Case Study and Care Plan

Case Study and Care Plan

Assignment: Case Study and Care Plan
Assignment: Case Study and Care Plan
The purpose of a case study is to describe an individual situation/case in nursing that allows the student to identify key issues of the case, analyze the case using relevant theoretical concepts from nursing and psychiatric nursing and recommend a course of action for that case.
Students are presented with a case study and will work through the critical thinking exercises.
They will utilize the nursing process and present a plan of care that addresses the holistic needs of the client and the focuses on theoretical understandings of forensic psychiatric nursing care.
Develop a holistic care plan based on the “Incarcerated and Substance Use” Case Study. Using the Care Plan template as a guide and the resources presented in this course, create a care plan that utilizes each phase of the nursing process (ADPIE). Use APA format for your assignment, including a title and reference page.
Your Care Plan must include:
1. Written assessment including subjective, objective and historical data – clear, concise and to the point.
2. Written MSE from the information available. Keep your report clear and concise.
3. Create one 3-part Nursing Diagnosis following the guide described in the NANDA Nursing Diagnosis Guide – choose what you feel is a PRIORITY consideration for this client – think about what the most important consideration for this client at this time is.
4. Develop one goal for your Nursing Diagnosis
5. Create three interventions to support the client obtaining the goal (6 total)
6. Scientific rationale/principle with references for each selected intervention (6 total)
7. Evaluation of interventions selected (6 total)
Marking Guide:
Assessment: Includes subjective, objective, and historical data that support nursing diagnosis.
1 mark for subjective data. 1 mark for objective data. 1 mark for historical data to support the nursing diagnosis
1 mark for appearance. 1 mark for behaviour. 1 mark for affect and mood. 1 mark for thought process. 1 mark for thought content. 1 mark for speech. 1 mark for cognition. 1 mark for insight and judgment.
NANDA Nursing Diagnosis (2 ND)
4 marks for each complete NANDA diagnosis as per correct accuracy and priority sequence. 1 mark for including ‘as evidenced by’. 1 mark for including ‘related to’. 2 marks for appropriate choice of what is a priority for this client.
Goal/Outcome Criteria
2 Marks for the goal. 1 mark for a goal related to the diagnosis. 1 mark for use of evidence/ reference to support use of the goal.
Nursing Interventions
1 mark for each intervention (3 in total). 1 mark for each use of evidence/ reference to support efficacy of the chosen interventions.
Evaluation of Interventions
2 mark for each method of evaluating the 3 interventions including use of literature/ evidence to support the evaluation process.
Medication Regimen
2 marks for identifying possible medications to benefit the client. 2 marks for evidence/ reference to support these choices.
Referrals to community supports
0.5 mark for each support identified (up to 4 services) including a description of the service. 1 mark for including supportive evidence for each service.
APA Reference Page
1 mark for including a reference page in APA formatting. 1 mark for completed reference list used in the care plan.
Case Study and Care Plan

Case Study and Care Plan

Student’s Name
Institutional Affiliation
Course Name and Number
Instructor’s Name
Due Date

1. Brief assessment Data (subjective, objective, historical assessment):
Chief Complaint: “I can’t handle how I feel; I am on the verge of exploding at every minute.”
History of present illness: The patient is a 37-year-old Caucasian male and currently not married and presented for incarceration and substance use problems. The patient was involved in driving under the influence of alcohol, spitting, and resisted arrest. The patient’s drinking behavior started at age 16 when the urge to drink continued to increase over the years. His alcoholic problem worsened when he lost his driving license due to driving under the influence of alcohol and even more after losing his job. The patient stated that he felt the need to drink more alcohol to feel normal and to quiet his mind. The patient reports feeling angered all the time with a feeling of freaking out or committing murder. He has been involved in fights with fellow inmates at the jail. He currently experiences sadness, difficulty in concentrating, angered most of the time, appetite fluctuations, and sleeping disorder. He also reports a history of disturbing thoughts where he recalls the death of his father and the physical abuse his father caused to her mother.
Past Psychiatric History:
General statement: The patient does not have any history of mental conditions or psychiatric treatment except for his rehabilitation period. The patient denies having suicide attempts as well as no personal psychiatric provider. The medication he was using is fluoxetine which he stopped using as it made him feel worse.
Hospitalization: The patient denies any past hospitalization
Medical History: No reports of medicinal, environmental, or food-related allergies. The patient also does not have any history of major medical and surgical illnesses. The patient reports several concussions from fighting over the years.
Substance History and Current Use: the patient started using alcohol socially at the age of 16 years followed by alcohol abuse at 27 years. Currently, the patient refers to himself as an alcoholic, rehabilitated once in the year, and completed the required 28-day program. The patient has a history of cocaine use in the past one year, use of cannabis since he was 13 years old, and last use six months ago.
Family History: the patient’s family history is associated with alcoholism as the patient’s father was an alcoholic and died due to colon cancer at the age of 45 years. The patient’s brother is also reported of using hard drugs which caused him to be incarcerated several times. His mother has no diagnosed health problem and is currently living with her boyfriend.
Current Medication: he was prescribed fluoxetine which he was using but later stopped as it made him feel worse and more irritable. He does not have a history of homeopathic products.
Trauma/Abuse History: he was involved in an abusive relationship where his father abused him in his adolescent age as well as witnessed his father physically abusing his mother at his tender age. Also, the patient had a babysitter who sexually touched his private parts and demanded to be touched back. Later in the years, he was jailed together with this babysitter and he once punched him in the stomach. The patient states that he did not receive any therapy for this abuse and never disclosed it to anyone.
Physical examination: Not applicable
Diagnostic results: No diagnostics or lab examination were done on the patient.
2. Mental Status Exam:
The patient is a 37 years old Caucasian male who presented for a mental examination. During the clinical visit, the patient is well-groomed for the examination as per the weather, in a blue jail jumper. He did not seem to fully observe his body hygiene, as he presents with facial hair. He has normal walking patterns with some psychomotor agitation. During the examination, the patient’s leg was seen shaking throughout.
3. Nursing Process grid (ADPIE):
Nursing Care Plan for Substance Use Problem 1
NANDA Nursing Diagnosis and Support Data (one NDx) Goal/Outcome Criteria
(at least 1/diagnosis) Nursing Interventions
(at least 3/goal) Scientific Rationale/Principle
(with reference) Evaluation of Intervention
Disturbed sensory perception related to chemical alterations diminished, distorted, and impaired response to stimuli as evidenced by low concentration, poor hygiene (hairy face), and positive psychotic symptoms.
The patient will regain control over his consciousness, perform self-care activities, and effectively identify factors affecting his sensory-perceptual capacity.
Monitoring the patient’s ability to respond to stimuli and his level of consciousness (Bilsen et al., 2020).

It is important to assess the patient’s ability to respond which can indicate judgment and muscle coordination problems (Imkome, 2018).
The patient was able to establish control over his consciousness (Bilsen et al., 2020).

According to Gulanick, observing the patient’s behavioral reactions such as sleep patterns, agitation, and moods, as well as noting them is effective for addressing negative sensory perception (Gulanick, & Myers, 2022).
The patient’s behavior towards others is important in identifying impending intrusive thoughts. Sleeplessness is mainly caused by a decline in the sedative effect offered by alcohol (Imkome, 2018).
The patient was able to manage his anger and freely expressed his feelings as well as have adequate sleep (Morgan, & Freeman, 2009).

Ensure that the environment the patient is associated with is free from potential stressors, kept quiet and peaceful and calmness is maintained (Pincus, & Tucker, 2002).
This is to reduce the risk of hyperactivity which might be caused by a raucous or disorderly environment. Also approaching the patient in a calmer tone reduces the occurrence of intrusive thoughts.
From Tucker’s study if the patient does not react aggressively and expressed calmness throughout, then the intended goal is achieved.

Nursing Care Plan for Substance Use Problem 2
NANDA Nursing Diagnosis and Support Data (one NDx) Goal/Outcome Criteria
(at least 1/diagnosis) Nursing Interventions
(at least 3/goal) Scientific Rationale/Principle
(with reference) Evaluation of Intervention
Risk for violence: self-harm or harm directed at other people related to the patient’s manic state and instabilities in his biochemical processes due to long-term alcohol use as evidenced by agitation, involvement in fights with fellow inmates, and the patient’s murder thoughts.

The patient will be able to manage his emotions, control his thoughts, and will not cause violence to the people around him.

According to Canadian Network for moods and anxiety treatments, the first intervention is to constantly monitor the patient and his manic episodes, his moods, and hyperactivity actions such as agitation and sadness.
This patient is already a threat to other people as indicated by the frequent fights he picked in jail. Therefore, early proper management of this patient is essential and most effective when his manic episodes are quickly detected (Imkome, 2018).
The patient openly expressed his feelings openly and directly (Bond et al., 2018).

From research, recording the patient’s behaviors which indicates the escalation of his manic episodes and strategies which aid in managing such behaviors (Conus et al., 2008).
Identifying patterns of behaviors of the patient which leads to the rapid increase in their manic episodes assists in a more systematized and quicker response addressing the violence risks of the patient to other people or himself.
The patient was able to practice non-violent behaviors to deal with stressful and difficult situations as well as manage his agitation (Morgan, & Freeman, 2009).

Installing materials to use in case of the patient’s violent behaviors in his room such as punching bags. Based on Kelley’s research, this will redirect the patient’s violent tendency to such materials other than harming others and himself (Kelley et al., 2010). Due to his agitation and unstable moods, the patient may tend to become violent to relieve these feelings. Materials such as punching bags are important in assisting him to relieve these feelings of anger as well as muscle relaxation (Tolliver, & Anton, 2022). The patient was able to relieve his sad feelings, agitation, and violence on other materials as well as minimal violence toward others was detected (Morgan, & Freeman, 2009).


Nursing Care Plan for Substance Use Problem 3
NANDA Nursing Diagnosis and Support Data (one NDx) Goal/Outcome Criteria
(at least 1/diagnosis) Nursing Interventions
(at least 3/goal) Scientific Rationale/Principle
(with reference) Evaluation of Intervention
Imbalanced nutrition: less than body requirements related to inadequate nutritional consumption to achieve metabolic requirements resulting from psychological and physiological considerations secondary to alcohol abuse as evidenced by fluctuations in the patient’s appetite (Gulanick, & Myers, 2022).

The patient will establish nutritious eating patterns, balanced rest, sleep, and activity.
Assess the patient’s height, weight eating patterns, exercise habits, and rest levels as well as the state of his oral cavity. Form evidence, it will help identify the patient’s nutritional requirements (Barry, & Merianos, 2016)
Assessing these personal factors is important as it will inform the care providers on where to base calorie requirements and dietary plans. The cavity state will inform the type of food consumed.
The patient was able to adapt to and maintain healthy nutrition (Ackley, et al., 2020).
Discussing the patient’s nutrition imbalances with a nutritionist (Ackley, et al., 2020).
Involving a nutritionist in the management of this patient is essential as the nutritionist will assist in the identification of the patient’s nutritional needs and plans as well as adding adequate learning resources on the same (Ackley et al., 2020).
The patient was ready to maintain a nutritious diet and follow the nutritionist’s guidelines (Ackley, et al., 2020).

Case Study and Care Plan
The third intervention is to give the patient the freedom to choose his favorite foods and snacks which match his nutritional needs (Gulanick, & Myers, 2022).

By allowing the patient to choose their foods and snacks, they feel engaged and given a sense of control. The technique aids in the resolution of malnourishment and assists in educating the client about proper nutrition.
The patient was ready to choose the food needed most (Gulanick, & Myers, 2022.

Medication Regimen
Apomorphine: according to research by Bonin, Apomorphine is a dopamine antagonist appropriate for the treatment of consciousness disorders. The drug is used in small amounts which exhibits behavioral safety for patients. It works through modulation of the anterior forebrain mesocircuit which makes it effective for the patient (Bonin et al., 2019)
Antabuse (Disulfiram): Disulfiram is a medication approved for the management of patients with alcohol use problems and addiction. Disulfiram works by establishing a severe adverse reaction when taken with alcohol. It causes nausea and vomiting in a person which creates a deterrent to drinking (Warren et al., 2021).
Referrals to Community Supports
Smart Recovery: this is a support group that assists individuals with different types of addiction through physical or visual meetings. The organization is essential for this patient as it educates addicts on how to overcome alcoholism, and maintain an alcohol-free life and a balanced life (Kaskutas et al., 2018).
Secular Organizations for Sobriety: these organizations assist alcohol users with ways to quit alcoholism through physical meetings. The organizations are all spread in the US and extend their help in assisting alcohol users to overcome alcoholism as well as associated eating disorders (Kaskutas et al., 2018).
American Academy of Addiction Psychiatry (AAAP): the organization helps alcohol addicts to locate nearby specialists to seek help. It produces addiction journals with detailed information about substance use (Frances et al., 2020).
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
Barry, A. E., & Merianos, A. L. (2016). Alcohol as food/calories. Current Addiction Reports, 3(1), 85-90.
Conus, P., Ward, J., Hallam, K. T., Lucas, N., Macneil, C., McGorry, P. D., & Berk, M. (2008). The proximal prodrome to first episode mania–a new target for early intervention. Bipolar disorders, 10(5), 555-565.
Frances, R., Nace, E., Khantzian, E., & Kaufman, E. (2020). The American Psychiatric Association Creates a Subspecialty: The Birth of Addiction Psychiatry, Early Years of the American Academy of Addiction Psychiatry. The American Journal on Addictions, 29(5), 365-369.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
Imkome, E. U. (2018). Nursing Care for Persons with Drug Addiction. Drug Addiction, 49.
Klostermann, K., Kelley, M. L., Mignone, T., Pusateri, L., & Fals-Stewart, W. (2010). Partner violence and substance abuse: Treatment interventions. Aggression and Violent Behavior, 15(3), 162-166.
Morgan, R., & Freeman, L. (2009). The healing of our people: Substance abuse and historical trauma. Substance Use & Misuse, 44(1), 84-98.
Pincus, J. H., & Tucker, G. J. (2002). Behavioral neurology. Oxford University Press.
Sanz, L. R., Lejeune, N., Blandiaux, S., Bonin, E., Thibaut, A., Stender, J., … & Gosseries, O. (2019). Treating disorders of consciousness with apomorphine: protocol for a double-blind randomized controlled trial using multimodal assessments. Frontiers in neurology, 10, 248.
Shirley, D. A., Sharma, I., Warren, C. A., & Moonah, S. (2021). Drug repurposing of the alcohol abuse medication disulfiram as an anti-parasitic agent. Frontiers in Cellular and Infection Microbiology, 11, 165.
Six, S., Bilsen, J., Laureys, S., Poelaert, J., Theuns, P., & Deschepper, R. (2020). A reflection on using observational measures for the assessment and/or monitoring of the level of consciousness in palliatively sedated patients. Journal of Palliative Medicine, 23(4), 442-443.
Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., … & Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97-170.
Zemore, S. E., Lui, C., Mericle, A., Hemberg, J., & Kaskutas, L. A. (2018). A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD. Journal of substance abuse treatment, 88, 18-26.

Case Study and Care Plan

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