Case Study Chart Review:

1. Client initials & age

J.S.; 21 y/o Male

2. Diagnosis

Axis I-Opioid Dependence, Nicotine Dependence, Cannabis Dependence, Cocaine

Dependence; ADHA, Asthma, GERD (Acid Reflux)

3. What medications are prescribed for this client?

Suboxone- 4mg every 6 hr.

4. What are the side effects of those medications?

Headache/mild dizziness, numbness/tingling, drowsiness or insomnia, stomach pain,

vomiting, constipation, redness or numbness in your mouth, trouble concentrating

5. What are the goals for this patient's episode of care?

At Talbot Hall, patient stated his goals were: detox w/ suboxone, continue w/ home
medication and basic blood work, participate in group, work with counselor for plan of
care after TH

After Talbot Hall, patient stated his goals were: vivitrol shot 1x/month and continue
with Intensive Outpatient (IOP) at Talbot Hall

6. What precautions does this client have?

Aspiration/Choking on solid food based off occurrence happening in the past

7. What is the client's family situation?

Patient lives at home with mother, boyfriend, and younger sister; Patient comes from
middle/upper-middle SES where he stated drugs were not in his neighborhood;
Patient’s paternal uncle heroin usage; Patient’s mother is diagnosed with depression;
Patient is supported by his family during recovery process but also has parental strain
due to previous attempts and then failures of recovery through span of 5 years

8. Identify any services involved with this client.

At Talbot Hall, patient is under care of: counselor/social work, nursing, doctor, and
AA/NA groups run by many services (occupational therapy, nursing, Chaplin, nurse
practitioner, aroma therapy, and counselors)

Recommendations for patient plan of care by 2 other professions:

1. Nursing-patient should follow up with psychiatry to address anxiety and becoming

less irritable with his ADHD, patient should seek doctor to re-evaluate ADHD
medicine and dosage
2. Counselor/Social Work- patient should move to a long-term recovery facility such
as a half-way house or salvation army program, since he has had the most success
there in his past attempts at recovery; patient should stay with vivitrol shot and
not suboxone; patient should attend family therapy to gain support in recovery
process, especially with his mother who will be driving him to sessions and sister
since they are close in age and have a close relationship; patient should identify
that recovery is first, not obtaining his GED or returning to work-those all come
after being stable in recovery. With this, patient needs to acknowledge recovery
comes first and needs to focus on what his goals are, not what people want to hear