Explain how ethical considerations may impact your treatment plan and communication with patients.

BACKGROUND
Mrs. Maria Perez is a 53 year old Puerto Rican female who
presents 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 2 years, she has
been having more and more difficulty maintaining her sobriety since the opening
of the new “Rising Sun” casino near her home. Mrs. Perez states that she and a
friend went to visit the new casino during its 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 2 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
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 she 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 borrowed
over $50,000 from her retirement account to pay off her gambling debts, and her
husband does not know.
MENTAL STATUS EXAM
The client is a 53 year old Puerto Rican female who is alert
and 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.
When 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 and
self-reported mood. She denies visual or auditory hallucinations, and 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
Points:
Select what you should do:

Vivitrol (naltrexone) 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
Decision
Point One
*Vivitrol (naltrexone) injection, 380 mg intramuscularly in
the gluteal region every 4 weeks
RESULTS OF DECISION POINT ONE
Client returns to
clinic in four weeks
Mrs. Perez says she
feels “wonderful” as she has not “touched a drop” of alcohol since receiving
the injection
Client reports that
she has not been going to the casino, as frequently, but when she does go she
“drops a bundle” (meaning, spends a lot of money gambling)
Client She is also still
smoking, which has her concerned. She is also reporting some problems with
anxiety, which also has her concerned
Decision
Point Two
*Refer to a counselor to address gambling issues
RESULTS OF DECISION POINT TWO
Mrs. Perez returns in
4 weeks and reports that the anxiety that she had been experiencing is gone.
She reports that she
has met with the counselor, but she did not really like her.
She also started
going to a local meeting of Gamblers Anonymous. She states that last week, for
the first time, she spoke during the meeting. She reports feeling supported in
this group.
Decision
Point Three
Explore the issue that Mrs. Perez is having with her
counselor, and encourage her to continue attending the Gamblers Anonymous
meetings
Guidance to Student
Although controversy exists in the literature regarding how
long to maintain a client on Vivitrol, 8 weeks is probably too soon to consider
discontinuation. The psychiatric mental health nurse practitioner should explore
the issues that Mrs. Perez is having with her counselor. As will be covered in
more depth in future courses, ruptures in the therapeutic alliance can result
in clients stopping therapy. Clearly, if the client does not continue with
therapy, the likelihood of the gambling problem spontaneously remitting is
lower (than had the client continued to receive therapy). Recall that there are
no FDA-approved treatments for gambling addiction. The mainstay of treatment
for this disorder is counseling. Since Mrs. Perez reports good perceived
support from the Gamblers Anonymous meetings, she should be encouraged to
continue her participation with this group.

You need to discuss smoking cessation options with Mrs.
Perez in order to address the totality of addictions, and to enhance her
overall health.
Introduction to the case (1 page)
Briefly
explain and summarize the case for this Assignment. Be sure to include the
specific patient factors that may impact your decision making when
prescribing medication for this patient.
Decision #1 (1 page)
Which
decision did you select?
Why
did you select this decision? Be specific and support your response with
clinically relevant and patient-specific resources, including the primary
literature.
Why
did you not select the other two options provided in the exercise? Be
specific and support your response with clinically relevant and
patient-specific resources, including the primary literature.
What
were you hoping to achieve by making this decision? Support your response
with evidence and references to the Learning Resources (including the
primary literature).
Explain
how ethical considerations may impact your treatment plan and
communication with patients. Be specific and provide examples.
Decision #2 (1 page)
Why
did you select this decision? Be specific and support your response with
clinically relevant and patient-specific resources, including the primary
literature.
Why
did you not select the other two options provided in the exercise? Be
specific and support your response with clinically relevant and
patient-specific resources, including the primary literature.
What
were you hoping to achieve by making this decision? Support your response
with evidence and references to the Learning Resources (including the
primary literature).
Explain
how ethical considerations may impact your treatment plan and communication
with patients. Be specific and provide examples.
Decision #3 (1 page)
Why
did you select this decision? Be specific and support your response with
clinically relevant and patient-specific resources, including the primary
literature.
Why
did you not select the other two options provided in the exercise? Be
specific and support your response with clinically relevant and
patient-specific resources, including the primary literature.
What
were you hoping to achieve by making this decision? Support your response
with evidence and references to the Learning Resources (including the primary
literature).
Explain
how ethical considerations may impact your treatment plan and
communication with patients. Be specific and provide examples.
Conclusion (1 page)
Summarize
your recommendations on the treatment options you selected for this patient.
Be sure to justify your recommendations and support your response with
clinically relevant and patient-specific resources, including the primary
literature.

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