1. Prior to Ms Warrals discharge you refer to her nursing history of osteoarthritis (OA) in her knee, What questions might you ask her to help determine the severity of her OA and how may OA impact her activities of daily living? (50-100 words)
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Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the “Discharge Summary” template. This discharge summary should address the following:
What behaviors would indicate that the client is sustaining at a healthy baseline?
How would you determine if Eliza met her treatment goals?
What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).
How would you encourage involvement in community-based resources?
Part 2: Write a 700-1,050-word summary statement about your client, Eliza.
Include or address the following in your summary statement:
Demonstrate whether or not the client met the goals of the treatment plan.
What specifically contributed to the success of the treatment plan or lack thereof?
What language would you use to communicate the outcome to the client?
How would you document the final session?
Include at least three scholarly references in your paper.
Submit your discharge summary and summary statement to your instructor.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.
This assignment meets the following NASAC Standards:
73) Conduct continuing care, relapse prevention, and discharge planning with the client and involved significant others.
74) Assure the accurate documentation of case management activities throughout the course of treatment.
75) Apply placement, continued stay, and discharge criteria for each modality on the continuum of care.
112) Prepare and record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.
114) Prepare an accurate, concise, informative, and current discharge summary.
Based on the assessment of Liza after second referral, it was evident that she was suffering from anxiety reduction, which can be alleviated through cognitive behavior therapy. This will help client to achieve the first goal of increasing self-awareness and self-confidence. To determine whether Liza has met this treatment goal, it is important to engage her in open-ended questions to identify her thoughts, feelings and behavior about the college and home (Ball, et al., 2011). Some of the positive signs that showed that Liza has responded to the treatment goals is determined based on how she maintain good relationship with her parents and the peers in college. Another behavior that determines whether Eliza is sustaining healthy baseline is the show of interest to join clubs in campus. By joining new clubs in campus is the opportunity for her to meet new friends. These are among the behaviors that will show whether Eliza is sustaining a healthy baseline. Based on these, it is possible to determine whether the treatment is working and has achieved the treatment goals. Depending with the information gathered from Eliza coupled with various diagnosis, it will be prudent to use Level 2 depression Cross Cutting Measure to access Eliza’s responses to the treatments. This approach will also determine whether Cognitive Behavioral Therapy is working as planned or the treatment should be reevaluated (Dziegielewski, S. F., 2014). Another approach to determine whether Eliza met her treatment goals is the use of Patient Health Questionnaire. Through this tool the it is possible to determine the degree and the frequency of the symptoms. The score recorded from the client tells whe…………………………………………………………………………………………………
A 20 year old sexually active female presents today with “vaginal discharge and would like to get on the pill”. She describes the discharge as “watery, grey and smells bad”. She has a new sexual partner since her last visit. She has never had this problem before. She is otherwise healthy, with no past medical or surgical history and on no medications.
What is the differential diagnosis? How will you treat and follow-up? Is she a candidate for starting an oral contraceptive? Why or why not?
