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Saint Louis University
School of Nursing
Graduate School Program
In Partial Fulfillment
Of the Course
Masters of Science in Nursing
In Partial Fulfillment
Of the Course Requirement
In Behavioral Perspectives in Heatlh
A Case Analysis
Using Health Models and Nursing theories
Submitted to:
Ms. Teresa Basatan, MSN
Professor
Submitted by:
Charmaine Acosta Baniqued
MSN student
September 25, 2012
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Table of Contentsi. BACKGROUND .................................................................................................................................. 3
ii. DISCUSSION/ ANALYSIS ................................................................................................................ 6
iv. EVALUATION................................................................................................................................... 17
v. REFERENCES ................................................................................................................................. 18
APPENDICES
CONSENT
DOCUMENTATION
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i. BACKGROUND
Worldwide, between 80,000 and 100,000 kids start smoking every
day. Approximately one quarter of children alive in the Western Pacific Region* will die
from smoking.
The World Health Organization (WHO) has compiled worldwide smoking statistics for
the year 2002. The smoking facts and stats presented are sobering.
GLOBAL SMOKING STATISTICS
About a third of the male adult global population smokes.
Smoking related-diseases kill one in 10 adults globally, or cause four million
deaths. By 2030, if current trends continue, smoking will kill one in six people.
Every eight seconds, someone dies from tobacco use.
Smoking is on the rise in the developing world, tobacco consumption is rising by
3.4% per year.
About 15 billion cigarettes are sold daily - or 10 million every minute.
Among WHO Regions, the Western Pacific Region - which covers East Asia and
the Pacific - has the highest smoking rate, with nearly two-thirds of men smoking.
Youth
Among young teens (aged 13 to 15), about one in five smokes worldwide.
Between 80,000 and 100,000 children worldwide start smoking every day -
roughly half of whom live in Asia.
Evidence shows that around 50% of those who start smoking in adolescent years
go on to smoke for 15 to 20 years.
Peer-reviewed studies show teenagers are heavily influenced by tobacco
advertising. About a quarter of youth alive in the Western Pacific Region will die from
smoking.
*The 37 countries and areas comprising the WHO Western Pacific Region include
Philippines.
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With the concrete presented statistics above, it’s definitely alarming for me to turn
a blind eye with the rising incidence of smoking especially to those who are still studying
basically who are already employing a maladaptive coping towards stress. Another
reason for choosing him as my patient was that, if he is not into his smoking and
drinking, he seems so kind, respectful and responsible towards other people. What
gives him that “hard man” effect is that when he does the inhaling and exhaling of
smoke! So, I wanted to explore what is beyond his smoking and alcohol drinking.
My case is that of Mr. RT who is a 22 year old male with a history of smoking
way back since 3rd
year high school apparently all because of curiosity to try it. It is not
known from his family because accordingly, he will be reprimanded for the behavior. He
is the last child in the family having 3 siblings, 2 females and a male. No other family
smoke aside from his father whom he also claimed is into gambling.
When he reached college and being away from his family, he already started
smoking regularly with the freedom provided. He claimed that it makes him calm when
tense especially with regards to his problems (school and relationships). He also
claimed that he is into reinforced drinking every time he has money (allowance)
because of the urge to spend the money at hand. Accordingly because of his allowance
is not sufficient and is not given on time which makes a problem for him.
With school, he verbalized problems like lacking motivation to study, and that he
garnered couples of failing grades already and because of this, the more he smokes
because of frustrations and the feeling of losing control to what is happening.
Furthermore, he felt pressured because all of his siblings are already finished college.
Adding insult to an injury, his past 2-year relationship with his ex-girlfriend has no
closure. He verbalized that at the time of the interview, he really has a lot of things
making his thought messed-up. One is that, his ex was the one who became unfaithful
to their relationship resulting to their breaking apart and after some months later now
she claims that he is the father of the child she has gave birth.
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With all of these troubles he is into, he claimed that he is not open to any
member of his family to have at least one whom he can vent out his feelings, emotions
and problems. He also tends to keep these from his college friends. So, to
compensate, he struggles to appear happy by having a “happy-happy moments with
them”. That is, by having more frequent smoking episodes and drinking sprees.
Mr. RT chooses not to be in detail of these things but at the time of the interview,
he seems bothered. Anyway, he claimed to be aware of smoking hazards that it
imposed to his health, but he also claimed that, smoking is the only way that calms his
nerves and that’s the time he could think clearly then about things that troubles him.
Accordingly, he tried to stop smoking but he can’t just do it especially if he is faced with
problems/troubles again like that of his ex kept demanding from him, the school grades
are failing and the like.
All of these factors as he claimed had aggravated his smoking and alcohol
indulgence.
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ii. DISCUSSION/ ANALYSIS
Basing from the case, the appropriate model for giving interventions for this
particular client is the Cognitive Behavioral Model- Laps e-Relapse Proces s . Clearly
because of the imbalanced lifestyle, and yes, I cannot deny the fact of the severity of his
problems he is going through, but instead of directing through these problems, he is
coping in a maladaptive way which is smoking and drinking but more into his smoking
and not seeking any social support. He decided somehow to start smoking cessation
but have been unsuccessful for many times, and these past attempts gave him the
feeling that he cannot do the behavioral change desired and so the further involvement
in the vices.
There is the existence of maladaptive behavior, together with the desire for it. If
one is not equipped/ guided through the knowledge of effective coping mechanisms,
one would easily give in. Especially so, because Mr. RT uses rationalization or denial
that makes that maladaptive behavior correct or the effects that could serve him right. In
our life where stress is everywhere and it could be basically anything owing to our
individual differences. Stress is the one that provokes him to indulge to this maladaptive
behavior so stress management is very important to address this problem and self-
efficacy plays a pivotal role in doing this change.
It is also appropriate to integrate Health Promotion Model by Pender, the Health
Belief Model and Theory of Reasoned Action together with nursing theories of Betty
Neuman which is the Health Care Systems Model and of Imogene King which is the
Goal Attainment theory along with that of Tannahill’s Model of Health Promotion.
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Pender’s Model
Prior related behavior:>Ineffective copingmechanism
Smoking Drinking
Personal factors: Male College
student Ineffective
Stressmanagement
Perceived benefits fromsmoking:
Makes him calm
Helps him tothink well
Perceived self-efficiencyin stopping smoking:
Cannot stopsmoking
He believes tobe addicted to it
Belief that it is intheir bloodline
Interpersonal influences: Father also
smokes Peers in school
and his cousinsalso smoke anddrink ROH
Situational influences: Nothing could
relieve his stressexcept for smoking/drinking(situational)
Presence of problems (failinggrades, failurerelationship)
SMOKING/ DRINKING
No commitment/ plan tstop smoking/ drinking
1
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CBT-RP
2
Existence of maladaptivecoping:Smoking,alcohol andnot seekingsocialsupport
Desire for indulgence;so muchmore if there is/areproblemsencountered/ stress:schoolproblems,relationshipissues
Gives into theurgesandcravingsand itspositiveeffects itoffers:smoking,alcoholdrinking
Rationalizesthat thismaladaptivebehavior isthe only waythat helpshim relaxand thinkclearly
Exposure todifficultsituationswhere copingis needed(failinggrades,unsuccessfulrelationships,no one toverbalizeupon):maladaptivecoping
Problemsnotaddressed;lack of copingmechanismandproblemsolvingcapabilities
Due tounresolvedproblems;feeling of inadequacy(decreasedself efficacyisexperienced)
Substanceabuse(smoking/alcoholdrinking)
Abstinviolatieffectnot hathe poto stosmokbecauconstastress& the of beifailureeveryhe triestop,
just ca
do iteffect
creasing lifestyle balance:
Encouraged him to developpositive addictions like playingmetal puzzles and Sudoku whenhe is under stress to makehimself busy since he said thathe loves playing those. Suggested that if he needed abreak, maybe, he could go for astrolling with his peers Reinforced him to study and notto be lazy about it by keeping inmind those people whom are thereasons why he is studying andkeep his goals and continue
striving for his dreams by doinghis part as a student
Stimulus controltechnique: Taught him of
avoiding or removing of items/ situationsthat is associatedwith his smoking(Not stocking or buying cigarettes,not going toevents that wouldsmoking)
Revisedecisionmatrix:Weidentifiedtogether thepositive&negativeeffects of smokingto him(Pros &Cons)
Relapse road maps andcycle is explained to him.We identify together theusual situations whichposes inevitable risks for him to smoke: he saiddrinking with his peersand when some mishapsoccurred like if he hasfailing grades, quizzes/exams, and when his exkeeps confronting him)
Self-monitoring and
behavior assessment:
When he experienced
difficulty of saying “NO”
to a temptation of
smoking, try not to
smoke to relax him.
Suggested act.: listen to
music, watch television,
have a time for self
alone to meditate andthink what was really is
the problem
Efficacy enhancingstrategies:
Counseled him to
think of a
possible solution
that is attainable
at a shortest
time.
Reminded himthat this is a formof skill acquisition,so keep avoidingit and practiceresolving
problems directly.
Lapse mgt: Setting contract to l
smoking again Taught him how to
up with a lapse by nhaving a negative sconcept.
He was also given by telling it immediato the nurse.
We had evaluatedreadily what hadtriggered the lapse.(failed grades)
As a form of urge mgt:
Taught him of distractionsmethod like watchingmovies and informed himabout urge surfing
Educated himon warningsignals of relapse. (Givingas an examplewas what heexperiencedpreviously)
Avoidancestrategies: Saying no to
high risksituations
Told to keepin mind thathe couldcontrolhimself
We also brought up to the present the experiences and howhe looks at up himself after giving into his past relapses
Coping skillstraining: Suggested
opening up histo his siblings if he cannot directit to their parents.
Stress mgt:(praying,confrontproblems, focuson emotions,use problemsolving
technique)
Eliminating myths
and placebo effects: The beneficialpsychologicaleffects of smokingto him: cannotdefecate withoutsmoking, cannotthink clearly & thecalming effect
Taught him onimmediate andlong term effectsof smoking andhe has beenscared of to learnthat smoking mayalso cause CA ingenitourinarys stem.
Cognrestru Told
thatnot thatinefrathcopmec
Go streskilltrain
HEALTH PROMOTING BEHAVIOR
3
4A
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TRA+HBM
2
Plan or complianceto stop/controlsmoking &drinking
Attitude beliefs: Evaluation: It’s a good
decision to stop smoking
Perceived self-efficiency: After interventions done in
the CBM-RP, perceived self
efficiency improves “I can do this time” as
verbalized by Mr. RT
Cues to action to stopsmoking: Counseled upon by the
nurse of the long and shortterm effects of smoking
Feeling of a weakened body Apparently, he reported
there’s blood in his urineand he associate thispossibly by smoking
Advocacy program of city
Susceptibility to the disease: Family history of cancer in
maternal side Male is commonly more
affected by lung cancer Statistics say that the
leading cancer is lung
cancer for males.
Severity Aware about smokers body
diseases and afraid of itsomehow
He is also afraid of havingliver diseases associatedwith reinforced drinking
Perceived benefits of stopping:
Health promotion Smoking-related diseases
prevention
Normative beliefs: His siblings expect him to
stop smoking His current girlfriend wants
him to stop smoking
Attitude: Trying to stop smoking
Motivation to comply: He value much of his
girlfriends want andexpectations
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3
Stressors: Failing grades du
lack of motivationstudy
Failed relationsh When stressed:
seeking socialsupport
BasicEnergy
Re-sources
Basic structure: factors: Innate survi
factors Genetics (m Response p
(maladaptivcoping)
Strength/weaknesses
E o
Environment
Primary prevention: Advised to reduce
possibility of encounter withstressors byavoidance strategytowards the ex
Counseled onadaptive and copingmechanisms use
Response pattern:(personal factors) Feeling of loss Feeling of pain Being hopeless at the
moment Smoking and drinking
behaviors
Feelings of
guilt
Feelings of
inadequacyInterventions: Strengthen physiologic response
towards stress by advising adequatefood intake, balance between rest andplay
On psychological: Stress managementtechniques
Developmental: the need to beresponsible by studying as his part
Sociocultural: Socializing with peers yetdoing the right things (avoid vices);identify balancing factors: seeking helpfrom f riends/cousins
Spiritual: Advising to go to church,saying prayers
Goal: Control/ stop smoking anddrinking. Learns increasing balance inlifestyle, makes use of effectivecoping mechanisms and stressmanagement and problem solvingtechniques
Anticipated outcome: able tocontrol/stop smoking and drinking as acoping mechanism for stress
Prevention of progression to the
need of secondary and tertiary
prevention
Reconstitution: Could begin at any
degree/ level of reaction
Support for successful
A
HEALTH CARE SYSTEMS MODEL
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r. RT has lack of nowledge regarding
ress managementnd adaptive copingechanisms
4
Mr. RT
Mr. RT isaware of his mal-adaptivecopingresponse
Learning
Time
Space
Growth& Dev’t
Body
COMMUNICATION COMMUNICATION
TRANSACTIONMr. RT and the nurse communicates
about goal-setting and agreement
GOAL
SETTING
AGREE-
MENT
GOAL
Goal Setting: To develop effective copingmechanism/ problem solving and stressmanagement techniques
Agreement: To stop/control smoking anddrinking
Goal Attainment Scale: Health promotingbehavior
5
Learning: Takes place when there is
effective communication Mr. RT gained knowledge
of his maladaptivebehavior and proper techniques to handle it.
GOAL IS
ATTAINED
A
GOAL ATTAINMENT THEORY
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5
Educate on health promoting behaviorsReinforce on the use of proper stress
management and use of adaptive copingmechanisms and problem solving strategies
By supporting psychological,physiological and sociologicalstrengthening of the clienttrough ways of under health
education, my client is alsospared from secondary/tertiary prevention is alsospared.
In support of the gov’t for
the smoking hazards,Baguio city governmentimplemented law on nosmoking at public places
TANNAHILL’S INTERLAPPING SPHERES
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iii. PLANS/ INTERVENTIONS
Upon the first meet up, the client was cooperative and opens himself to the nurse
readily. This may indicate that he is actually willing to make a behavioral change,
geared toward health promoting behaviors and to learn on how to manage these
“undesirable health habits” that he is currently having.
To be further aware of my clients needs and for appropriate models to be
employed for initiating change, I validated with him my “findings” on his case and the
client validated that understanding upon his case is correct and he participated well with
the planning of interventions for the succeeding weeks. Here, we could integrate the
transaction process and learning concept of King from her model.
Prior to that, the model by Pender was used to explain the current behavior of
the client on how things lead to the behavior.
It is therefore useful for Mr. RT to adapt the interventions from the model of CBT-
Relapse Model because this is the key for achieving the goals from the different
models and theories that could be integrated in this study. To start with: to increase
lifestyle balance, I encouraged him to develop positive addictions like playing metal
puzzles and Sudoku when he is under stress to make himself busy since he said that he
loves playing those. I also suggested that if he needed a break, maybe, he could go for
a strolling with his peers. I also reinforced him to study and not to be lazy about it by
keeping in mind those people whom are the reasons why he is studying and keep his
goals and continue striving for his dreams by doing his part as a student
**The client said that he would be trying these things and that he will inform me of his
possible signs/symptoms that he could experience related to the desired goal.
For stimulus control technique, I taught him of avoiding or removing of items/
situations that is associated with his smoking (Not stocking or buying cigarettes and
alcohol, not going to events that could entail the need for him to smoke and drink). And
as a form of urge management, I taught him of distractions like watching movies and
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informed him about urge surfing for him not to think immediately that he cannot do it if
he experienced urge.
**True enough, Mr. RT at the 1st
3days of managing his urges experienced difficulty and
thought of giving up the process and almost gave in to his cravings. The difficulty
experienced is brought about by the need to adjust without the cigarette or drinking.
So, with the experience of urge surfing, I introduced him immediately to revised
decision matrix. We identified together the positive and negative effects of smoking and
drinking to him. Like if he has been drunk, this would definitely impair his functioning
instead of him studying his lessons. I also educate him on warning signals of relapse.
(Giving as an example was what he experienced previously). Relapse road maps were
also initiated. (We identify together the usual situations which poses inevitable risks for
him to smoke: he said drinking with his peers and when some mishaps occurred like if
he has failing grades, quizzes/ exams, and when his ex keeps confronting him). We
also brought up to the present experiences and how he looks at up himself after giving
into his past relapses. This is done for analyzing his past relapse fantasies.
**Mr. RT further looks himself as a big failure when he was reminded about his past
relapses and does not want to experience losing control of his self again. This gave him
however a positive effect: He said to himself then and to the nurse that he should do
this by this time!
So to reinforced him that when he experienced difficulty of saying “NO” to a
temptation of smoking (like when he is presented with the stimuli he just said earlier),
might as well try not to smoke to relax him, rather. I suggested for him to listen to music,
watch television, have a time for himself alone to meditate and think what was really is
the problem and think of a possible solution that is attainable at a shortest time that is a
form of enhancing the feeling of self-efficacy. I reminded him that this is a form of skill
acquisition, (how to resist temptations apparently and have that behavioral change).
And if it is a skill, one needs to practice it over and over again. So, for him, he just
needs to practice not holding on to smoking also when there is an opportunity that he
was faced with a stressor. Practice avoiding it and practice resolving problems directly. I
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also suggested opening up his problems to his siblings if he cannot direct it to their
parents but he refused saying that all of them are not really opening up to one another.
**Mr. RT realized that, of course, there is no easy way to acquire skills. So, he needs to
work upon it by not giving to the urges and cravings.
**He also said that, there is one cousin who is really close to him, at that he is the one
he will try to open up upon when problems crashes him.
To further enhance the coping mechanisms and self efficacy, concepts from
Health Care Systems Model are lifted particularly; the strengthening or supporting the
intervention from the primary prevention so that it would not lead further that
necessitates secondary or tertiary prevention or penetrating all of his defenses and
worst: entropy.
We then moved in to eliminating myths from him, typically the beneficial
psychological effects of smoking to him. Like he said, he cannot defecate without
smoking, he is apparently constipated and that he cannot think clearly if there is an
existing uneasiness within him. He also learned about the immediate and the long term
effects of smoking and he has been scared of to learn that smoking may cause any
cancer in the body. Like in the genitourinary system particularly, because lately, he
claimed that he has blood in his urine without any other cause. Moreover, he also
claimed that recently, he has again another ineffective relationship with his new
girlfriend because of his ex and his smoking and drinking habits. According to him, his
girlfriend matters to him ant that she is the one that matters most aside from his siblings
in stopping his smoking and drinking when feeling troubled.
With the preceding paragraph above, this is in relation to Health Belief Model
and Theory of Reasoned Action conceptual framework. The subjective norms andattitude beliefs also influence him to further contribute for the proposed goals. In
conjunction with the Goal Attainment, wherein the perspective of the nurse of what is
deficit leads to the formulation of appropriate goals, learning is a key concept for the
client to move towards achieving his potentials. That is where health education is also
needed to be emphasized. Moreover, in King’s theory, health is the focus, which is the
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counterpart of disease prevention in Tannahill’s Model and it is also in this model that
legislations in influencing the health is taken into consideration since Mr. T also
verbalized that the regulation on smoking of the city government has also a bearing on
minimizing his smoking in public places since then.
After for some time of not seeing him, I had been to Mr. RT to see how he was
coping with his progress to the proposed behavioral change.
**He said that for many times, he had been tempted to start smoking again especially if
he sees people who are smoking and also when he was upset about his school
requirements but insisted to keep up with the planned interventions and what has taught
to him for effective coping.
After the midterm examinations, Mr. RT experienced the initial lapse of
substance use because apparently he has almost sure failing subject again just after
taking the exams. He said that he suddenly thought of about her ate who sends him to
school. He seemed distraught with the outcomes of his grades and the lapse he
experienced.
**Lapse management has been initiated then with Mr. RT by setting contract to limit
smoking and drinking again, and taught him how to cope up with a lapse by not having
a negative self concept. He was also given credit by telling it immediately to the nurse.
We had evaluated readily what had triggered the lapse. I immediately assessed him for
abstinence violation effect. He might be feeling some decreased self-efficacy to
continue with the behavioral change. We did cognitive restructuring by not letting him
feel he is a failure.
**He said the next time he would be confronted again with such immense problem, he
would try to go and seek the availability of the nurse and his available social supportwhich is the dearest cousin to him ASAP.
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iv. EVALUATION
Ineffective stress management and coping mechanism; impaired problem solving skills:
smoking and drinking
The goal/s with Mr. RT are fully met basing it to the Lapse-Relapse Process
Model and Goal attainment theory. Change is in line with the time frame provided in
Goal attainment scale. Also, the other models/ theories that helped in enhancing the
efficacy and coping mechanisms in achieving the health promoting behavior also
succeeded in enhancing the desired behavior change. It has been almost 4 months
since we set the goals. It is not because Mr. RT experienced relapse made my goal for
him partially met. Because, infusing him with an insight is the primary goal, and he had
been receptive to those. Behavior change is not achieved over night but it is achieved
over time.
The client identified the presence of a problem, the client identified the triggering
factors that let him do to smoke, helped the client verbalize feelings and thoughts
regarding the coping mechanism used, the client eradicated the smoking as a coping
mechanism and he also addresses problem directly by having a confrontation with his
ex and he initiated the closure accordingly (however, the client is still under observation
and monitoring, the last time he smoked was September 9, 2012 and as of this moment,
he still not smoke), The client developed and maintained a healthy coping mechanism.
According to him, he plays guitar, sings and he even clean the house when he feels
stress now.
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v. REFERENCES
George, Julia (2002). Nursing Theories: The Base for Professional NrsingPractice 5th ed. Singapore. Pearson publishing
Global lifestyle self control strategies handout from Mam Basatan in BehavioralPerspectives in Health
Marlatt, Allan G. (1984) Society for the Study of Addiction to Alcohol and other Drugs. Relapse Prevention: Introduction and Overview of the Model. Bntish
joumalof Addiction79(1984), 261-273 Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: Maintenance
strategies in the treatment of addictive behaviors. New York: Guilford Press. World Health Organization - Smoking Statistics http://recoveryroadmap.com/Members/RP-Pages/RP8-TheoryPractice.html http://books.google.com.ph/books?id=Fx9oqIbIQ_QC&pg=PA4&lpg=PA4&dq=La
pseRelapse+Process&source=bl&ots=tllzVeBNej&sig=QGDNBmx4qEaFgrLBIJjgGJulaQI&hl=en#v=onepage&q=Lapse-Relapse%20Process&f=false
Downie RS, Fyfe C & Tannahill A (1990). Oxford: Oxford University Press, Tannahill A.( 1985) What is health promotion? Health Education Journal
Health Protection Agency. What the Health Protection Agency Does. 2010 (last
updated 12 April). Last viewed 22 June 2011.
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APPENDIX 2
DATE ACTIVITIES DONE SIGNATURE
July 7,
2012
Asking for informed consent and divulging
intentions/ purpose
Building rapport
Interview/ eliciting initial database
July 14,
2012
Validating data for correct understanding of the
case situation
Formulation of planning and interventions with
the client for the next weeks
July 21,
2012
Interventions on increasing lifestyle balance
How to avoid high risk situations
Urge management
July 24,
2012
Identified the positive and negative effects of
smoking to him
Discussed on warning signals of relapse. (giving
as an example was what he experienced
previously)
Identifying usual situations which poses
inevitable risks for him to smoke
We reflected at his past experiences and how he
looks at up himself after giving into his past
relapses
Constant reinforcements of interventions
previously taught
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Problem solving techniques discussion
Stress management options
Discussion on effective coping mechanisms
Discussion on the beneficial psychological
effects of smoking to him and about the
immediate and the long term effects of smoking
August
12, 2012
Visit to Mr. RT
He related his experiences about being tempted
to smoke/ drink
Sept. 9,
2012
Mr. RT experienced the initial lapse of substance
use.
Lapse management by setting contract to limit
smoking again, and taught him how to cope up
with a lapse by not having a negative self
concept.
He was also given credit by telling it immediately
to the nurse.
We had evaluated readily what had triggered the
lapse.
I immediately assessed him for abstinence
violation effect. We did cognitive restructuring.