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Nursing People with Substance Use Disorders Essay

Nursing People with Substance Use Disorders Essay

Description

Reflection questions:

  1. What are your nursing experiences with persons with substance use disorder (SUD)?
  2. The case scenario describes a lawyer who is using heroin. Prior to the training, were you aware that according to the World Health Organization (2020), drug use disorders are the most stigmatized conditions by health care providers? Did you think that a successful person could suffer from substance use disorder?
  3. Did completing this training change how you will screen for SUD and treat clients who suffer from SUD? Why or why not?
  4. Do you plan to complete the MAT training and become Suboxone-waivered? Why or why not?

Psychiatric Note Format

Demographic data: Do not include identifying information. Must be HIPAA compliant.

Chief complaint:

History of present illness:

Current working diagnoses:

Current psychiatric medications:

Non-psychiatric medications:

Allergies:

Review of Systems: As appropriate, listed by body systems in bullet form

Mental Status Exam:

Physical Exam: Physical exams should be appropriate for the patient and your clinical setting. For example: a telehealth follow up for MDD versus an inpatient psychiatric unit for acute psychosis will have different physical exams.

VS: If obtained

Results: If applicable and results obtained

PHQ9: HAM-A

Labs:

Impression: Narrative discussion of current status and symptoms, how the patient is tolerating the current treatment and any progress toward goals. Also discuss any change in diagnoses or changes to the plan and the reason why. Always discuss the safety evaluation and current safety plan.

Plan:

  • Medication orders
  • Psychotherapy orders to begin or continue
  • Safety orders
  • Non-pharmacologic orders – labs, psychoeducation, referrals
  • Follow up

Signature: Current credentials, PMHNP student

  • What is the diagnosis? “Substance Use disorder”, “Withdrawal symptoms”

(The use of opioids over time changes the brain resulting in cravings and tend to change individual’s behavior)

  • Is this patient a candidate for treatment with buprenorphine? No, I contained to the weekend and use more therapy and discussions. Finally, start tapering off the buprenorphine and stop it use.
  • What are the treatment goals? Listen to the patient; Understand what the patient goal is; Reduce the use of buprenorphine; Use therapy; Educate patient about the use of buprenorphine; Find other non-substance related ways that he can maintain that pleasure.

Ultimately goals for the treatment: Abstinence from illicit drug use; Stabilization of his disease.

  • What is the initial treatment plan? 

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