Crisis Paper

Casie Yu

MCPHS University

Patient Background
Sammy is 27 year old, female patient who came into the hospital for opiates withdrawal/dependence. Sammy is white American and has been baptized but doesn’t attend to church regularly. She is admitted to the hospital for a detox for opiate dependence. Patient states that she currently uses “two bundles of heroin per day through shooting up for the past month. I also shoot up $20 of cocaine for the past month and I smoke marijuana once per week for the last three years”. Sammy has started using three years ago. Sammy also smokes tobacco about one pack per day for about ten years.
Three years ago, Sammy got in a serious car accident that hospitalized her. The medical complications that followed up with the car accident is diagnosed with having reflex sympathetic dystrophy of the lower limbs and had a spinal cord stimulator implanted. The first surgery was faulty because the implanted battery wasn’t working. During the second surgery, the wiring of the batteries was wrong and the stimulator was stimulating the wrong leg. Sammy went back the third time and finally, the stimulator was working where it is suppose to be. Although the stimulator was working and suppose to help sooth the pain, Sammy still could not bear the pain. Due to the reflex sympathetic dystrophy of the lower limbs after the car accident, Sammy stated that she could not stand for long periods of times and she cannot lift more than twenty to thirty pounds. This left Sammy to lose her job and left her claiming government disability. The disability that Sammy claimed was only partial. Her lawyer told her to lie to the judge during her court session to gain full disability, but Sammy didn’t feel right lying to the judge. The decision came down to if she would be able to find a job with her disability. The judge named one job that she might be able to try but it didn’t work for Sammy. Sammy has to go back to her lawyer and file for full disability after discharge.
The chronic pain bothered Sammy a lot. She was prescribed Percocet, which is a controlled substance containing oxycodone and acetaminophen. At that time, her cousin was an opioid dependent and also a dealer. Sammy’s cousin would ask Sammy for her medications and her cousin would sell them. One day, Sammy was in a lot of pain and need her medication. Unfortunately, the medications are controlled substance and pharmacies normally do not allow early refill or need another script from the doctor. Sammy was out of options and she gave money to her cousin to go buy her some oxycodone off the streets. When Sammy’s cousin came back, he grabbed her arm and poked a needle into Sammy’s arm. Sammy didn’t care at the moment. The drug hit her quick and she felt better. Later that day, Sammy ask her cousin “Hey, whatever that was, I need some more of it”. Her cousin confessed to Sammy that the drug he gave her wasn’t oxycodone. It was actually heroin. After that time, Sammy started using and started to mix heroin with cocaine.
Sammy had two suicide attempts in the past. In January of 2013, while intoxicated, she called up her psych therapist and told the therapist “goodbye”. Sammy then found all the medications that she could in her medicine cabinet and took them all. The therapist heard the message right away and got in contact with a family member of Sammy’s. They brought her straight to the emergency room of the local hospital. Luckily, Sammy was saved. The second attempt was in October of 2013. Sammy had friend where were EMTs. Sammy attempted the suicide the same why but taking all the medication she could find on hand. A friend walked in on her right after she took all the pills and her friend called her EMT friends right away. Once again, Sammy got to the hospital on time. She woke two days later and was very confused and lost. Sammy attempted those suicides because she couldn’t handle the face that she could not go back to work and could not bear the pain.
Less than a year ago, Sammy’s cousin (who gave her the first dose to heroin) passed away. She laid his side during his last breath. His last words to Sammy were “I’m sorry Sammy. I did this to you. I shot that heroin up your arm that day. It was my fault”. To this day, Sammy does not blame him for being addicted to drug and being dependent on opiates. She admits to being an opiate dependent and states “I’m stupid for shooting up” but, she doesn’t know blame her cousin for it. Sammy had trouble getting the lost of her cousin. He meant a lot to her. She was using more and talks a lot about her cousin. Sammy does not admit to having grief issues but states “it hurts a lot”.
In the past, Sammy has done a detox in July of 2015. She relapsed and brought herself to this detox. She claims that she attends to AA meetings and it works really well for her. She enjoys attending to them.
Patient Balancing Factor, Cultural and Development Influences
Sammy lack many factor that affect her recovery. When asked about effective coping strategies, she states she has none. She learned some from the educational group that is mandatory during her rehabilitation stay but, she has not tried them yet. Sammy said she used to cut herself long time ago. Cutting herself helped her relieved her stress.
Sammy also lacks a support system. Sammy says she cannot return home to her mother’s after treatment because her mother enables her drug use. Sammy’s mother would give her money to go out and buy drugs. Sammy also cannot go to her aunt’s house because it is next door to her mom and it her two other cousin are addicts. Sammy’s two older brothers are addicts as well. Sammy never mentions her dad being there for her. Sammy states she will be living with a friend after treatment.
As a child, Sammy was baptized. She grew up being catholic but she doesn’t attend to church. She doesn’t consider herself as spiritual. However, Sammy does make a lot of friend during her hospital stay. She active and participates during group therapy that is offered at the hospital. She engages all different age groups of patients without hesitation.
Sammy smiles majority of the time. She a lively person and brings happiness around her. Even when talking about her cousin who passed, she finds a way to distract herself or changes the topic and brings back a smile on her face. Sammy doesn’t feel that she is grieving too harsh about her cousin but knows that her opioid dependence is not helping her.
Health Maintenance, Educational Needs and Community Resources
Coping strategies is much needed to Sammy. She needs to learn to cope which is the “changing [of] cognitive and behavioral efforts to manage specific demands that are appraised as taxing or exceeding the recourses of the person” (Lam & Wong, 2005). Its not going to be easy and it may just be like medication, trying different kinds until you find the right one. Sammy will have to experience different coping strategies and find the ones that are most effective. For example, doing a puzzle works for some patients. However, if Sammy cannot handle the time consuming and difficulty of working of a puzzle then, doing a puzzle wouldn’t be very effective. Alone with coping strategies, Sammy needs to continue to her medications that are needed. Recovery will be more successful with both medications and learning. In a study by Dominic Lam and Grace Wong stated “the thinking is that medication may stabilize and deal with biological side, while psychotherapy deals with issues that may affect the course of illness” (Lam & Wong, 2005).
Sammy states that she has a safe place to go after her treatment at the hospital, which is to a friend’s house. She also states that she will attend to local AA meetings. AA meetings are free and available in all different forms such as open, closed, women only. Because of her history of tobacco use, it might trigger her to smoke more often because there is a good amount of people who attend to AA meetings go out for a cigarette during the break. If Sammy makes a commitment to attend to AA meeting regularly, it gives Sammy a sense of responsibility just to even try to attend on a regular basis. AA meetings have also worked for Sammy in the past. Sammy states that it kept her sober during that time. AA meeting will also help her spiritually because the AA handbook is basis off spirituality and gives Sammy a sense of hope and support.
Besides attending to AA meeting, Sammy should also attend to an outpatient therapy. Adcare Hospital in Worcester has an outpatient clinic. Sammy finished the detox at Adcare and went to continue on with Adcare rehab. Being accepted for their outpatient clinic would be easier. Sammy will have to get a referral from her counselor. Since she stayed at the hospital, Adcare already accepts her insurance and she wouldn’t have to worry about her insurance not being accepted for outpatient. As stated before, the counselor will determine if the patient qualifies for outpatient treatment. The counselor will also establish why outpatient therapy will help the patient. The outpatient treatment is a bit intensive. The patients are required to meet up six days and attend to one-hour sessions of individual counseling and group education. Patients can also decide to attend three to five days a week and attend to three-hour sessions of individual counseling and group education. This will benefit Sammy because this is a huge commitment. The outpatient treatment will help her stay sober longer because she has these requirements. Sammy will also be attending to education groups to further her knowledge of coping strategies to help her from relapsing. The outpatient therapy is scheduled by the counselor for an appointment within twenty-four hours of the patient’s discharge so they don’t relapse. In a study done by Michael J. Stark specified that dropping out of a substance abuse treatment is severe and dropping out will have the same outcome as an untreated patient. As stated before, if the patient is discharged and doesn’t have an outpatient therapy appointment they will relapse and the patient will be similar as to not being treated. Adcare outpatient program also involves family of the patient. Adcare offered an individual and family counseling service where there is a one on one session to provide services to the family members that have been affected to the problem o the patients. Adcare takes it step by step and getting the family members involve will have a more successful outcome. Involving Sammy’s family such as her mother into her recovery will help a lot. Not only for Sammy’s mother’s support but also Sammy’s mother can learn some techniques of supporting and stop enabling Sammy of her drug abuse.
Sammy is young and still has a long way to go for her recovery. She can be successful in staying sober and also using that skill to create a career. One of Sammy’s personal goals was to go back to school and get a degree. Having been through so much, Sammy will do great at counseling and using her experience to influence others.

NURSING CARE PLAN

Nursing Diagnoses | Intervention | Short Term Goal | Long Term Goal | Evaluation | Risk for suicide related to history of previous attempts (Townsend, 2011). | 1. Ask patient “have you ever had thoughts about hurting yourself? If so, what do you plan to do? Do you have the means to carry it out?” The patient is at higher risk if they have a plan and the means to carry out the plan. 2. Create a safe environment for the patient. Remove all potentially harmful objects such as sharps. Client safety is priority. 3. Perform room searches. Client safety is priority. 4. Maintain observation of the patient. For example, every 15 minute checks or provide an one-to-one contact. Observation is to ensure that the patient does not harm self in any way. It is important to be alert for suicidal attempts to prevent them (Townsend, 2011). | Patient will seek help from staff when patient has a feeling of urge to harm self (Townsend, 2011). | Patient will not harm self (Townsend, 2011). | Patient states that she does not have an urge to harm self and has no plan of making a suicide attempt. Patient also states “I promise I will come to you (nurses) when I feel like I want to die” (Townsend, 2011). | Imbalanced nutrition, Less than body requirements related to lack of appetite as evidence dehydration and poor muscle tone (Townsend, 2011). | 1. Provide client with high-protein and nutritious food and drinks that can be consumed on the run. Patient is more likely to consume the food and drinks that an be carried around and eaten with little effort. 2. Have snacks and drinks available on the unit at all times. Nutritious intake is required on a regular basis and they compensate for increase caloric requirement. 3. Weigh patient daily. Monitor weight loss or gain is important for nutritional assessment information. 4. Determine patient’s likes and dislikes of food and provide the patient with their favorite foods. The patient is more likely to eat the foods they like (Townsend, 2011). | Patient will consume sufficient finger foods and eat snacks between meals (Townsend, 2011). | Patient will have no signs or symptoms of malnutrition (Townsend, 2011). | Patient met the goal. Patient is drinking Mighty Shacks during free time and eats a peanut butter and jelly sandwich (Townsend, 2011). | Ineffective coping related to inadequate coping skills as evidence by patient states “I have never tried any coping strategies” (Townsend, 2011). | 1. Establish trust with client. The therapeutic nurse-patient relationship is built on trust. 2. Encourage patient to verbalize feelings, fear, and anxieties. Having the patient verbalize feelings in a nonthreatening environment can help the patient come to a consensus with their unresolved issues. 3. Explain to the patient about the effects of substance abuse on the body. The patient may lack knowledge about the effects and major complications on the body for example, diabetes and heart disease. 4. Encourage client to be as independent as possible and provide positive feedback. Positive reinforcement improves their self-esteem and encourages the patient to repeat the behavior (Townsend, 2011). | Patient will express feelings associated with their substance abuse as practice of coping with stress (Townsend, 2011). | Patient will be able to express adaptive coping strategies to use (instead of substance abuse) in response to stress (Townsend, 2011). | Patient did not meet goal. Patient verbalizes that she has learned one coping strategy but has not tried it out yet. Patient also states that she just results in substance abuse when she is in a stressful situation (Townsend, 2011). | Complicated grieving related to real loss of a family member as evidence by obsession with past experiences (Townsend, 2011). | 1. Determine the patient’s stage of grief and the behaviors associated with this stage. Accurate baseline assessment is needed to effectively plan care for the patient. 2. Develop trust with the patient by showing empathy and care. Trust is the basis for a therapeutic relationship. 3. Have an acceptable attitude and let the patient express feelings openly. An accepting attitude lets the patients believe they are a worthwhile person. 4. Encourage the patient to reach out for spiritual support. Assess spiritual needs for the patient (Townsend, 2011). | Patient expresses feelings toward their lost (Townsend, 2011). | Patient will verbalize behaviors associated with normal stages of grief and recognize their current stage of grief (Townsend, 2011). | Patient partially met the goal. Patient expressed her feelings toward the lost of her family member. Patient denies any behavior related to her stages of grief (Townsend, 2011). |

Reference
Lam, D. & Wong, G. (2005, December 1). Prodromes, coping strategies and psychological interventions in bipolar disorder. Elsevier.
Stark, Michael. “Dropping out of Substance Abuse Treatment: A Clinically Oriented Review”.
Clinical Psychology Review, July 2002. Web.
Townsend, M. (2011). Nursing diagnoses in psychiatric nursing care plans and psychotropic medications (8th ed.). Philadelphia: F.A. Davis.
Townsend, M. (2013). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (6th ed.). Philadelphia: F.A. Davis.