What’s Wrong, A Short Assessment

Assessment Case Studies

Directions: Choose one of the individuals described in the case studies in Chapter 6 of your textbook: Ann (page 61), Daniel (page 65), Sam (page 67), or Dean (page 72). Based on the information in the textbook, complete the following form.

PSYC FPX 2300 Assessment 2 What’s Wrong? A Short Assessment

Substance Use History

Drug	First Use:  Yes or No	The pattern of use over time?	What frequency of use in the past month?	Date/amount of most recent use?
Alcohol	no	Occasional drinker initially. Ann became a frequent drinker over time.	Up to seven days per week.	One day before

Sociocultural Factors

Educational level	Education level is not specified
Employment status	Ann has a job. She has missed her work recently due to an increase in drinking frequency.
Current living situation	Ann has a flat having two bedrooms. She lives with her husband, two children, and one parent.
Current or past legal problems	No past or current legal issues are present.
Describe the family history of substance use	There is no substance use family history.
Describe the client’s social support system	Norris is Ann’s husband. He is very caring and wants Ann to be well. Both Ann and Norris are understanding the problem and aim to seek professional medical help and therapy.

PSYC FPX 2300 Assessment 2 What’s Wrong? A Short Assessment

Diagnostic Criteria Checklist

Criteria	Yes	No	Criteria	Yes	No
Was the substance taken in larger amounts or over a longer period of time than intended?	YES		Were important social, occupational, or recreational activities given up or reduced because of substance use?	YES
Is there a persistent desire or unsuccessful efforts to cut down or control substance us?	YES		Has the substance been used recurrently in physically hazardous situations?	YES
Was a great deal of time spent in activities necessary to obtain or use the substance, or recover from the substance?	YES		Has use continued despite knowing of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by substance use?	YES
Have they continued to use the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance use?	YES		Has recurrent use of the substance resulted in a failure to fulfill major role obligations at work, school, or home?	YES
Is tolerance present?	YES		Is withdrawal present?		NO
Is there a craving or strong desire or urge to use the substance?	YES
DSM-5 Diagnosis:	AUD (Alcohol Use Disorder)		DSM-5 Diagnostic Code:	303.90 F10.20

Basis of Diagnosis (A 2–4 sentence explanation of why you chose this diagnosis.)

There were several observations present in Ann’s case. She has a severe condition with 6+ symptoms. The observed symptoms are as follows:

• More use than indented
• Use despite negative effects
• Activities are given up because of use.
• Unable to fulfill major role obligations.
• Activities are given up 
• Recurrent use in hazardous situations.
• Continued use despite interpersonal and social problems. 

Applicable Addictions Perspective (A 2–4 sentence description of a theoretical perspective that would explain this client’s substance use history.)

Life circumstances of Ann played a major role in her drinking habit. Ann is stressed and feels burdened as she is a working mom of two kids who are both younger than three years. Ann started using alcohol as a stress reliever and nerve settler (Carvalho et al., 2019). With time, her drinking increased and she became dependent on it. Hence drinking became her habit. (Hardy et al., 2021) explained that substance use is usually connected with a reason such as deposition, environment or others. The same goes in the case of Ann, her stress level makes her drink more. 

Ethical Considerations (Based on the NAADAC code of ethics, describe how will you store and protect assessment information. Cite the NAADAC code of ethics.)

Ethical considerations are very important. Any information provided by the patient must be treated with utmost confidentiality. Therefore, as a healthcare nurse, I will help Ann and make sure her personal and medical information is kept safe. Using the NAADAC code of ethics, I will guide Ann with her diagnosis and any additional treatment that is required (NAADAC, 2021). 

Moving on, there are many ways in which we can be confident that ethical considerations are properly met. Some of them are as follow:

• All the patient’s information in a password-protected storage
• Only a few healthcare professionals should have access to patient’s data and records
• There should be extra security on the wireless network used by the facility to ensure that there is no data and records theft.

PSYC FPX 2300 Assessment 2 What’s Wrong? A Short Assessment

Reference

Carvalho, A. F., Heilig, M., Perez, A., Probst, C., & Rehm, J. (2019). Alcohol use disorders. The Lancet, 394(10200), 781–792. 

https://doi.org/10.1016/s0140-6736(19)31775-1 

Hardy, A., Chesnut, S., & Brown-Rice, K. (2021). Mandatory reporting of child abuse/neglect among substance use counselors. Journal of Public Child Welfare, 1–18. https://doi.org/10.1080/15548732.2021.1989125

NAADAC, the Association for Addiction Professionals (2021). NAADAC/NCC AP Code of Ethics.

Alexandria, VA: NAADAC. Retrieved from:

https://www.naadac.org/assets/2416/naadac_code_of_ethics_112021.pdf