Hernandez Family Assessment

Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues. As you examine the Hernandez Family: Sessions 1-6 videos in this week’s Learning Resources, consider how you might assess and treat the client family.

                                                             Learning Objectives

Students will:

· Assess client families presenting for psychotherapy

To prepare:

· Review this week’s Learning Resources and reflect on the insights they provide on family assessment.

· View the Hernandez Family: Sessions 1-6 videos, and consider how you might assess the family in the case study.

Note: For guidance on writing a comprehensive client assessment, refer to pages 137–142 of Wheeler (2014) in this week’s Learning Resources.

                                                                 The Assignment

Address in a comprehensive client assessment of the Hernandez family the following:

· Demographic information

· Presenting problem

· History or present illness

· Past psychiatric history

· Medical history

· Substance use history

· Developmental history

· Family psychiatric history

· Psychosocial history

· History of abuse and/or trauma

· Review of systems

· Physical assessment

· Mental status exam

· Differential diagnosis

· Case formulation

· Treatment plan

Note: Any item you are unable to address from the video should be marked “needs to be added to” as you would in an actual comprehensive client assessment

                                                               Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.

• Chapter      12, “Family Therapy” (pp. 429–468)

Nichols, M. (2014). The essentials of family therapy (6th ed.). Boston, MA: Pearson.

• Chapter 3, “Basic Techniques of Family Therapy” (pp.      29–48)
• Chapter      4, “The Fundamental Concepts of Family Therapy” (pp. 49–68)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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Note: It is highly recommended that you use this resource as a reference guide throughout the course. 

L’Abate, L. (2015). Highlights from 60 years of practice, research, and teaching in family therapy. American Journal of Family Therapy, 43(2), 180–196. doi:10.1080/01926187.2014.1002367

Mojta, C., Falconier, M. K., & Huebner, A. J. (2014). Fostering self-awareness in novice therapists using internal family systems therapy. American Journal of Family Therapy, 42(1), 67–78. doi:10.1080/01926187.2013.772870

Nichols, M., & Tafuri, S. (2013). Techniques of structural family assessment: A qualitative analysis of how experts promote a systemic perspective. Family Process, 52(2), 207–215. doi:10.1111/famp.12025

Papero, D. V. (2014). Assisting the two-person system: An approach based on the Bowen theory. Australian & New Zealand Journal of Family Therapy, 35(4), 386–397. doi:10.1002/anzf.1079 family therapy.

                                                                         Required Media

Laureate Education (Producer). (2013a). Hernandez family> Sessions 1—6 [Video file]. Author: Baltimore, MD.

N.B: PLEASE ATTACH WITH THIS ASSIGNMENT IS THE 6 VIDEO TRANSCRIPT DOWNLOADED IN PDF FORMAT FOR THIS ASSIGNMENT SINCE THE VIDEO AND THE AUDIO IS NOT AVAILABLE AT THIS TIME, AND A SAMPLE FORMAT FOR THE ASSIGNMENT.

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Accessible player  –Downloads– Download Video w/CC Download Audio Download Transcript 

Psychotherapy.net (Producer). (2006). Tools and techniques for family therapy. [Video file]. Mill Valley, CA: Author. 

 

Hernandez Family Episode 1

Hernandez Family Episode 1 Program Transcript

JUAN HERNANDEZ: But we didn’t do anything wrong. That woman, that social worker, who came to our house, I told her, me and Elena, we decide what’s best for our boys, not her. Telling us we punish to hard. She doesn’t know anything about us.

ELENA HERNANDEZ: We give our sons a good life. We love them very much. It’s not fair what she said about Juan and me. We’re good parents.

FEMALE SPEAKER: Mrs. Hernandez, I understand how difficult this is for you–

JUAN HERNANDEZ: I don’t think you do. Everything that we do, we do for them, everything. We work hard. We take care of them. And when they don’t follow the rules, they get punished, strictly. The old fashioned way.

ELENA HERNANDEZ: Shh. Quiet. I told you.

JUAN HERNANDEZ: Sometimes I’m not strict enough with them. Look, I punish my sons the way I see fit. That’s the only way they are going to learn. That’s how we learned from our parents, right? Nobody took parenting classes. That’s ridiculous.

FEMALE SPEAKER: I understand you’re angry. And you’re raising your children the way you were brought up to do. But ACS has required that you do this.

JUAN HERNANDEZ: What if I don’t want to be required?

ELENA HERNANDEZ: I have a question.

FEMALE SPEAKER: Of course.

ELENA HERNANDEZ: If we go through with this, the things we talk about with you, will it be private?

JUAN HERNANDEZ: But we have not agreed to do this.

ELENA HERNANDEZ: I don’t want to be here either. But I don’t want to loose our children. Would it be private, what we talk about?

FEMALE SPEAKER: The information we share is between us. The only exception to that is if one of you says you’re going to hurt yourself or hurt someone else. In that case, I have to report it to the ACS worker. But everything else is strictly confidential.

© 2017 Laureate Education, Inc. 1

Hernandez Family Episode 1

So how do you think we can work together to make this a positive experience for both of you?

JUAN HERNANDEZ: Parenting classes, really? What about the bills? I’m not going to be able to work overtime.

ELENA HERNANDEZ: If we do what we’re supposed to do, would it be OK with our family?

FEMALE SPEAKER: There are no guarantees. But here’s what I can say. We’ll all work together to create a plan based on what the ACS worker has required and recommended. Then it will be up to her what the outcome will be.

So shall we make a plan?

Hernandez Family Episode 1 Additional Content Attribution

MUSIC: Music by Clean Cuts

Original Art and Photography Provided By: Brian Kline and Nico Danks

© 2017 Laureate Education, Inc. 2

Hernandez Family Episode 2

Hernandez Family Episode 2 Program Transcript

FEMALE SPEAKER: It’s good to see all our parents again tonight. And I want to say thank you for being here these last few weeks. Today, we’re going to talk about child development, specifically the behavior of our children, and what are some realistic expectations we can have about how they behave, depending on how old they are.

Part of understanding human behavior is looking at where someone is in their life, as well at the impact of their environment, whether it’s school, home life, family, or friends.

MALE SPEAKER: What’s there to understand? I mean, come on. They’re kids. They shouldn’t be seen or heard, right?

FEMALE SPEAKER: We all want our children to behave. But throughout childhood, there are certain behaviors that come with certain ages that can be very challenging to deal with.

FEMALE SPEAKER: Tell me about it.

FEMALE SPEAKER: So let’s talk about some of your expectations about your children’s behavior.

MALE SPEAKER: Well, my son is nine. That age, I expect him to do his chores and listen to me. When I was nine, you better believe I was listening to my old man, or else, you know?

MALE SPEAKER: You’ve got that right. And I don’t understand why my son doesn’t listen to me when I tell them to do something. I mean, what if I didn’t listen and come to this class? We might lose our kids. How do I deal with this better? I mean, get him to listen and behave?

FEMALE SPEAKER: Well, Juan Junior is eight, and at that age, their attention can be really hard to not only gain, but–

Hernandez Family Episode 2 Additional Content Attribution

MUSIC: Music by Clean Cuts

Original Art and Photography Provided By: Brian Kline and Nico Danks

© 2017 Laureate Education, Inc. 1

Hernandez Family Episode 3

Hernandez Family Episode 3 Program Transcript

JUAN HERNANDEZ: Do you have any idea how hard it is for us to get to these classes?

ELENA HERNANDEZ: And there’s only one class a week. We don’t have a choice when to come.

FEMALE SPEAKER: That is why we offer the parenting class at night, to make it easier for working families to attend.

ELENA HERNANDEZ: That’s fine for some people, but that’s when Juan gets his overtime. He can’t do both. Every time we come here it costs us. We lose money. And the way things are, we can’t afford to lose a dime.

FEMALE SPEAKER: I understand that missing overtime is having a big impact on you financially. And I understand what you’re saying about the class only being offered one night a week. If we could offer it several times a week, that would probably be more helpful. But in the meantime–

JUAN HERNANDEZ: Look, let’s stop dancing around what’s really wrong here. We appreciate what you’re doing. You want to help parents do a better job with their kids. But we’re good parents. We love our kids. Yes, they get punished when they need to be punished, just Elena and I when we were growing up. But we don’t hit our boys. We don’t hurt them.

If anything, you hurt them by making us come here when I could be out there making extra money, money that the family needs. Do you hear me? This class this, whole policy is the real problem. That’s what needs to change, not us.

Hernandez Family Episode 3 Additional Content Attribution

MUSIC: Music by Clean Cuts

Original Art and Photography Provided By: Brian Kline and Nico Danks

© 2017 Laureate Education, Inc. 1

Hernandez Family Episode 4

Hernandez Family Episode 4 Program Transcript

FEMALE SPEAKER: So how’s your week going? What’s happening with that Hernandez family? That’s their name, right? You were having some challenges there?

FEMALE SPEAKER: They’ve missed four of their parenting classes, so far.

FEMALE SPEAKER: So they haven’t completed the parenting group?

FEMALE SPEAKER: I have to call the ACS worker and let her know. They’re probably going to have to take the classes over again, and that’s going to be tough. The father misses overtime to come to the classes, and they really rely on that money to make ends meet.

FEMALE SPEAKER: You have something else on your mind. Say it.

FEMALE SPEAKER: I should have discussed this with you earlier. I don’t know why I didn’t. But perhaps they weren’t the best candidates for this to begin with.

FEMALE SPEAKER: Because of their financial situation?

FEMALE SPEAKER: Yes, and something else. I remember the ACS worker. And when she talked about wanting Elena, she kept calling them Mexicans. It was really derogatory the way she said it.

FEMALE SPEAKER: So you’re saying she might have been biased into mandating that they take these classes?

FEMALE SPEAKER: Yes. The more I think about it, she never talked to me about trying to understand the way they’re raising their children. And that Mexican remark, it just really wasn’t respectful. It’s like she had already made up her mind about people from that culture, and now they’re paying the price for it family therapy.

Hernandez Family Episode 4 Additional Content Attribution

MUSIC: Music by Clean Cuts

Original Art and Photography Provided By: Brian Kline and Nico Danks

© 2017 Laureate Education, Inc. 1

Hernandez Family Episode 5

Hernandez Family Episode 5 Program Transcript

FEMALE SPEAKER: They’ve missed four of their parenting classes so far.

FEMALE SPEAKER: So they haven’t completed their parenting group?

FEMALE SPEAKER: I have to call the ACS worker and let her know. They’re probably going to have to take the classes over again, and that’s going to be tough. The classes caused the father to miss overtime at work, and they really rely on that money to make ends meet.

FEMALE SPEAKER: But they have to finish the program. They’re only allowed three missed classes. There’s another problem. You know the agency’s been conducting a study of our performance. Well, it lowers our completion numbers. Lower numbers put our funding at risk. Our bosses start questioning the credibility of what we’re trying to do here.

FEMALE SPEAKER: But I can’t give the Hernandez family the post test. They won’t be able to complete it.

FEMALE SPEAKER: No, that’s not why I brought this up. The agency needs data to determine how effective these parenting classes are. The more attrition we have when parents don’t finish the program, there’s no data. No data means no support for what we’re teaching or how it might benefit other populations.

FEMALE SPEAKER: Maybe we should account for the attrition then. Maybe there’s something we can learn from it?

Hernandez Family Episode 5 Additional Content Attribution

MUSIC: Music by Clean Cuts

Original Art and Photography Provided By: Brian Kline and Nico Danks

© 2017 Laureate Education, Inc. 1

Hernandez Family Episode 6

Hernandez Family Episode 6 Program Transcript

FEMALE SPEAKER: So last week I showed you how to make a genogram, like this one. Now, the idea behind making a genogram is to help you draw a picture of your family history. And then we use that to discuss the relationships and connections among your relatives. OK? So Juan, why don’t you start off and talk about what you came up with.

JUAN HERNANDEZ: So we’re starting with my family. My father, Hector, he’s still alive. And he married my mother, Freda. And she passed away two years ago. And then there’s their children, myself– I’m the oldest– and then there’s my three sisters, Marie, Senta, and Rose.

FEMALE SPEAKER: Good. And Elena, what about your family?

ELENA HERNANDEZ: Well, here’s my father, Anthony. He met and married my mother, Sofia. They are both still alive. They had five children. Firstborn was my brother Daniel, then my brother Tomas, then my sisters Martina and Camila, and there’s me, the baby.

And then I met Juan, and we started our own family. And we have two beautiful sons that you met, one, Junior, who is eight, and Alberto, who is six.

FEMALE SPEAKER: Good. So for the last several weeks we’ve been talking a lot about how you discipline your sons at home. And both of you mentioned how your parents used to punish you when you were growing up. Juan, why don’t you talk about that and point to anybody on the genogram as you mention them?

JUAN HERNANDEZ: Sure. So my dad, when he was mad at me he would send me to get books from the encyclopedia. And he’d make me hold them out, straight out like this, until he told me to stop. It caused so much pain in my arms, I mean, my arms felt like they would break off.

And my mom, she did basically the same thing. Except when she was really mad, when would make me get more books than my dad. I hated those books so much. I never went near them on my own. To me, they only meant one thing, misery. And now, I guess I inherited that from them.

FEMALE SPEAKER: Elena, how about you?

ELENA HERNANDEZ: Yes, misery. That’s what it was like for me, too.

© 2017 Laureate Education, Inc. 1

Hernandez Family Episode 6

Hernandez Family Episode 6 Additional Content Attribution

MUSIC: Music by Clean Cuts

Original Art and Photography Provided By: Brian Kline and Nico Danks

© 2017 Laureate Education, Inc. 2 family therapy

A physician-hospital organization (PHO) consists of 15 hospitals – with 2,247 staffed beds – and approximately 500 physicians. The PHO operates in a very large section of south Georgia, including the cities of Valdosta, Tifton, Thomasville, Moultrie, and Waycross. The PHOs’ physician members represent approximately 90 percent of all physicians practicing in the region. Why An Arrangement Would Be Found "Per Se" Illegal Under The FTCs’ Analysis.

The PHO served as a vehicle through which competing hospitals and physicians could bargain collectively with health plans to obtain higher fees for themselves. The owner PHOs, member hospitals, and member physicians canceled contracts with payors and informed them that the PHO would be the sole entity through which they would enter into payor contracts. To contract with the PHO, payors allegedly have had to accept the fixed physician fee schedule and fixed discount of no more than 10 percent off hospital list prices.

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1. Explain why this arrangement would be found “per se” illegal under the FTCs’ analysis.
2. What kind of actions could be taken to restructure this arrangement to avoid a determination that it is per se illegal?
3. Discuss the alternate FTC analysis that is applied to such cases if they are suspect but not found to be per se illegal.

1. Limit your responses to a maximum of three pages, not including title and reference pages.
2. Be sure to utilize at least 3-4 scholarly references to support your discussions.
3. Be sure to properly cite your references within the text of your assignment and listed at the end.

Across health care settings, many different terms are used to describe the same or similar conditions. For example, a bed sore may alternatively be called a pressure sore, a pressure ulcer, or a decubitus ulcer. While it may be fairly manageable for a nurse to make the connection among these terms, the same cannot be said for a computer system. Nurses have the ability to reason and reflect upon their clinical knowledge. Computer systems are linear, relying on user input to output information. When diverse terms are used, systems are unable to make the connections between the data. For this reason, the health care industry is vigorously moving towards the standardization of terminologies The Standardization Of Health Care Terminologies.

Learning Resources

Saba, V. K., & McCormick, K. A. (2015). Essentials of nursing informatics (6th ed.). New York, NY: McGraw-Hill.

· Chapter 8, “Standardized Nursing Terminology”

This chapter introduces the problems related to terminology and vocabulary standardization across the broader health care field. Nursing-specific.

· Review Chapter 7, “Health Data Standards: Development, Harmonization, and Interoperability”

Health standards, rules, and definitions are requirements for effective and efficient electronic health records (EHRs). This chapter explains various options for these areas and discusses how they can be incorporated into EHRs.

· Appendix A, “Overview of the Clinical Care Classification System”

In this chapter, the authors describe challenges in health care related to clinical care classification and terminology standards. These issues are analyzed and possible solutions are overviewed.

Scherb, C. A., & Weydt, A. P. (2009). Work complexity assessment, nursing interventions classification, and nursing outcomes classification: Making connections. Creative Nursing, 15(1), 16–22. 

Retrieved from the Walden Library databases.

The authors of this article discuss the Work Complexity Assessment (WCA), a process that allows nurses to better understand interventions for patient care. The connection between the WCA, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) are also discussed.

Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal, 39(2), 37–39. 

Retrieved from the Walden Library databases.

This article focuses on the Systemized Nomenclature of Medicine – Clinical Terminology (SNOMED CT) and how it can be used to support electronic health records (EHRs). The authors describe how SNOMED CT can contribute to EHR improvement with regard to patient safety, quality care delivery, and decision support functionality.

Cimino, J. J. (1998). Desiderata for controlled medical vocabularies in the twenty-first century. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415631/ 

Discussion: James Cimino’s Desiderata

Desiderata is a Latin word that translates to “something that is wanted or needed.” It is obvious that James Cimino had this translation in mind when he created his “Desiderata for Controlled Medical Vocabularies.” In his work, Cimino outlines 12 desiderata he believes the health care community should consider when constructing medical vocabularies. He also highlights the need to control the vocabulary used within terminology sets, as well as the requirements for doing so.

For electronic health records (EHR) and clinical decision support systems (CDS) to truly be successful, Cimino, along with many other health care professionals, expresses the vital need to standardize and control the terminology being used in health care settings.

For this Discussion, you will use one of Cimino’s desiderata (or themes) to critically appraise a nursing terminology set:

Cimino’s 12 themes for the 21st century:

· Vocabulary content

· Concept orientation

· Concept permanence

· Nonsemantic concept identifiers

· Polyhierarchy

· Formal definitions

· Reject NEC “Not Elsewhere Classified”

· Multiple granularities

· Multiple consistent views

· Representing context

· Graceful evolution

· Recognize redundancy The Standardization Of Health Care Terminologies

To prepare:

· Review the article “Desiderata for Controlled Medical Vocabularies in the Twenty-First Century” in this week’s Learning Resources. Consider how each theme aims to control the vocabulary used by nursing terminologies.

· Reflect on prominent standardized nursing terminologies sets, such as NIC, SNOMED, SABA, NANDA, and NOC. How might these terminologies compare to the requirements outlined in Cimino’s 12 themes?

· Select one nursing terminology set and one of Cimino’s themes to further examine. Does the terminology align with the requirements of this theme? Why or why not?

By Day 3

Post a brief description of the nursing terminology set and theme you selected. Explain whether this terminology aligns with the requirements and why. Provide terminology and vocabulary examples to support your answer. 

· For this discussion I choose NANDA and Formal definitions. (If it difficult, you can choose NANDA and another one of the 12 Cimino’s Theme’s.

· APA Style, 500-600 words minimum, Master Degree Quality Discussion/assignment work. 

· Please follow the instructions and read the part that say “to prepare” before do the paper. 

. Deadline: 4/18/18 at 8:00pm ET.

· For this discussion I choose NANDA and Formal definitions. (If it difficult, you can choose NANDA and another one of the 12 Cimino’s Theme’s.

· APA Style, 500-600 words minimum, Master Degree Quality Discussion/assignment work. 

· Please follow the instructions and read the part that say “to prepare” before do the paper.   

BACKGROUND

Mrs. Maria Perez is a 53 year old Puerto Rican female who presents to your office today due to a rather “embarrassing problem.”

SUBJECTIVE

Mrs. Perez admits that she has had “problems” with alcohol since her father died in her late teens. She reports that she has struggled with alcohol since her 20’s and has been involved with Alcoholics Anonymous “on and off” for the past 25 years. She states that for the past two years, she has been having more and more difficulty maintaining her sobriety since they opened the new “Rising Sun” casino near her home. Mrs. Perez states that she and a friend went to visit the new casino during their grand opening at which point she was “hooked.” She states that she gets “such a high” when she is gambling. While gambling, she “enjoys a drink or two” to help calm her during high-stakes games. She states that this often gives way to more drinking and more reckless gambling. She also reports that her cigarette smoking has increased over the past two years and she is concerned about the negative effects of the cigarette smoking on her health.

She states that she attempts to abstain from drinking but that she gets such a “high” from the act of gambling that she needs a few drinks to “even out.” She also notices that when she drinks, she doesn’t smoke “as much” but enjoys smoking when she is playing at the slot machines. She also reports that she has gained weight from drinking so much- she currently weights 122 lbs., which represents a 7 lb. weight gain from her usual 115 lb. weight.

Mrs. Perez is quite concerned today because she has borrowed over $50,000 from her retirement account to pay off her gambling debts. She is very concerned because her husband does not know that she has spent this much money.

MENTAL STATUS EXAM

The client is a 53 year old Puerto Rican female who is alert, oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. Her speech is clear, coherent, and goal directed. Her eye contact is somewhat avoidant during the clinical interview. As you make eye contact with her, she looks away or looks down. She demonstrates no noteworthy mannerisms, gestures, or tics. Her self-reported mood is “sad.” Affect is appropriate to content of conversation & self-reported mood. She visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Insight and judgment are grossly intact, however, impulse control is impaired. She is currently denying suicidal or homicidal ideation.

Diagnosis: Gambling disorder, alcohol use disorder

Decision Point One

Antabuse (Disulfiram) 250 mg orally every morning ON 

Naltrexone (Vivitrol) injection, 380 mg intramuscularly in the gluteal region every 4 weeks

Antabuse (Disulfiram) 250 mg orally daily

Campral (Acamprosate) 666 mg orally three times/day MENTAL STATUS EXAM

E

·  Client returns to clinic in four weeks

·  Mrs. Perez states that she has noticed that she has been having suicidal ideation over the past week, and it seems to be getting worse

·  Clientis She is also reporting that she is having “out of control” anxiety.. 

Decision Point Two

Educate Mrs. Perez on the side effects of Campral and add Valium (diazepam) 5 mg orally TID to address anxiety symptoms

RESULTS OF DECISION POINT TWO Decision Point Two

Select what the PMHNP should do next:

Add on Valium (diazepam) 5 mg orally TID/PRN/anxiety

Refer to a counselor to address gambling issues

Add on Chantix (varenicline) 1 mg orally BID

• Client returns to clinic      in four weeks
• Mrs. Perez reports that      when she first received the valium, it helped her tremendously. She states      “I was like a new person- this is a miracle drug!” However, she reports      that she has trouble “waiting” between drug administration times and      sometimes takes her valium early. She is asking today for you to increase      the valium dose or frequency
• Although she reports that      her anxiety is gone, she still reports suicidal ideation, but states “with      that valium stuff, who cares?”;;;;;;;; 
• Decision Point Three
• Add on Wellbutrin (bupropion) XL 150 mg orally daily
• Guidance to Student
  
   
• Given her weight (less than 60      kg), Campral should have been started at 666 mg orally BID. It is possible      that the higher dose may be responsible for the severity of the symptoms      that Mrs. Perez is experiencing.
• Technically, the drug should      have been stopped (not simply decreased) once Mrs. Perez reported suicidal      ideation. Even with the decrease in dose, she is still having suicidal      ideation, which indicates the need to discontinue the drug. Although      controversy exists regarding how long to use pharmacologic approaches to      treatment of alcohol dependence, 8 weeks is probably insufficient,      therefore, the drug should not simply be discontinued without using a      different agent in its place.
• Mrs. Perez should be started on      Antabuse at 250 mg orally daily and referred to psychotherapy to address      her gambling issue.
• In all cases, the PMHNP needs      to discuss smoking cessation options with Mrs. Perez in order to address      the totality of addictions and to enhance her overall health. The decision      to begin Wellbutrin XL 150 mg orally daily may help achieve this goal, but      this choice does not address her abstinence from alcohol.
• Additionally, it should be      noted that although Mrs. Perez reports that she has been avoiding the      casino secondary to her fear that she will drink, this “fear” has not      actually treated her gambling addiction. This particular addiction has      resulted in considerable personal financial cost to Ms. Perez. Mrs. Perez      needs to be referred to a counselor who specializes in the treatment of      gambling disorder, and she should also be encouraged to establish herself      with a local chapter of Gamblers Anonymous.
• Examine Case Study: A      Puerto Rican Woman With Comorbid Addiction. You will be asked to make      three decisions concerning the medication to prescribe to this client. Be      sure to consider factors that might impact the client’s pharmacokinetic      and pharmacodynamic processes.
• At each decision point stop to      complete the following:
• Decision #1

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• Which decision did you select?
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #1 and the results of the      decision. Why were they different?
• Decision #2
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #2 and the results of the      decision. Why were they different?
• Decision #3
• Why did you select this      decision? Support your response with evidence and references to the      Learning Resources.
• What were you hoping to achieve      by making this decision? Support your response with evidence and      references to the Learning Resources.
• Explain any difference between      what you expected to achieve with Decision #3 and the results of the      decision. Why were they different?

edit this or redo other assignment. 

Assessing and Treating Clients with Impulsivity, Compulsivity and Addiction 

Pharmacotherapy practice to treating substance use disorders is often referred to as medication assisted treatment (MAT) (Sharp et al., 2018). In this practice, specific medications approved by Federal Drug Administration (FDA) are used in combination with counseling and behavioral therapies in treatment of a substance use disorder (Sharp et al, 2018) Medications can reduce the cravings and other symptoms associated with withdrawal from a substance by occupying receptors in the brain associated with using that drug (agonists or partial agonists), block the rewarding sensation that comes with using a substance (antagonists), or induce negative feelings when a substance is taken ( SAMHSA, 2016). MAT has been primarily used for the treatment of opioid use disorder but is also used for alcohol use disorder and the treatment of some other substance use disorders. This paper focuses on pharmacotherapy approaches to treatment of alcohol use disorder, gambling disorder and smoking addiction in a 53 year- old female of Puerto origin. 

Case Scenario 

Decision Number One

Naltraxone (Vivitrol) injection, 380 mg intramuscularly in gluteal region every four weeks.

Rationale: Pharmacotherapy should be used in patients with alcohol use disorder who have current, heavy use and ongoing risk for consequences from use, motivated to reduce alcohol intake and do not have medical contraindications to the individual drug choice (SAMHSA, 2016). As the 53 year-old female has acknowledged that she has a drinking problem and has tried psychosocial approach with alcoholic anonymous(AA) without success, adding medication such as naltrexone would be warranted as next step. In random clinical trials (RCTs) naltrexone medication has been shown to reduce heavy drinking and enhance the likelihood of abstinence ( Garbutt et al.,  2014)

 Naltraxone is mu opioid receptor antagonist, can be in form of oral ( Revia) and injection( Vivitrol) ( Stahl, 2017). Naltraxone is FDA approved to treat alcohol dependence, blockade of effects of exogenously administered opioids (oral) and prevention of relapse to opioid dependence (Stahl, 2017).  Naltrexone reduces alcohol consumption through modulation of opioid systems, thereby reducing the reinforcing effects of alcohol and opioids (cravings, rewarding effects). Moreover, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption. 

The recommended naltrexone injectable (vivitrol) suspension is 380mg and should be administered via intramuscular (IM)injection to the gluteal area using the provided 1.5 inch 20-gauge needle(Drugs.com, 2017).  Vivitrol is extensively metabolized in humans, and elimination half-life of naltrexone via injection is 5–10 days (Drugs. com, 2017) Common side effects of naltrexone are nausea, headache, and dizziness, joint or muscle pain which subside with continued use. Special considerations include that vivitrol should not be given to patients taking opioids, and if opioids are required to treat pain, naltrexone should be discontinued. Naltrexone is contraindicated in acute hepatitis or liver failure. 

The advantage usage is that naltrexone can be initiated while the individual is still drinking (Canidate et al., 2017) This allows treatment for alcohol use disorder to be provided in community-based practice at the point of maximum crisis without the need for enforced abstinence or detoxification, thus beneficial for the client. Additionally, depot preparations of naltrexone may improve adherence by reducing the frequency of medication administration from daily to monthly and by achieving a steady therapeutic level of medication, thus avoiding peak effects that can exacerbate adverse events.

  The reason I did not select disulfiram (Antabuse) which by intent leads to adverse effects ( nausea, vomiting, metallic taste, tachycardia) when combined with alcohol intake, was that it  should only be used by abstinent patients in the context of treatment intended to maintain abstinence. In regards of Acamprosate, I did not select the medication because research indicates that Acamprosate should be used once abstinence is achieved (Yahn, Witterson, & Olive, 2013). 

The main goal of prescribing medication for treatment for alcohol use disorder is abstinence, which remains a primary treatment focus. However, decrease of heavy drinking can be accepted as an alternative treatment goal, especially if unwanted risks (health, social and financial) are reduced. 

The client returns four weeks after the injections, she has been sober since receiving injection, she denies any side effects from medications. The main chief complaint is gambling, but client is also concerned about her smoking and anxiety MENTAL STATUS EXAM. 

  Decision Two

  Refer to a Counselor for Gambling Issues 

Rationale:  Several different types of therapy are used to treat gambling disorder, including cognitive behavior therapy, psychodynamic therapy, group therapy and family therapy (American Psychiatric Association, 2016) As recent, there is no FDA approved pharmacotherapy for gambling disorder. But, pharmacotherapy approaches for problem gambling can be effective when directed toward the patient’s comorbid psychiatric condition such as bipolar disorder, obsessive compulsive disorder(OCD), and substance abuse.  

  The client was concerned about her smoking and appeared to be motivated to stop smoking, hence adding medication to assist her to quit would have been a reasonable approach to avoid health complications (e.g cardiovascular, pulmonary) associated with smoking. However, I did not select the answer as the starting dosage (Varenicline 1mg PO BID) was slightly higher than recommended starting dose. Initial 0.5 mg/day; after 3 days increase to 1 mg/day in two divided doses; after 4 days can increase to 2 mg/day in two divided dose(Stahl, 2017) . Starting at a higher would have increased the possibilities of adverse effects such nausea, vomiting and even agitation.  

  Adding Diazepam (Valium) would not be a good option, as Valium is an addictive benzodiazepine with longer-lasting effects than other drugs in its class. In the light of the client’s history substance use disorder and addiction, adding another addictive substance such as valium would cause more harm. 

The client returns in four weeks, reports that anxiety has gone. Client reports not liking the therapist, but she has joined gambling anonymous group.

Decision Number Three

 Explore the issue that Mrs Lopez is having with her counselor, and encourage her to continue attending Gamblers Anonymous meetings

Rationale: Despite that Mrs. Lopez did not have a good relationship with the counselor, but she remained committed to fighting her addiction by joining Gamblers Anonymous group. Still, counseling remains the main approach in gambling addiction treatment, hence exploring the issues that Mrs. Lopez had with counselor would help to guide the next step in treatment. Also, smoking cessation needs to be explored at this time. Assessing the client’s willingness to quit is the first step as smokers differ in their readiness to change their tobacco use (Niaura, 2017). Understanding the smokers’ perspectives is essential to providing useful assistance. 

Ethical and Legal Implications in Prescribing Medications to Treat Substance Use Disorders.

 In order to optimize care of clients with substance use disorder, health professionals are encouraged to learn  and appropriately use routine screening techniques, clinical laboratory tests, brief interventions, and treatment referrals ( Garbutt, 2014). Using screening tools such as CAGE Questionnaire for alcohol use dependence, would be ideal in guiding treatment approach. Additionally, client’s autonomy and confidentiality must be maintained before prescribing medications to treat an addiction. When a legal or medical obligation exists for  a health professional to test clients for substance use disorder, there is an ethical responsibility to notify clients of this testing and make a reasonable effort to obtain informed consent ( Garbutt, 2014)

References

American Psychiatric Association. (2016). What Is Gambling Disorder? Retrieved from https://www.psychiatry.org/patients-families/gambling-disorder/what-is-gambling-disorder

Canidate, S. S., Carnaby, G. D., Cook, C. L., & Cook, R. L. (2017). A Systematic Review of Naltrexone for Attenuating Alcohol Consumption in Women with Alcohol Use Disorders. Alcoholism: Clinical and Experimental Research, 41(3), 466-472. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=14&sid=183cffb8-9da8-48b2-a1b7-66c14f735856%40sessionmgr101

Drugs.com. (2017). Vivitrol Dosage Guide – Drugs.com. Retrieved from https://www.drugs.com/dosage/vivitrol.html

Garbutt, J. C., Greenblatt, A. M., West, S. L., Morgan, L. C., Kampov-Polevoy, A., Jordan, H. S., & Bobashev, G. V. (2014). Clinical and biological moderators of response to naltrexone in alcohol dependence: a systematic review of the evidence. Addiction, 109(8), 1274-1284. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=41ca863e-175d-45ae-ba36-43317c3c58e5%40sessionmgr4008

Niaura, R. (2017). Learning From Our Failures in Smoking Cessation Research | Nicotine & Tobacco Research | Oxford Academic. Retrieved from https://academic.oup.com/ntr/article/19/8/889/3888613

SAMHSA. (2016). Treatments for Substance Use Disorders | SAMHSA – Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/treatment/substance-use-disorders

Sharp, A., Jones, A., Sherwood, J., Kutsa, O., Honermann, B., & Millett, G. (2018). Impact of Medicaid Expansion on Access to Opioid Analgesic Medications and Medication-Assisted Treatment. American Journal of Public Health, 108(5), 642-648. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=5&sid=21e9426c-0afa-475e-9a9a-e1872d98830d%40sess

Stahl, S. M. (2017). Essential psychopharmacology: The prescriber’s guide : antipsychotics and mood stabilizers. Cambridge: Cambridge University Press.

Yahn, S. L., Watterson, L. R., & Olive, M. F. (2013). Safety and Efficacy of Acamprosate for the Treatment of Alcohol Dependence. Substance Abuse: Research and Treatment, 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565569/ /span> MENTAL STATUS EXAM