencing some backaches, but now, feels okay. During the remainder of the session, the patient discussed her plans for the Easter holiday and also shared with this writer that today is her son birthday.

Met with PO for 30 minutes individule session. The session was focused on reviewing treatment progress and discuss continuing care plan.

The patient arrived on for his counseling session. Reports stability on his current dose and denies the need for a dose increase or decrease when offered by the writer. The patient was made aware that he will be reassigned to counselor, Scott effectively immediately as his new assigned counselor will schedule his next session. The patient reports of no update with his medical pertaining to a referral to another PCP as he is currently still seeing the same medical provider.

P-The patient and this writer agreed to meet bi-weekly on Tuesdays at 9:30am. The next appointment is scheduled on 03/29/2016 at 9:30am.

D-The patient arrived on time for her appointment. Reports stable on her dose and wants to continue to voluntary taper dose until she reaches 10mgs. The patient is going through some financial difficulties as her significant other lost his employment and the family is surviving on savings, which will end by the end of the July. This writer provided the patient with a list of temp. agencies and also, information about CT works for further assistance.

The patient is upset that his dose was decrease and at first, struggled with the