heroin addict POC - help!

  1. 0
    Hello,

    I am an RN with 20 years experience prior to taking time off to raise my family. I am taking a refresher course to reinstate my license and re-enter practice. I am doing a care plan on the following patient: 15 year old female, heroin addict, in and out of rehab several times, well-off family, 18 and 12 year old siblings, parents have consulted various counselors including the family priest. Attitude of 15 year old is "you have to take care of me until I am 18 ...it's the law".

    I have identified three potential problems: (1) potential for alteration in physical health secondary to continued heroin use (2) potential for alternation in family dynamics due to ongoing needs of 15 year old.

    I am comfortable identifying a plan of care for these two things.

    What I need help with is ---what does a family do in this situation? I will develop a problem regarding the inability of the 15 year old to get clean, but what type of interventions would there be? I would think the ultimate goal would be a time period of being clean, but is that reasonable considering her history, or is it a "never give up" situation? In your experience, what do families actually do in situations like this? I am sure there are some legal issues, but I do not have experience in this area, and so far have not come up with anything helpful on line.


    Thank you ! I have 3 more modules to do and I am done with the theory portion of my course, then onto clinical in Sept.

    Linda in NJ
  2. 9 Comments so far...

  3. 0
    Hi,
    Well the kid is right, she is their responsibility until 18 or the state takes her from them. Is this a real client or a scenario?

    My thoughts would be that the family should immediately take her to the ED and have them make the calls to get her into an inpatient program. Since she is a frequent flier she probably needs a longer stay and yes imo it is a "never give up" situation and something that you keep doing until she makes the decision to stay clean or she will likely end up dead. They need to keep her in a program even if they have to pay out of pocket because this is a matter of life and death. One of the big problems imo is that the family usually not only enables them by giving them money, not supervising them properly etc. but think of the temptation for a teenager to come out of rehab and be thrust back in the same neighborhood, same school with the same loser friends and yet we expect them to stay sober.
  4. 0
    Jules,

    So sorry I didn't clarify - it's a scenario. And it really left me curious as to what happens in "real life".

    In real life, what could parents do if a kid refuses to go to an ED? Would they have to wait for the kid to do something dangerous or be high before they could call the police to physically force it?
  5. 0
    Quote from linda1959
    Jules,

    So sorry I didn't clarify - it's a scenario. And it really left me curious as to what happens in "real life".

    In real life, what could parents do if a kid refuses to go to an ED? Would they have to wait for the kid to do something dangerous or be high before they could call the police to physically force it?
    In my experience not with addicts necessarily but with mentally ill kids if the parents can't take them to the ED their parents call the police and off they go. I admitted one of our "regulars" last week and this time the chief complaint was that he was cussing at everyone. This is a downward spiraling pattern with this child so we knew where he was headed and there isn't the same burden as with adults of proving they are a danger to themself or others before being admitted. Their parents can just voluntarily sign them in. Are you thinking about doing child/adolescent psych?
  6. 2
    god bless you for wanting to get back in the game after raising your family! there is care plan writing information on this sticky thread in the student forums:
    you need to decide who your care plan is focusing on: the 15-year old girl or the family. who is the patient here? potential for alteration in physical health secondary to continued heroin use is focused on the 15-year old girl and is an anticipated problem, not an actual problem that is occurring. potential for alternation in family dynamics due to ongoing needs of 15 year old is focused on the family and, again, is an anticipated problem, not an actual problem--at least not the way you have worded it.

    you use "potential for" or "risk for" diagnoses when you think a specific problem "might happen" to the patient. since these are potential, or anticipated, problems there are no signs and symptoms to use as evidence to support the diagnosis as there are with actual problems. you have to have a very clear and defined idea of the problem(s) you are attempting to prevent, so you must know it's signs and symptoms and preventative measures. interventions for these nursing diagnoses are limited to:
    • strategies to prevent the problem from happening in the first place
    • monitoring for the specific signs and symptoms of this problem
    • reporting any symptoms that do occur to the doctor or other concerned professional
    • if symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis
    these types of nursing diagnoses do not have the same priority as actual nursing problems. actual problems are usually attended to first.


    so, for the first problem of potential for alteration in physical health secondary to continued heroin use (and i have to tell you that this is not an official nanda diagnosis, but if this is allowed by your instructors, i can work with it--the nanda diagnosis to use would be risk for injury) you have to know what the signs and symptoms of altered physical health in heroin addicts is. did you research this?
    • i found, from http://www.nida.nih.gov/researchrepo...3.html#chronic
      • scarred and/or collapsed veins
      • bacterial infections of the blood vessels and heart valves
      • abscesses (boils) and other soft-tissue infections
      • liver or kidney disease
      • various types of pneumonia and tuberculosis due to heroin's depressing effects on respiration
      • many of the additives in street heroin may include substances that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain leading to infection or stroke
      • immune reactions to the additives in the street heroin or other contaminants can cause arthritis or other rheumatologic problems
    based on that information your nursing interventions for this diagnosis of potential for alteration in physical health secondary to continued heroin use, or risk for injury, would be:
    • strategies to prevent the problem from happening in the first place
      • placement in a drug rehab program to quit using
    • monitoring for the specific signs and symptoms of this problem
      • monitor the patient for evidence of infection at possible areas being used as injection sites on arms, hands, feet, and legs (and any other places you can research or think of)
      • assess the skin for boils
      • monitor lab results of kidney and liver function test
      • assess breath sounds (list a frequency)
      • monitor vital signs (list a frequency)
      • assess for physical signs and symptoms of pain.
    • reporting any symptoms that do occur to the doctor or other concerned professional
      • report abnormal liver or kidney tests to the doctor
      • report any adventitious or absent breath sounds and productive cough to the physician
    • if symptoms occur, you have an actual problem on your hands and you need to re-evaluate the care plan and change the nursing diagnosis
    you go through the same process for your diagnosis of potential for alternation in family dynamics due to ongoing needs of 15 year old. you will need to find information on what normal family dynamics are. that, personally, is why i would stay away from this diagnosis. i am not a psych nurse and do not pretend to know anything about this.

    there is more information on heroin addiction at:
    however, i do a lot about care plan writing and something was very prominent to me when i read your post. you have identified no actual nursing problems. your two problems are stated in such a way as to say that they are things that could happen. this is an addict. that is a fact. she has said to her family, "you have to take care of me until i am 18...it's the law." now, i said to myself, that's a snotty teenager talking--i used to be one of those. i was also thinking that having never seen this actual patient, what are the instructors wanting you to focus on here? the law? treating the addiction? helping the family? what? i worked on an alcohol detox unit and am well aware of how interventions work (have you seen the weekly program about interventions on a&e). i tell the students on the student forums all the time that the first step of care planning is to assess the patient. i think that you need to identify who your patient is here: the kid or the family. with drug addiction you often have a nursing diagnosis of impaired adjustment which was re-titled as risk-prone health behavior in 2007and is the inability to modify lifestyle/behaviors in a manner consistent with a change in health status (page 18, nanda-i nursing diagnoses: definitions & classification 2007-2008). that pretty much sounds like your 15-year old girl in this scenario and it describes an actual problem. it's signs and symptoms are (you're gonna love this!):
    • demonstrates nonacceptance of health status change (in other words, won't quit using heroin)
    • failure to achieve optimal sense of control
    • failure to take action that prevents health problems (i think saying something like, "you have to take care of me until i am 18...it's the law." pretty much demonstrates that)
    • minimizes health status change
    some interventions for this are to:
    • assess the patient's perception and attitude about their heroin addiction
    • assess the socioeconomic strengths and weaknesses
    • assess their support system
    • determine if they are ready for change
    • determine if the patient is willing to cooperate
    • determine if there is any denial or grief going on
    • discuss potential goals with the patient
    • allow the patient to make choices
    • provide resources
    • refer to community resources
    ineffective coping is another diagnosis that may be relevant here. it is the inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources. (ineffective coping) if you access the weblink i posted you can get nursing interventions. there is also compromised family coping.

    something else that a nursing instructor would want addressed (i am aware that you are in a refresher course, however) is the developmental tasks required of a 15-year old. you would assume (since this is a hypothetical situation and you can do that) that she is most likely so hung up on her drug culture that she's missing out on being a 15-year old and doing 15-year old things. because i'm sure you don't have your growth and development textbook (me neither!), here's a web site where you can get that information:
    some of the things she's supposed to be doing are:
    • creating her own identity
    • adjusting to puberty self-consciousness.
    • establishing independence
    • exploring career options (not as a drug dealer!)
    • preparing for marriage and family life
    • achieving socially responsible behavior
    a nursing diagnosis that applies to this is either delayed growth and development (delay in performing skills of her age group) or risk for delayed development (due to substance abuse). one is an actual problem; the other an anticipated problem. the list of developmental tasks not obtained would be a sign or symptom of the delayed development. since the cause of the developmental delay is the drug abuse, the interventions would primarily focus on a drug intervention and stopping the drug use.

    i hope i am making sense and haven't confused you. the problem with doing care plans of scenarios is that the patients do not exist. you have to take the information you are given and expand and extrapolate on it in order to get your signs and symptoms to support the problems that you are going to find. keep in mind that just as doctors treat underlying causes of disease and the symptoms, so do we. the thing is that nursing diagnoses aren't as straightforward in their listing of symptoms as medical diseases are, particularly when you get into these behavioral and psychosocial nursing diagnoses. these are the three diagnoses i would use and the order of priority i would sequence them:
    1. risk-prone health behavior secondary to heroin addiction r/t negative attitude toward health care aeb refusal to stop using heroin and verbalized statement "you have to take care of me until i am 18 ...it's the law". i listed the interventions above for you.
    2. risk for injury r/t drug addiction i listed the interventions above for you.
    3. risk for delayed development r/t substance abuse if you decide to use this one, you'll have to give the interventions a whack yourself.
    coastiewifejenna and Thunderwolf like this.
  7. 0
    Linda;
    1st of all, welcome back!
    2nd: daytonite CERTAINLY did a wonderful job answering your question! It's a plan of care your instructor is asking for.
    3rd: real life??? send the kid to a well researched wilderness program. I've seen more than 100 girls come out of some very good programs, parents who thought they had lost their kid forever got them back. Some kids of course need more than one trip but, it's way better than 10-100 trips in and out of acute care. Just an FYI.
  8. 0
    My dh and I have started the civil committment process for our son. We discussed it with the doctor after bring our son to the ED finding him incoherent and parnoid after days on end using herion and other drugs. He was also suicidal. The doctor has signed the paperwork petitioning for a dual diagnosis treatment center.

    Although our son is older than 15, he has been denied by insurance, he has lost his car, he is at rock bottom. Besides the guilt, we also have an overwhelming sense of our son's safety now. Now that he is hospatilized we know he is alive.

    His first court appearance is this coming week. He has a court appointed attorney at this point and is reluctantly starting to admit he can't beat this addiction on his own.

    I feel we did what we had to do and what most any parent would do.

    Good luck with your care plan. Daytonite really laid it out there with wonderful information.
  9. 1
    Thank you all for sharing your insight and experience!
    Jules - I actually am not quite sure what area I will focus on when I am reinstated. Definitely peds/adolescent, but it really depends on what is available in my area. I am also considering working towards my school nurse certificate. My kids are still young - 9 and 7- so I have lots of working years ahead of me. I was fortunate to be able to stay home for 9 years, and actually always thought when I went back to work it would be a career change into family/parent advocacy for special ed. kids, but that isn't going to happen now. I am actually excited about re-entering practice, and also really scared. Keep having some awful dreams!! .....missed meds, forgotten patients.....

    Daytonite - Thanks for the very helpful information and re-focusing. Actually, the instructor has been pretty flexible on the POC aspect. She most wants to see that you can apply pertinent problems and critical thinking of interventions. I was curious . .. what do you do that you are so well-informed on care-plan writing?

    Mish - Thanks for the idea as a wilderness program as an alternative for this client. I'd like to include various alternatives.

    Sharona97 - Thank you for being kind enough to share your real-life experience. While my care plan is for a fictitious client, it really made me curious as to what options parents have in "real-life". Such a difficult situation to be in . . . sending you prayers for a positive outcome for your son . . . it could be anyone of us....

    Thanks again everyone . . . I've put off this care plan for about 3 weeks, and really need to get restarted, and feel much better equipped to complete it!

    Linda
    sharona97 likes this.
  10. 0
    Quote from linda1959
    Daytonite - Thanks for the very helpful information and re-focusing. Actually, the instructor has been pretty flexible on the POC aspect. She most wants to see that you can apply pertinent problems and critical thinking of interventions. I was curious . .. what do you do that you are so well-informed on care-plan writing?
    Write/teach care plan writing
  11. 0
    Linda1959

    Thanks for the prayers. The real-life situation is bizzarre, a jaw dropper and relentless research on how to help your kid, let alone how to reach your kid.


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