K. M. is a 23 year old single, bi-racial male, self-admitted to Interval Brotherhood Home. He has resided in Cuyahoga Falls, Ohio for his entire life. K. M. has a black father and a white mother. His father left the family when he was twelve years old. K. M. was extremely upset with his father’s abandonment. K. M went thought a period of extreme anger and hatred toward all black people. K. M. even went as far as getting a swastika tattoo on his right leg. He no longer takes his father’s desertion out on other blacks and has since had the tattoo covered.

As a result of his father K. M. began using heroin at the age of thirteen in order to escape the reality of his broken family. It was not uncommon for K. M. to spend over one hundred dollars per day to support his addiction. He has two sisters who are also heroin abusers, one of which is now clean. He has also used methamphetamine, however heroin was his drug of choice. K. M. told the student that he has been sober since January 22, 2013. He was not able to enter Interval Brotherhood earlier due to the long waiting list. K. M. has enjoyed his time thus far at Interval Brotherhood home and has a very optimistic view of the treatment center.

However, he has commented to the student that he would prefer the female residents to be in a separate facility with no contact whatsoever. From what the student can gather, K. M. is serious about staying clean and has already made living arrangements that will facilitate this upon his completion of the treatment program. According to Townsend (2012), “The APA endorses case evaluation on a multi-axial system, to facilitate comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem.

Each individual is evaluated on five axes. ” For the purpose of this paper the student has been instructed to leave out Axis V – Global assessment of functioning as the new DSM V does not recognize this axis. K. M. ’s DSM five axial diagnosis is as follows: Axis I - opioid dependence.

Axis I examines clinical disorders and other conditions that may be a focus of clinical attention. This comprises all mental disorders (Townsend, 2012). Axis II – deferred. Axis II examines personality disorders and mental retardation. These disorders typically begin in early childhood or adolescence and persist in a stable form into adult life (Townsend, 2012). Axis III – no current medical conditions. Axis III – examines general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder (Townsend, 2012).

Axis IV - parent abandonment, family drug use, unemployed, few sober support, court fines, financial resources. Axis IV examines psychosocial and environmental problems. These may affect the diagnosis, treatment, and prognosis of mental disorders named on axes I and II. These include problems related to primary support group, social environment, education, occupation, housing economics, access to health care, and interaction with the legal system or crime (Townsend, 2012). K. M. was casually dressed and appeared to be well-groomed.

He was pleasant and cooperative during the entire interaction with the student. His speech was clear and fluent and she was alert and oriented to person, place and time. The interaction occurred on an outdoor walk around the facility grounds. K. M. and the student have a good relationship that is between the orientation and working stage of the nurse-client relationship. K. M. and the student had briefly met the previous week and continued to get to know each other this week while incorporating more therapeutic communication.

The objective of the interaction for K. M.’s therapy was for the student to understand how he was feeling about being at Interval Brotherhood and if he thought that his time there has been beneficial to getting her healthy. The student’s personal growth goal during the interaction was to develop skill in observing, recording, and interpreting meanings of behavior and to also utilize collected data regarding the interaction to assess needs, plan, implement and evaluate nursing interventions on a conscious rather than intuitive level. This conversation effectively helped to promote the therapeutic nurse/client relationship.

It also met the initial objectives of understanding what K. M. was feeling about being at Interval Brotherhood Home and letting the student develop skill in observing, recording, and interpreting meanings of behavior. The student was also mindful of the client’s feelings during the interaction and responded positively to everything the client said. Both the client and the student left the conversation on good terms. The strengths of the communication techniques was that a lot of the questions allowed for the client to explain his feelings further and lead to new topics to talk about.

Weaknesses included not focusing on a single issue or delving deeper into the client’s feelings about a certain topic. Not much teaching was accomplished during this interaction. It was more about gaining knowledge about what the client was feeling at the time about being at Interval Brotherhood Home. Further teaching could be done with regards to a plan upon K. M. ’s exit from Interval Brotherhood Home. The student did not have time during this conversation, however, and was not able to go into the issue any further.

K. M. ’s should start thinking about who he will surround himself with when he leaves the treatment facility. The client should also attempt to find a residence that will not tempt him into relapsing. During a later conversation, K. M. stated that he wants to attend Kent State University in the spring of 2014. This will help keep him occupied, however he should be careful with who he surrounds himself with while attending college. The pertinent assessment points evidenced by this data are primarily emotional.

Overall, the client seemed to be in a good mood and showed positive feelings toward his present condition being at Interval Brotherhood Home. The student did not discover any potential safety issues during the interaction. The client seemed to be motivated to continue his treatment, has supportive co-residents, and a substantial history of sobriety. The client is currently taking two medications, Effexor and Vistaril. Effexor’s therapeutic classes are antidepressants and antianxiety agents.

The indications for Effexor are major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder. The adverse reactions and side effects of Effexor are neuroleptic malignant syndrome, seizures, suicidal thoughts, abnormal dreams, anxiety, dizziness, headache, insomnia, nervousness, rhinitis, visual disturbances, epistaxis, tinnitus, abdominal pain, altered tasted, chills, serotonin syndrome, and photosensitivity (Deglin & Vallerand, 2011). Vistaril’s therapeutic classes are antianxiety agents, antihistamines, and hypnotics. The indications for Vistaril are treatment of anxiety, preoperative sedation, antiemetic, and antipruritic.

The adverse reactions and side effects of Vistaril are drowsiness, agitation, anxiety, wheezing, itching, dry mouth, bitter taste, constipation, nausea, urinary retention, and flushing (Deglin & Vallerand, 2011). From the interaction the student did not identify any “here and now” issues. The client seemed to be happy in his current situation and did not express any concerns besides the embarrassment of his swastika tattoo. Faye Glenn Abdellah and colleagues developed a list of 21 nursing problems and identified 10 steps to identify the client’s problems.

The 10 steps to identify the client’s problems are: learn to know the patient, sort out relevant and significant data, make generalizations about available data in relation to similar nursing problems presented by other patients, identify the therapeutic plan, test generalizations with the patient and make additional generalizations, validate the patient’s conclusions about his nursing problems, continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior, explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan, identify how the nurse feels about the patient’s nursing problems and discuss and develop a comprehensive nursing care plan. Abdellah’s theory provides a basis for determining and organizing nursing care based on the needs of the client. She also explained nursing as a comprehensive service, which includes providing continuous care to relieve pain and discomfort and provide immediate security for the individual (Current Nursing, 2011).

The student did not encounter any legal, ethical, or advocacy issues related to this data. The student evaluated the care this client was receiving as satisfactory because the client did not express any issues that he was having with the nurses, resident supervisors, counselors, or psychologists and described all of them as being “nice”. This clinical rotation has given the student a lot of experience working with populations that he does not usually encounter. It has helped him grow as a professional and become more comfortable talking to people in informal settings. By observing the staff, the student has realized that her communication skills need some work, but are also improving with each day at clinical.