Demographic Information
Jodi is a 22-year-old Hispanic female. She is a single mother but does not live with her daughter who enrolled in the foster care system. She completed her general educational development (GED) tests, but her Certified Nursing Assistant Training Program is still pending. Her past medical history indicates that she gave birth prematurely but has no known allergies.
Assessment of Data
Jodi became pregnant and gave birth to a daughter after a raped ordeal. She patient has a five-year addiction to treatment. She administers the drug five to six times a day through the intravenous route. She enrolled in both the outpatient and inpatient detoxification programs but did not finish. She was treated with Suboxone for one month before she abandoned the pharmacological therapy and has a history of marijuana and alcohol abuse. Moreover, Jodi has depression that has led to a suicide attempt. Despite being diagnosed with post-traumatic stress disorder (PTSD), no treatment or remedies have been administered. She visited the emergency department in the past month for treatment of an abscess; it was unpacked and an antibiotic administered. However, she did not complete the dose and noticed some recent redness and swelling in the area.
Additional Data Needed by Counselor to Plan Treatment
Jodi is noncompliant to her pharmacotherapy treatment. She has failed to finish her detoxification sessions on two occasions. Moreover, she did not complete her antibiotics that were administered after abscess treatment. She has basic education and can understand medication instructions regarding the duration, dose, and frequency. Jodi has recently been arrested for prostitution; she should be advised on using condoms to protect herself from HIV/AIDS and other sexually transmitted diseases. A medical examination revealed that she was underweight and had irregular menses.
Standardized Screening Measures
Before the screening, it is essential to note down all the relevant historical information about a patient whether medical, hospitalizations, social or family. The goal of screening is to identify any drug-related problems. Testing of drug-related issues is mainly done by conducting interviews with the patient or asking them to fill in a questionnaire. The Alcohol Use Disorder Identification Test (AUDIT) can be used to identify any complications resulting from her alcohol use. It contains ten questions that are highly related, and there is a scoring guideline used to determine the severity of a case. The Beck Depression Inventory-II can be used to identify any changes in her mental health. It covers any short terms changes that include depression, anxiety, somatic signs, and social dysfunction of any kind. There is no specific tool for safety screening of suicidal thoughts and para-suicidal attempts and the questions a clinician asks only act as a guide to avoid underestimating the risk of Jodi injuring herself.
PTSD can only be appropriately screened by asking relevant questions regarding the history of a traumatic event in the life of Jodi. Additionally, symptoms that have persisted for longer than 30 days should be noted that have led to her decline in how she relates to people, and avoidance of questions regarding the trauma. The use of heroin can be screened using the use of the NIDA quick screen test and the NIDA modified assist. It asks questions that check for the use of illegal drugs and prescription drugs for nonmedical uses. A resultant score chart is used to identify the risk level of the patient. If the total points are more than 27, a patient can be considered as being at high risk, and the clinician should offer the relevant support for the condition. However, a score between 4 and 26 puts the patient at medium risk, and the doctor should consider referral based on the clinical judgment. Finally,...
References
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