TASK 34 Ms. Amy Vineyard is a patient in your care at the St. Kilda women’s Refuge Centre. She is 6 week pregnant with her first child. She presented two days ago, requesting help for her substance abuse problems. She reports a desire to reduce or cease her alcohol consumption and desire to reduce a cease her drug use. No desire has been indicated to decrease or stop cigarette use. She now wishes to be discharged but will require ongoing support throughout her pregnancy.
DISCHARGE SUMMARY:
Name : Ms. Amy Vineyard
Age 21.
Admission : 6/1/09
Diagnosis : Pregnant substance abuse Discharge : 8/1/09
PLAN: Community mental health nursing required daily next 2 weeks minimum.
Pt wishes to continue living with a friend on her sofa
Psychiatric support needed for depression. Methadone program Alcoholics Anonymous meetings.
I trimester Ultrasound at 2 weeks; Maternal clinic appointment needed.
REASON FOR ADMISSION
Pt. self-admitted due to concern about pregnancy. Confirmed pregnancy test the days before (5/1/09)
Reported pain in lower back. Weight loss (6 kg over 2 months).
Some memory loss. Tingling in feet, difficulty sleeping, excessive worry and hallucinations
Feeling depressed-history of depression No pain in hips or joints.
No decrease in appetite No double vision
TREATMENT: Pt. monitored and blood tests for HIV/AIDS and STDs
Counseled re nutrition and pregnancy. Counseled re HIV/AIDS and STDs risk
Discussed possibility of rehabilitation clinic for ‘driving out’
LIFESTYLE: Nicotine-daily 30-40 cigarettes Started smoking at 15 years old
Drugs used cannabis, amphetamines, cocaine, and heroin Started all above at 16 years old
Injects heroin, occasionally shares infecting equipment Alcohol 8 units/day- max, units/day-15
Started drinking at 16 years old. Lives with a friend, Sophie, on her sofa No contacts with parents
HISTORY Suicidal thoughts, self-harm in past Never seen a psychiatrist
WRITING TASK: Using the notes, write a letter about Ms. Vineyard’s situation and history to new community health nurse. Address your letter to Ms. Lucy Ban, Registered Nurse, Community Health Centre, St Kilda.
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