Case Study on Confidentiality: Patient X, Assessment and Planning

This case study examines a patient, identified as Patient X for confidentiality, presenting with a complex situation involving both substance abuse and mental health concerns, specifically depression and suicidal tendencies. The assignment focuses on the necessity of a dual diagnosis, considering both alcohol and cannabis abuse alongside the patient's mental state. The assessment section details the need for mental health evaluations, including family history, background, and DSM-V assessments, alongside physical assessments to determine the impact of alcohol abuse, utilizing tools like SMAST-G. The study also emphasizes the assessment of alcohol and drug abuse using tools such as the Addiction Severity Index (ASI) and Diagnostic Interview Schedule – IV (DIS – IV). Furthermore, it outlines a comprehensive cannabis assessment, incorporating screening and diagnostic instruments, including the timeline follow-back method, Marijuana Smoking History questionnaire, Marijuana Consequences Questionnaire, Comprehensive Marijuana Motives Questionnaire, Marijuana Expectancy Inventory for Children and Adolescents (MEICA), and various coping and self-efficacy tests. The care planning section proposes a MAT treatment for alcohol, Cognitive Behavioral Theory treatments, and educational information to address self-denial. The case study emphasizes the importance of a three-tiered approach to patient care: understanding the client, conducting appropriate assessments, and developing effective care plans based on the diagnosis.

Surname 1
Case Study on Confidentiality.
Student’s Name
Unit Name
Institutional Affiliation
Date of Submission

Surname 2
Susanis’ Case Study on Confidentiality
Introduction
In order to provide effective care, it is important to diagnose well the root causes of the symptoms
being presented by a patient. The purpose of this essay is to provide assessments that would need to be
carried out in order to plan for effective case towards Susan. For this case, it may be important to
conduct a dual diagnosis. Dual diagnosis means that a person has a mood disorder that includes
depression as well as a problem with alcohol or drugs. The person is likely to have two separate
illnesses which requires different treatment plans. In this case, Susan presents a case needing dual
diagnosis. This is because while she exudes issues with drug and alcohol abuse, she also suffers from
depression which leads to suicidal tendencies.
Supported scientific proofs exhibit that substance disorders can be practically be treated in an
effective manner with lesser recurrence frequency than asthma, hypertension and diabetes. In this case
study, the patient who I will call patient X for confidentiality purposes has a drug abuse history as per
Council, (2015). Patient X has been using cannabis over the past years in addition to losing control
over intake of alcohol. Patient X is already experiencing paranoia when we consider the insecurity that
X experiences by fearing that people may be looking for her. She has lost interest in the hobbies she
liked and currently spend more time in smoking cannabis because that is what relaxes her. Therefore,
cannabis helps reduce anxiety. The positive part of the situation is that she is already having concerns
about her state but doesn't know what to do. Alcohol is also becoming the remedy for the voices she
hears (Dasilva & Rivadulla, 2016, pg.180).
Assessments
Mental Health Assessments
In order to make an assessment of the mental health of the patient, it would be important to fist
fiund out the family history of the patient. This would be done to identify any patterns concerning the

Surname 3
health of the individual and how genetics may have contributed to the state of mind. Next it would be
important to find out some of the background of the patient in order to understand what factors may
have influenced such a reaction and what are some potential triggers. After that is done, it may be
useful to conduct a DSM – V assessment in order to evaluate the type of mental disorder that the
patient might have. In this case, it would be necessary to pinpoint the type of disorder so as to treat it
appropriately. The already existing paranoia; where patient X feels everyone is looking for her thus she
only stays inside her room in addition to the voices signaling a mental disorder, will certainly require a
psychiatrist for assessment. Therefore, I would refer her to the psychiatrist as soon as I finish my
evaluation to help give a solid report. There is no existing treatment for Marijuana based disorders, but
MAT is very effective for individuals with alcohol-based disorders. MAT (Medical- Assisted
Treatment) is formed by a combination of behavioral interventions and medications geared towards
treating the existing disorders. While several studies deem Marijuana to serve as a pain reliever for
UTIs, in the case of patient X it must be reassessed as the state of the patient's addiction is related to it.
Marijuana may also have varying effects on different individuals as commented by Hernandez-Avila,
Rounsaville, and Kranzler, (2004, pg. 268).
Physical Assesments
To establish the cause of the Urinary Tract Infection the initial test I will carry out is the
assessment in relation to the Alcoholism. This would help determine the extent of the impact of abuse
of alcohol as a drug. I would need The Short Michigan Alcoholism Screening Instrument of the
Geriatric version (SMAST-G). An achievement of a score of 2 and above "yes" feedbacks shows the
existence of alcohol addiction. I would the utilize the scores from the Short Michigan Alcoholism
Screening Instrument (SMAST-G) to discuss the need for reduction of alcohol intake in the patient.
The SMAST-G assessment should always be the initial step a nurse should take in the Brief

Surname 4
Intervention, Referral to the Treatment process. The SMAST-G test is a self-scoring questionnaire that
will establish the intensity of the alcohol drinking problems. And it establishes the possibilities of
alcohol abuse (Cugh and Koul, 2018, pg, 123).
The Nurse whom I will call Anna for confidentiality purposes has already established some
background information that forms the initial stage of assessing patient X to establish the extent of
complication that the urinary tract infection could be associated with. From the history of substance
use, Patient X would probably have a complicated Urinary Tract Infection. Therefore, I would carry out
a physical examination encompassing checking critical signs, carrying out an abdominal and flank
evaluation. I would also conduct an external genital examination which may reveal the presence of
atrophic vaginitis. A urine dipstick is also able to show the presence of a specific Urinary Tract
Infection.
Alcohol and Drug abuse assessment
To assess for alcohol and drug abuse, it may be useful to use the addiction severity index (ASI). The
ASI can be used as a tool to measure the severity of the problem in addicted patients. It is a
standardized and reliable way for evaluating drug abusing clients. The ASI is able to cover the current
medical status of the patient, employment and support status, legal status substance abuse, family and
relationships as well as the person’s psychiatric status. Another useful tool would be the Diagnostic
Interview Schedule – IV (DIS – IV). It also provides an assessment on a variety of orders and can be
quite easy and straightforward to understand.
The already existing paranoia; where patient X feels everyone is looking for her thus she only
stays inside her room in addition to the voices signaling a mental disorder, will certainly require a
psychiatrist for assessment. Therefore, I would refer her to the psychiatrist as soon as I finish my
evaluation to help give a solid report. There is no existing treatment for Marijuana based disorders, but

Surname 5
MAT is very effective for individuals with alcohol-based disorders. MAT (Medical- Assisted
Treatment) is formed by a combination of behavioral interventions and medications geared towards
treating the existing disorders. While several studies deem Marijuana to serve as a pain reliever for
UTIs, in the case of patient X it must be reassessed as the state of the patient's addiction is related to it.
Marijuana may also have varying effects on different individuals as commented by Hernandez-Avila,
Rounsaville, and Kranzler, (2004, pg. 268).
The next assessment I would conduct is the Cannabis assessment because the patient is already
experiencing the harmful effects of its use. She already has social consequences and mental disorders. I
would use screening and diagnostic instruments to establish the extent of intervention required for
patient X. According to Cottler, (2000), a screening and diagnostic instrument should have the
following attributes: reliable, valid, adaptable to the various consumption patterns, short enough,
applicable in daily use, clear, and usable in various settings and population set up. I would implement a
careful diagnostic clinical interview. I would use timeline follow-back method to establish the patterns
of cannabis use that patient X has experienced in conjunction with Marijuana Smoking History
questionnaire. I would use the Marijuana Consequences Questionnaire to establish more effects in
addition to the one already realized by the initial evaluation. The craving extent will also enable me to
know the severity of the cannabis dependence. This step would be implemented using the
Comprehensive Marijuana Motives Questionnaire. The second last assessment I would conduct is the
Expectancies and Experiences test which determines the expected impacts of taking cannabis and the
attitude towards the use of the drug. The Marijuana Expectancy Inventory for Children and
Adolescents (MEICA) would be used for the execution of the assessment. The last assessment I would
carry out concerning cannabis will be about the copying and efficacy. This test would help in knowing
the copying approach of the patient while the self-efficacy can show how they maintain the behavior

Surname 6
transitions in relation to cannabis use. The Copying Strategy Scale will assess the copying strategies
while the Reduction Strategies Self-Efficacy Scale will include the cognitive behavioral strategies that
a person may use to decrement marijuana intake (Cottler, 2000, pg. 220).
Care planning
On the event that the patients agree that the drugs are having impacts on her and accept a
treatment, after the series of assessments, I would administer a MAT treatment for alcohol. At this
moment I would have determined her need for medication considering her motivation for treatment, the
intensity of co-existing situations and the potential relapse. I would also consider the effects that every
method has: considering Disulfiram, acamprosate, and naltrexone as the approved medications
available in accordance to Substance, Mental, and Office of the Surgeon General (US, 2016). In
addition, I will employ Cognitive Behavioral Theory treatments. The treatment would encompass 12 to
24 weekly personal sessions with patient X. The sessions will intensively explore the pros and cons of
the use of substance and self-monitoring as the basic method to establish the yearnings and conditions
that may result in a relapse of an individual. I anticipate that this mechanism will help in prevent
mental disorders. Patient X seemingly is in denial. She does not know that the alcohol abuse is
affecting her health while the cannabis abuse is not relaxing her but bringing more paranoia. Therefore,
I would ensure that my Cognitive Behavioral theory treatment is well seasoned with educative
information concerning self-denial.
Conclusion
The process of taking care of a patient is a three tired process. First it begins by taking adequate time to
know the client and understand their needs. To some extent it may even involve gaining trust of the
client since they are your primary resource person for information. The second step requires one to
make the right assessments to diagnose the client problems. This many involve the use of different
tools for different problems especially if a dual diagnosis is required. Lastly, there is need for effective

Surname 7
care planning depending on what has been found out from the diagnosis. This may involve lifestyle
changes, medication and coping mechanisms to allow the individual to get back on track.
References
Dasilva, M., Grieve, K. L., & Rivadulla, C. (2016). Cannabis, Endocannabinoid CB1 Receptors, and
the Neuropathology of Vision. In Neuropathology of Drug Addictions and Substance Misuse (pp. 738-
748).
Chugh, N.A., Bali, S. and Koul, A., 2018. Integration of Botanicals in Contemporary Medicine: Road
Blocks, Checkpoints and Go-ahead Signals. Integrative Medicine Research.
Cottler, L.B., 2000. The CIDI and CIDI-Substance Abuse Module (SAM): Cross-Cultural Instruments
for Assesing DSM-III, DSM-III-R and ICD-10 Criteria. In Problems of Drug Dependence 1990
Proceeding of the 52nd Annual Scientific Meeting (p. 220).
Council, N.M., 2015. The code: professional standards of practice and behaviour for nurses and
midwives. London: NMC.
Hernandez-Avila, C.A., Rounsaville, B.J. and Kranzler, H.R., 2004. Opioid-, cannabis-and alcohol-
dependent women show more rapid progression to substance abuse treatment. Drug & Alcohol
Dependence, 74(3), pp.265-272.
Substance, A., Mental, H.S.A.U. and Office of the Surgeon General (US, 2016). Facing addiction in
America: The Surgeon General's report on alcohol, drugs, and health.

Surname 8