LASA 2: Case study: Diagnosis and Treatment Recommendations

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LASA 2: Case study: Diagnosis and Treatment Recommendations

This assignment is designed to help you synthesize the course material and apply the material in creating an assessment, and generating a diagnosis, as well as treatment recommendations.

Read the case study provided and write a clinical report which includes:

  1. A summary of the major issues facing the client needing to be addressed.
  2. A working diagnosis for the client (with diagnostic summary and rationale) utilizing the following information from the CAGE screening tool and case history information.
  3. A Mental Status Exam which applies the information from the case history.
  4. Detailed treatment recommendations determining which modality (family, individual, group, or couples) is most appropriate for this client.  Be sure to provide the rational for your choice by integrating information from the case summary.
  5. Recommendations on whether individual is a good candidate for treatment placement (inpatient, residential, or outpatient) and an analysis of the pros and cons for your selection based on a summary of the issues.

Your paper should be at least 4 pages long. Remember to include a cover page and reference page, and to support your arguments with information drawn from the online content, the textbook, and other credible, scholarly sources to substantiate the points you are making.  Apply APA standards for writing and citations to your work.

The case information is as follow:

Case Information

Client: Joseph Blackwell

Date of Birth: July 10, 1961

Identifying Information

Gender: Male

Age: 49

Religion: Baptist

Race/Ethnicity: Caucasian

Disability: No visible disabilities

Class: Annual income under $12,000

Educational Qualification: High School Diploma

Current Family Constellation and Living Arrangements

Married currently separated

3 children, ages  20, 15, 2

Currently homeless, staying with a friend

Other Family Information

Mother gives money to him on a consistent basis

The only person who “nags” him about his drinking is his wife

Other family members have covered for him on more than one occasion, telling his wife he was working when he was really getting high.

Employment Status

Recently lost job due to failure to show up.

Employed there for 6 months

Reports having over 10 jobs in the last 5 years

Skilled as a roofer

Legal Problems

Took a Plea for Treatment in lieu of conviction for current possession of cocaine charge

License suspended for Driving Under the Influence

Currently on Probation

Past/Current Psychological Problems

Reports a diagnosis of Bipolar Manic Depression made several years ago

States “I just wants it all go away, maybe it be better if I just went away, sometimes I cry when I wake up.”

Medication history

Records indicated that the client has been treated off and on with Seroquel and Lithium. He reported that both medications helped him feel more “calm and collected.” He has been off of medication for the past 2 months.

Substance Use history

The client stated that he drinks alcohol every day, usually 1 liter of vodka and a few beers.  This pattern of drinking endured for the past 10 years. He tried to stop drinking one time and the longest that he has abstained from drugs and alcohol was for a period of 3 months a few years ago. He also uses cocaine and marijuana several times per week.  He stated that he has thought about stopping the substance use, but is sure that he will never be able to abstain. The patient has a history of the shakes when he has attempted to stop drinking in the past. He has tried outpatient substance abuse counseling, though would usually relapse after a few sessions. He has never participated in inpatient detox.

Records reviewed (Psychiatric ER summary dated August 6, 2010)

Patient was admitted to the X psychiatric emergency room and placed on a 72 hour observation. He was brought in by emergency medical services and a police escort after he was found in the street yelling that he wanted to die and threatening bystanders at the local bus station.  His toxicology screening was positive for alcohol, marijuana, cocaine, and benzodiazepines.  After the 72 hour observation the substances had cleared, the patient was administered Librium for alcohol withdrawal complications, and by day 3 he denied suicidal, as well as homicidal ideation. Thus, he was released, in good behavioral control, and referred to an outpatient chemical dependency program. Records indicated that the pt has a diagnostic history that includes, Bipolar Disorder Not Otherwise Specified, Alcohol Dependence, and Polysubstance Abuse.

Last  evaluation: Wednesday, March 9, 2011

Client presented wearing a t-shirt stained with food and smelling of beer. His jeans were tattered with random holes and burn marks. His hair was long and tangled. He was malodorous. The client required multiple redirections to lower his voice and to get him back on topic as he kept changing the topic to discuss unrelated content, such as food that he wanted to eat and about a new pair of shoes that he hoped to buy. The client’s mood was unstable in that he vacillated between irritable, depressed, and euphoric states during this interview. He avoided eye contact and moving around in his chair often. He often laughed when discussing his most recent DUI and when discussing that he lost his most recent job. Client knew that he was at Agency X for a psychological evaluation, stated that it was Tuesday and that the year is 2010. He sleeps, at times, 3-4 hours per night, and sometimes does not feel the need to sleep at all. Client denied hearing voices, seeing things that others cannot, and is not paranoid. He denied any desire or plan to hurt other people. He admitted one suicide attempt by taking pain pills that were washed down with 1 liter of vodka last year because he wanted to “escape.” The client often ponders what it would be like to not be alive anymore and reported that he thought about taking a bottle of pain medication this morning in an effort to attempt suicide.

CAGE Screening Tools answers from client:

  1.  Have you ever felt you should “cut down” on your drinking?

Answer:   Yes, I have tried on several occasions to drink less.  The last time I tried was about 2 years ago.

  1.  Have people “annoyed” you by criticizing your drinking?

Answer:  That is why I left my wife.  All she did was nag about what and when I drink.  I got sick of it.

  1.  Have you ever felt bad or guilty about your drinking?

Answer:   Kind of sort of…

  1. Did you ever take an “eye opener” a drink first thing in the morning to steady your nerves or get rid of a hangover?

Answer:   Doesn’t everyone do this every once in a while.  It takes the edge off with everything I have going on.

 

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Executive Summary on 2 Healthy People 2020 health indicators with nursing diagnoses

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. Select 2 of the 15 elements below you collected data for. Use the outline format below and support your recommendations with up-to-date, peer-reviewed references (references must not be more than three to five years old, and you may use your course text for only one reference).

2. Using APA format, write an executive summary (no more than 1–1.5 pages for each problem identified or 3 pages total for the paper excluding the title page and reference pages) detailing the key findings of these elements from your windshield survey. Follow the outline below to guide you in writing your paper; contact your section instructor with any questions. The paper should contain a minimum of six peer-reviewed references in your discussion sections (three per problem identified).

Outline Format for Executive Summary Paper
1. For the introduction, briefly state that you are a community health nurse performing a windshield survey, the issue you are aIDressing, and why it is important that it be aIDressed.
2. Identify the survey location
3. Identify the target population . Be sure to include an objective identifier such as actual ages you are targeting.
4. State which Healthy People 2020 Leading Health/Millennium Development Goal Indicator you are targeting.
5. State which element from the windshield survey you are aIDressing (e.g., housing and zoning). Give a brief description of windshield survey findings that relate to your Leading Health Indicator/need for an intervention.
6. State your nursing diagnosis in the format requested in the assignment (risk of______ among _______ related to________) (Newfield et al., 2007).
7. Discussion Portion of Paper: This is a section separate from your two executive summaries discussing the communities and your suggested interventions. Here, you will write a page or so (still falling within the three-page recommendation for the assignment) justifying and showing evidence about your recommendations. Consider this a place for your final remarks, where you can make the argument why your recommendations and interventions should be aIDressed.
o Briefly state your recommendation/intervention and how it would benefit your target population. You may choose a recommendation/intervention from an existing program, or you may design your own. Support your recommendation/intervention with evidence from the literature (this is where the use of references comes in). For example, if you chose to recommend a substance abuse awareness programs for teens, you may want to look at what the National Institute on Drug Abuse says about programs that work. Be sure to consider the developmental stage of your target population when recommending/designing your intervention. Include a one- or two-paragraph discussion at the end of the outline discussing your recommendations for each intervention.
o Briefly state what teaching methods/strategies you would use to present your intervention (think about teaching/learning theories).
o Include a brief discussion of your role as the community health nurse in this intervention.

You will need to repeat this outline for both of your nursing diagnoses. Remember, the assignment is limited to 3 pages (excluding the title and reference pages). The paper must be in correct APA format, including the reference pages.

Windshield elements and outline:
1)Housing and zoning :What is the age of the houses, architecture? Of what materials are they constructed? Are all zoning neighborhood houses similar in age, architecture? How would you characterize their differences? Are they detached or connected to others? Do they have space in front or behind? What is their general condition? Are there signs of disrepair—broken doors, windows, leaks, locks missing? Is there central heating, modern plumbing, air conditioning?
2)Open space: How much open space is there? What is the quality of the space—green parks or rubble-?lled lots? What is the lot size of the houses? Lawns? Flower boxes? Do you see trees on the pavements, a green island in the center of the streets? Is the open space public or private? Used by whom?
3)Boundaries: What signs are there of where this neighborhood begins and ends? Are the boundaries natural—a river, a different terrain; physical—a highway, railroad; economic—difference in real estate or presence of industrial or commercial units along with residential? Does the neighborhood have an identity, a name? Do you see it displayed? Are there unof?cial names?
4) “Commons”: What are the neighborhood hangouts? For what groups, at what hours (e.g., schoolyard, candy store, bar, restaurant, park, 24-hour drugstore)? Does the “commons” area have a sense of “ territoriality,” or is it open to the stranger?
5) Transportation: How do people get in and out of the neighborhood—car, bus, bike, walk, etc.? Are the streets and roads conducive to good transportation and also to community life? Is there a major highway near the neighborhood? Whom does it serve? How frequently is public transportation available?
6)Service centers: Do you see social agencies, clients, recreation centers, signs of activity at the schools? Are there of?ces of doctors, dentists; palmists, spiritualists, etc.? Are there parks? Are they in use?
7 )Stores Where do residents shop—shopping centers, neighborhood stores? How do they travel to shop?
8)Street people: If you are traveling during the day, whom do you see on the street—an occasional housewife, mother with a baby? Do you see anyone you would not expect—teenagers, unemployed males? Can you spot a welfare worker, an insurance collector, a door-to-door salesman? Is the dress of those you see representative or unexpected? Along with people, what animals do you see—stray cats, pedigreed pets, “watchdogs”?
9)Signs of decay: Is this neighborhood on the way up or down? Is it “alive”? How would you decide? Trash, abandoned cars, political posters, neighborhood-meeting posters, real estate signs, abandoned houses, mixed zoning usage?
10)Race: Are the residents Caucasian, African-American, or of another minority, or is the area integrated?
11) Ethnicity: Are there indices of ethnicity—food stores, churches, private schools, information in a language other than English?
12)Religion: Of what religion are the residents? Do you see evidence of heterogeneity or homogeneity? What denominations are the churches? Do you see evidence of their use other than on Sunday mornings?
13) Health: and Do you see evidence of acute or of chronic diseases or conditions? Of accidents, communicable morbidity diseases, alcoholism, drug aIDiction, mental illness, etc.? How far it is to the nearest hospital? Clinic?
14) Politics: Do you see any political campaign posters? Is there a headquarters present? Do you see an evidence of a predominant party af?liation?
15)Media: Do you see outdoor television antennas? What magazines, newspapers do residents read? Do you see Forward Times, Hampton Post, Enquirer, Readers’ Digest in the stores? What media seem most important to the residents—radio, television, print?

 

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complete learning strategies assignment 1

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Instructions

As she continues her journey at CSU, Claudia has been asked to teach her fellow classmates about various learning strategies related to academic success.

Take all of the information that you have learned from the Unit III Lesson and the reading assignments, and create a PowerPoint presentation that helps Claudia teach the other students about achieving academic success at CSU. Click here to access the PowerPoint template for this assignment.

Your presentation should contain the sections listed below.

  • Include an introduction slide.
  • Explain how memory relates to learning new information.
  • Provide information on reading strategies.
  • Discuss some note-taking strategies.
  • Discuss the types of learning styles, and state your preference.
  • Identify the learning strategies that you will use to secure your academic success at CSU.
  • Include a references slide, and list all sources that were used.

For tips on how to create a PowerPoint presentation, click here to access a helpful tutorial. (Click here to access the transcript for the tutorial.)

Prepare a PowerPoint presentation of at least 10 slides. You must include a title slide and a references slide that lists the sources in APA format; however, these slides will not count toward meeting the minimum slide requirement. You must include at least one reference, which can be your textbook.

Resources

The following resource(s) may help you with this assignment.

  • Citation Guide
  • CSU Online Library Research Guide
  • Submit Writing Center Reques

 

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Personal and profession development

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self-reflection essay in which you discuss and evaluate what you have learned about yourself, your competences, values, strengths and areas for future development

Base on Emotional Intelligence, Expanding Self Awareness, Our Thinking Drivers and Values, Stress Drivers, Values, Integrity and Culture, Culture, Motivation and Manners